IMPLEMENTATION OF THE INTEGRALITY PRINCIPLE IN TECHNICAL NURSING COURSES AT SCHOOLS IN THE SUS NETWORK

APLICACIÓN DEL PRINCIPIO DE INTEGRIDAD EN LOS CURSOS TÉCNICOS EN ENFERMERÍA DE LAS ESCUELAS DE LA RED DEL SUS

ABSTRACT

Objective:

to understand how the coordinators of technical schools in the Unified Health System perceive the application of the integrality principle in the training process of nursing technicians.

Method:

qualitative research through the Collective Subject Discourse, involving 12 coordinators of technical nursing courses taught at technical schools of the Unified Health System.

Results:

two categories emerged from the analysis of the data: Teaching bond and difficulty to insert the integrality principle; and Weaknesses and potentials of student workers related to the integrality principle.

Conclusion:

according to the coordinators of the technical schools in the Unified Health System, the development of the integrality principle is an urgent need; and there are difficulties to structure it concerning the casualization of teaching work and resistance to change by the students workers. In contrast, the fact that these students are already inserted in practice seems to facilitate the understanding of the importance of continuously developing these principles.

DESCRIPTORS:
Education; nursing. Education; nursing; associate. Education; professional. Unified health system. Integrality in health.

RESUMEN

Objetivo:

Comprender la percepción de los coordinadores de las escuelas técnicas del Sistema de Salud sobre el principio de la integralidad en la formación de los procesos técnicos de enfermería.

Método:

Investigación cualitativa a través del Discurso del Sujeto Colectivo con 12 coordinadores de los cursos de enfermería técnicos de escuelas técnicas del Sistema de Salud

Resultados:

El análisis de los datos, emergieron dos categorías: Vinculación de la enseñanza y la dificultad para aplicar el principio de exhaustividad; y debilidades y potencialidades de los alumnos trabajadores relacionados con el principio de integralidad.

Conclusión:

Para los coordinadores de las escuelas técnicas del Sistema Único de Salud, el desarrollo del principio de integralidad es una necesidad apremiante y existen dificultades en su estructuración relacionadas con la precarización del trabajo docente y resistencia al cambio por parte de lo los alumnos trabajadores. Por otra parte, el hecho de que estos estudiantes ya están inmersos en la práctica parece ser un facilitador en la comprensión de la importancia de desarrollar continuamente estos principios.

DESCRIPTORES:
Educación en enfermeria; Graduación en auxiliar de enfermeria; Educación professional; Sistema único de salud; Integralidad en salud.

RESUMO

Objetivo:

compreender a percepção dos coordenadores das escolas técnicas do Sistema Único de Saúde sobre a aplicação do princípio da integralidade no processo de formação do técnico de enfermagem.

Método:

pesquisa qualitativa, realizada por meio do Discurso do Sujeito Coletivo, com 12 coordenadores dos cursos técnicos de enfermagem das escolas técnicas do Sistema Único de Saúde.

Resultados:

da análise dos dados, emergiram duas categorias: Vínculo docente e dificuldades para inserção do princípio da integralidade e Fragilidades e potencialidades dos alunos trabalhadores relacionadas ao princípio da integralidade.

Conclusão:

para os coordenadores das escolas técnicas do Sistema Único de Saúde o desenvolvimento do princípio da integralidade é uma necessidade premente; e há dificuldades para sua estruturação relativas à precarização do trabalho docente e resistência à mudança por parte dos alunos trabalhadores. Em contrapartida, o fato destes alunos já estarem inseridos na prática parece ser um facilitador do entendimento da importância de desenvolver continuamente esses princípios.

DESCRITORES:
Educação em enfermagem; Educação técnica em enfermagem; Educação profissionalizante; Sistema único de saúde; Integralidade em saúde.

INTRODUCTION

The Technical Schools of the Unified Health System (ETSUSs) are public institutions, created as from 1980, to be able to qualify and educate basic and secondary SUS workers. The methodological characteristics of these schools attempt to adapt the curricula to the regional context and promote the integration teaching/service, guided by the principles and guidelines of the SUS.¹

To date, 36 schools have been constituted across the Brazilian territory, which make up the Network of Technical Schools of the SUS (RETSUS), established by Decree 2.970 on November 25^th 2009. The Secretary of Health Work and Education Management (SGTES), affiliated with the Ministry of Education, is in charge of the coordination of this network.²

The ETSUSs are pedagogically organized through the problematization methodology, pedagogical training and competency-based certification.¹ In that sense, the professionals involved in the organization processes of the educational context and the ways in which teaching and learning are offered are essential, as they incorporate the guidelines the RETSUS disseminates in the classroom or in the educational context. In this reality, beyond the teachers committed to teaching, the role and importance of the coordinators at these schools should be considered, not only regarding their understanding of teaching or the guidelines proposed by ETSUS, but also regarding the operation of these premises and the schools' daily practice, functioning and relations with students and teachers.

The role of the general or pedagogical coordinators includes the ongoing articulation of the curricular actions and the favoring of the SUS' premises. Consequently, integrality, being one of the principles of the SUS, needs to be strengthened as a pedagogical principle in the health professionals' continuing education, through dialogical relations, collective reflections about the practices and attitude changes in the care spaces.³

The coordinator plays an essential role to put in practice the training and teaching/service articulation process, and should act in the management, supervision and coordination of all activities in the teaching-learning process of the course (s)he is responsible for, working to put in practice the institutional ideals and the quality and stay of the students throughout their educational construction process. The coordinator has the functions of trainer, articulator and transformer and (s)he is responsible for monitoring the program of actions that permit the creation of a group that works towards qualification, conducting productive changes in and outside the classroom, allied with the teachers' work.⁴

Based on the development of this SUS principle in the pedagogical practices and guidelines of the ETSUSs, this study was intended to understand how the coordinators of SUS technical schools perceive the application of the integrality principle in the proposal of the course for nursing technicians.^*

METHOD

Qualitative research, developed through the Collective Subject Discourse (CSD) method, intended to recover the social representations in the collective thinking, thus permitting the unveiling of the research subject's social field.⁵

This method is developed through the key expressions (KEs) in the discourse, which are continuous or discontinuous fragments the researchers should choose and which exhibit the core of the discourse. The meanings of the KEs are descriptively expressed through the core ideas (CIs). The KEs are basically subjective, descriptive and literary, while the CI is conceptual, precise and objective. Anchoring (AC) is the expression of ideologies embedded in the discourse. The CSD is the union in a single discourse of all KEs with a CI or AC.⁵

The social agents who participated in this study were the coordinators of the ETSUSs in Brazil. This choice is justified because of their relevant functions in the action proposals inherent in health education in the ETSUSs, articulating continuing education strategies for teachers and students and conducting changes.¹

The RETSUS consists of 36 technical schools and human resource training centers of the SUS existing all over Brazil, These public institutions are primarily and mainly focused on the training of secondary-level professionals already active in the SUS. Thirty-three of these schools are state schools, two municipal and one federal. The ETSUSs put forward the SUS principles as frameworks for professional training and try to respond to the regional demands in the technical training of secondary workers active in health services. The main characteristic of these schools is the ability to decentralize the curricula, using the health services as a space for teaching and learning.

After the initial contact by telephone and e-mail with the 36 ETSUS schools in the country and through the inclusion (being a coordinator and having participated in the training of at least one class of nursing technicians) 12 coordinators accepted to participate in the study, called social agents according to the method.

The data were collected between July 1^st and August 30^th 2013, developed through the software QLQT (on-line questionnaire for the collection of quantitative and qualitative data), which supports the execution of research at a distance and allowed the researchers to collect data on-line, which facilitated and sped up the receipt of the data and reduced the research costs.⁵

The initial analysis was based on a detailed reading of each questionnaire. Then, the answers were exported to another software, QualiQuantiSoft, in which the central ideas (CIs) of each of the questions were organized and categorized. Thus, the data evolved to the construction of the CSD, written in the first person singular. To elaborate the CSD, sex, age and service time were not analyzed, a process called departicularization, according to the premises of the method. Repeated ideas were also considered, taking care to recover the ideas expressed with distinct words, even if similar.

This research received approval from the Ethics Committee for Research involving Human Beings at Universidade Federal de Santa Catarina (UFSC) under Opinion 301492/2013, and all participants gave their formal consent by signing the Free and Informed Consent Form.

RESULTS AND DISCUSSION

Among the social agents who participated in this research, ten were female and two male. As regards the location of the schools, three social agents worked at schools located in the North of the country, two in the Northeast, two in the Central-West, three in the Southeast and two in the South of Brazil.

As regards the coordinators' education level, four held a post-graduation degree (Master's), six a specialization degree, one had finished secondary education and one did not inform this aspect. Concerning the education area, eight had graduated in nursing and the remaining four in dentistry, languages, no higher education degree and one did not inform.

Through the perceptions of the agents who coordinate the education processes, hire the teachers, participate in the pedagogical meetings and are close to the students, discourse was constructed to understand how the coordinators of the ETSUS courses perceive the adoption of the integrality principle in the daily practices and in what structures this process takes place. The analysis process of the data originated two categories: Teaching bond and difficulties to apply the integrality principle; and Weaknesses and potentials of the students related to the integrality principle.

Category 1 - Teaching bond and difficulties to apply the integrality principle

The teacher is the subject who has the important function to create and offer the students interaction possibilities, aiming to break with the culture of determinism and covering the original. It is in the field of the care practices that the actions truly take form, allowing the teachers to mediate the students' reflections and actions, favoring productive discussions and stimulating the education of a creative, critical and reflexive professional.⁶

Nevertheless, the absence or fragmentation of the teacher's job bonds with the schools can somehow make teaching work more precarious, as it distances him/her from the pedagogical experiences due to the absence of a bond, and almost always as a second job or complementary income.⁷ The difficulties related to the composition of the teaching staff is one of the Gordian Knots in the supply of high-quality technical professional nursing education at the secondary level: there is a lack of education for teaching (as the nurses obtain the bachelor degree in nursing and need specific pedagogical preparation for teaching), as well as non-attractive salaries and the preference of care activities that situate the nurse in a specialty and guarantee some degree of professional recognition and stability.⁸

Next, the two CIs are presented that constitute this category: The teachers' bonds with the ETSUS and the challenges of integrality; and Difficulties for the teachers to apply the principle of integrality and supply pedagogical workshops.

CI 1 - Teachers' bonds with ETSUS and the challenges of integrality

CSD: the teacher in the classroom does not always accompany the student in the field. In practice, that is the task of tutors indicated by the hospitals that offer the training areas, which does not guarantee the integrality of the actions. The teachers are not fixed, there is plenty of turnover, negatively affecting the continuing education processes or training. Working with teachers with a municipal job contract represents a challenge, that is, they are hired by the municipal governments and many work under a precarious job contract. In addition, the fragmentation of the work process can be mentioned, as the teacher may need to be with the students at a place opposite to his workplace. Even if the teachers are part of the institution and know it, it is not always available to permit the teaching-service integration, limiting the construction of reflexive practices, and sometimes ignoring the history and evolution of the SUS as a health policy and the health network the workers are part of.

The CSD reveals that, when the teachers' situation at the ETSUSs is described, the coordinators appoint the difficulties to articulate teaching and work. Limitations are related to the teachers who will work in the education process and the difficulty to maintain a cohesive and permanent group, as the turnover of teachers seems to be an imperative. The fragmentation, not only in teaching but also in theory and practice, seems to oppose the idea of integrating the contents by distancing the teacher in the classroom, dealing with so-called theoretical content, from the teacher who is active in practice.⁹ The latter even seems to be disarticulated from the schools' pedagogical proposals.

The tutor the coordinators mention is not only active as a teacher, but continues working as a clinical nurse for the institution, performing professional activities and at the same time supervising the students. The CSD reveals the reality of the schools that are constituted to disseminate and put in practice the premises of the SUS, but are unable to get means to turn the proposal of education centered on the human being into a reality, based on the principles of integrality.

In this context, there is an urgent need to make secondary nursing education less technical and develop critical and creative professionals. But observations are made on the teacher's lack of didactics with regard to the preparation of the classes.⁸ The difficulties observed by the coordinators, who select the teachers and develop in-service education activities with them, have already been identified in the history of secondary-level technical professional education in Brazil: there are curricular tensions and concerns with the pedagogical preparation of teachers affiliated with professional education. In this logic, teaching is considered as a way to prepare for a certain job, developed by a professional with specific knowledge on the craft he is about to teach. But when considering teaching as a highly complex activity, it is noticed that, due to the multiple nature of their knowledge, professional education teachers need didactical and pedagogical background.¹⁰

The teachers responsible for the professional training process of secondary level nursing professionals do not only lack specific training, but also need to cope with a series of requirements related to the contents and profile of the professionals they intend to graduate. Therefore, teaching/service integration can support education within the logic of the SUS principles and guidelines, although not in isolation.

A study proposed to analyze the teaching/service integration appointed the need for in-depth and significant changes, engaging coordinators, managers, workers, teachers and students, in a complementary manner, in all of its contexts, aiming for the strengthening of collaborative actions between teachers and clinical nurses.³

Collective, agreed and articulated work can offer quality to individual and collective health care, but also grant excellence to the professional education process.¹¹ By aligning the knowledge areas with the pedagogical strategies, the students, teachers and workers in the health service teams strengthen the bonds and also qualify professional care.¹²

CI 2 - Difficulties for the teachers to apply the integrality principle and supply pedagogical workshops

CSD: when we constitute the teacher team, we organize a pedagogical workshop where we share the mission and the intended student profile, as it is through the teachers that integral and interdisciplinary knowledge is possible. There is great difficulty, however, in the inclusion process of the integrality principle, because of the teacher's educational background, who was not trained within this logic and needs a critical and reflexive posture to change his practice in the classroom. In that sense, we have discussed to promote learning beyond the fragmented knowledge transmission.

The technical rationality has inspired professional education in a wide range of knowledge areas. Nevertheless, some understandings or even attempts to attribute a new meaning to this logic in the classroom are perceptible in health courses, in all contexts, and that is the aspect part of the reflection on contemporary teaching rests on.¹⁰

Teachers in secondary-level technical professional education are responsible not only for deviating from the technical, Cartesian and biological logic that separates and compartmentalizes the knowledge, and consequently care, but also for the need to understand and better articulate the principles the schools propose, qualitatively endorsing the bases of teaching that should integrate, socialize, agree on and articulate a wide range of scenarios and subjects in the educational processes.

It is also undeniable that the professionalization of nursing in Brazil followed the Nightingale nursing prescriptions, in a work organization focused on the supply of fragmented care, internally ranked in professional categories and executed in a universe that dichotomizes the world of work and the intellectual world.¹³

In the overcoming of this educational paradigm and the adoption of new principles and guidelines, necessary for teaching in health, the social agents who participated in this study appointed the need to structure proposals intended to offer and strengthen teacher training, within a permanent education logic.

Current attempts to break with the hegemonic hospital-centered/technical model of health teaching drive towards the need for new pedagogical practices and the inclusion of concepts that need to be incorporated in care practice.^14-15 The materialization of the integrality principle remains a challenge for health care due to the difficulties to overcome these paradigms and its importance in the education process of all health professionals, confirming the urgent need to develop spaces for discussion at the health services and schools.¹⁶

Category 2 - Weaknesses and potentials of the students related to the application of the integrality principle

In a context where the students have work experience, they have a wide range of expectations on the education, being confronted daily, in the education process, with a concrete reality of an increasingly complex universe.^10,17

Through the knowledge gained in the course of their professional life, the students bring into the classroom realities that permit important discussions, enriching and aggrandizing the teaching process as a whole, but it demands from the teacher the capacity to articulate this pre-existing knowledge with the new practices and public policies, stimulating reflection in the students' actions and creating the possibility of new actions.

Next, the CIs corresponding to this category are presented: the students' difficulties to modify practices established much earlier; and Knowledge on the Unified Health System.

CI 3 - The students' difficulties to modify practices established much earlier

CSD: our challenges include the overcoming of the concept of the maxim that states that experience is knowledge: 'I have done this for a long time, so I don't need to reflect on my professional practice'. Many students have been working for a long time and do not believe in the possibility of changes for the better in the health system. They show to be quite attached to the system, offering some resistance to what is considered new, and present difficulties when they are invited to think, question and change deep-seated professional paradigms.

When discussing the technical nursing education at the ETSUSs, students are described who are already working in the area, some of whom for many years, granting them considerable practical experience. In that sense, education moves beyond a role interwoven in teaching as mere scientific, pedagogical and didactical recycling,¹⁸ looking for the possibility to favor spaces of participation, reflection and education to allow the student to learn and adapt to the changes in the care process.¹³

The valuation of experience-based knowledge seems to be a way to take a position in practice, as this knowledge is constituted exactly in daily professional practice, based on work, derives from and is validated by experience.^16,19 Nevertheless, the fact that an activity has been done for many years and is part of experience-based knowledge does not replace the constant need for recycling and reconsideration of this knowledge, as the changes in society and technological innovations are clearly present in the health context. The actual modification and adoption of new concepts and principles in care or the incorporation of new public policies guide the practice and need constant review and an in-depth understanding of their logic.²⁰

CI 4 - Knowledge on the Unified Health System

CSD: a great facility that helps us and improves our actions is the fact that most students are included in the reality of the SUS as a public policy. Background knowledge of the system is an important factor to put integrality in practice. The students work at the health services and know the reality.

It is important to highlight that some coordinators also emphasized the importance of this background knowledge as a positive characteristic. From another perspective, the understanding that the student's experience is an important part of the knowledge on the job world turns this knowledge into a facilitator of the teaching process, as he uses actions the students know to problematize new possible actions, planning, attitude changes and the adoption of other concepts for nursing care. The possibility to develop criticality and reflection on the care process, through changes, can be favored if the student, in the reality, understands care from a perspective deriving exactly from the space where this care happens.

Although this study was not intended to assess the extent or range of the students' knowledge on the public policies, particularly the SUS principles, the coordinators' perception of the posture and integration of the knowledge in their education process is positive and fruitful and turns into actions that contribute to the teaching strategies and to the learning process.

The SUS principles certainly need to be broadly contextualized in the teaching practices through strategies in which the teacher is able to integrate the practice with classroom work, without undervaluing any of both, also stimulating the students to seek knowledge based on other entities and contact with other professionals in the job context they will take part in in order to problematize the knowledge.²¹

The integrality principle has not strongly found the visibility it deserves and needs yet with a view to a broad understanding in the professionals' teaching, education and practices, making it essential to incorporate its premises in order to fully achieve them.

FINAL CONSIDERATIONS

Through this study, it was shown that the application of the integrality principle in secondary-level technical professional education remains a desire and is being consolidated. Despite the existence of difficulties, paradigms and practices that do not comply yet with the principles needed to implement another care logic, concrete practices and postural changes need to be developed based on theoretical deepening and awareness raising.

In the CSD of the coordinators of the technical nursing courses at the ETSUS, the notion of the teachers' lack of training is present and even theoretical distancing from the principles to be discussed with the students. Therefore, there are proposals to construct this knowledge through training, intended to prepare and guide trained professionals to work in the different situations of nursing care.

Despite the limitations in this study, mainly deriving from the small number of coordinators interviewed, the evidence presented can be useful to discuss the theme, as well as to develop future studies on the importance of the coordinators and their role in the pedagogical choices for the technical courses, with a view to strengthening the importance of the Unified Health System.

The role of the coordinators at the SUS technical schools in this context surpasses the sphere of administrative course management, as their actions should be based on critical analyses of the teachers, students and training areas' realities, integrating and favoring the teaching processes.

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• ¹
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• *
  In Brazil, nursing is divided into three categories: nurse, nursing technicians and nursing auxiliaries, being the highest level is a nurse, followed by technicians and auxiliaries. Translator's note.

Publication Dates

• Publication in this collection
  2016

History

• Received
  04 Sept 2015
• Accepted
  24 May 2016