Resumen: Objetivo: conocer el proceso de integración enseñanza-servicio en la percepción de docentes, estudiantes y profesionales de salud. Método: investigación descriptiva, cualitativa. Los datos fueron recolectados por medio de entrevistas, con 31 protagonistas, entre los meses de octubre y diciembre de 2015 y analizados a partir del referencial teórico de Donald Schön. Resultados: surgieron dos categorías: construcción del proceso de integración enseñanza-servicio: el aprender por medio del hacer; límites del proceso de integración enseñanza-servicio: ¿una política instituida por la escuela y por el servicio? Consideraciones finales: la integración enseñanza-servicio es comprendida como un proceso fundamental para la formación de enfermeros y necesita rescatar, periódicamente, sus objetivos, entre ellos, aproximar a los estudiantes del escenario de la práctica. La dimensión política del proceso necesita ser retomada por los cursos de graduación en enfermería y por los servicios para la consolidación de una formación orientada al Sistema Único de Salud.

Descriptores: Servicios de integración docente Asistencial; Higher education policy; Enfermería

Introduction

With the advent of the Brazilian Unified Health System (SUS – Sistema Único de Saúde), the need to design a policy to train, train and evaluate health workers emerges. In the meantime, teaching-service integration has become a strategy to overcome the educational system’s gap with health workers, in addition to qualifying the assistance provided to the population.¹

With this in mind, the Ministries of Health and Education and Culture have invested in structuring interministerial health and education actions in order to strengthen health education. Among these actions, the Brazilian National Program for Reorientation of Vocational Training in Health (Pro-Health - Programa Nacional de Reorientação da Formação Profissional em Saúde) stands out, which proposes the use of health services as teaching-learning places, representing the inseparability between care, management and health training.^2-3

In response to this proposal, the Brazilian National Primary Care Policy (PNAB - Política Nacional de Atenção Básica), approved by Ordinance 2,436, September 21^th, 2017, reinforces that teaching - service integration benefits basic care, teaching and research institutions, workers, professors and students, and, above all, the population, with health professionals more qualified to act and to produce knowledge in primary care.⁴

Teaching-service integration as the accomplishment of a collective work agreed between students and professors with health professionals and managers, in order to reach the quality of training and assistance,⁵ considering the complexity of the SUS in professionals training. Teaching-service integration involves health problems arising from urbanization, social and environmental change, and older ones that remain immutable.⁶

The approach to care practice, still in nursing undergraduate, needs to provide actions connected to the day-to-day health services and with the population, and not only actions for the fulfillment of the curricular requirements.⁷ Services become “pedagogical ateliers in health”,⁸ that is, the locus of learning by doing, from practice to action, reflecting and promoting transformations necessary to bring these two “worlds” (of teaching and service) in particular, to improve health care. This approach also requires the gradual removal of technical rationality, which is characterized by the limitation of the actions of professionals to the option of technical means, supposedly more adequate for a given circumstance.^9-10

In this context, at least 30 years ago, the Brazilian government has encouraged professional qualification programs to overcome the dichotomies between health care and training. Pro-Health and Health Education Program of the Ministry of Health (PET-Health - Programa de Educação pelo Trabalho para a Saúde do Ministério da Saúde) are examples of Brazilian strategies to encourage integration of education and care, strengthening the perspective of integration of teaching and service.^11-12

The present research aims to know the process of teaching-service integration in the perception of professors, students and health professionals.

Method

Qualitative, descriptive research carried out with nursing professors and students and health professionals who embrace the students in health services of two Nursing Undergraduate Courses of Brazil’s South.

The criteria adopted for the selection of courses were limited to selecting nursing schools contemplated with the Pro-Health Program, and of these, the oldest nursing schools in the Southern region of Brazil. The option for schools contemplated with Pro-Health has to do with the objective of the program, which is the planning and development of health practices consistent with local reality, taking into account SUS guidelines and the training of professionals to work in this System. Thus, it is necessary to consider the principles of comprehensiveness, equity and universality, in order to overcome the hegemonic model centered in the biological and clinical for the valorization of social and subjectivity.

In order to do so, it demands profound changes in health practices, imposing significant changes in the training and development process of professionals in the area involving professors and students from two Higher Education Institutions and professionals from the local health services, as well as their managers. In addition, it considers teaching-service interaction as a fundamental element in the development of strategies that overcome the organizational challenges of vocational training.^2-3

To ensure anonymity, the courses were identified as Course A (CA) and Course B (CB). For Professors, the letter P was assigned, followed by an ordinal number (1, 2). The same occurred with Health Professionals (HP) and Students (S).

From the selection of the two schools the first participants were contacted through the coordinator of each course and later, non-probabilistic sampling of the snowball type.¹³ The invitation to participate in the research was carried out by institutional or personal email from the interviewee, provided by the course coordinator. Thirty-one participants were interviewed, of whom 17 were CA participants, among professors (5), students (6) and health professionals who embraced students in the service (6). At CB, 14 participants were interviewed, among professors (4), students (6) and health professionals who embrace students in the health service (4). The number of participants was defined from the saturation of the answers obtained.

The choice of students from the last year of the nursing course was justified by the possibility of having a broader view on the training process, being able to better detail this process. The selection of professors occurred by the time of performance of more than four years in school. Health professionals who embraced students had more than two years’ professional experience in the same place.

Data were collected through semi-structured individual interviews, face to face, with a mean duration of 40 minutes between October and December 2015. The triggering question of the interview was: what is and how is the integration between teaching and service?

The interviews were carried out according to the preference and availability of the interviewee, being carried out: in the professors’ room or office; in the internship field, in the interviewee’s house, in the school’s meeting room and in the region’s market. They were audio-taped, with authorization of the participant, and transcribed in full. They were then grouped into a single document per course so that the researcher could have a broad view on the data collected.

The operational proposal was used to analyze qualitative data.¹³ Firstly, the raw material was pre-analyzed, by means of the floating reading of the transcripts of the speeches and of the records in the field diary, in order to constitute the information corpus guided by the analytical question: how participants of the study perceive the integration teaching-service? Then the exploratory phase was carried out which resulted in the first codification, in order to reach the core of text comprehension. The data were grouped by similarity, 13 being assigned theoretical meanings and interpretations resulting in two categories from the Donald Schön’s theoretical framework supports the ‘learning by doing’, with retrospective pauses on the actions aimed at learning from the reflections performed. It is called epistemology of reflexive practice, opposing a teaching focused only on the triad science-application-stage, in which it supposes to be the mere application of technical and professional knowledge⁹: a) Construction of teaching-service integration process: learning through doing; b) Limits of the process of integration teaching-service: a policy instituted by the school and the service?

Schön’s theoretical framework supports the ‘learning by doing’, with retrospective pauses on the actions aimed at learning from the reflections performed. It is called epistemology of reflexive practice, opposing a teaching focused only on the triad science-application-stage, in which it supposes to be the mere application of technical and professional knowledge.⁸

This research was approved by the Research Ethics Committee with Human Beings of the Universidade Federal de Santa Catarina, in compliance with the criteria of Resolution 466/2012 of the Brazilian National Health Board (Conselho Nacional de Saúde),¹⁴ under the opinion constituted number 045931/2015, CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 45354115,8,0000,0121. Prior to voice recording, authorization and signing of the Free and Informed Consent Term (FICT).

Results and discussion

Construction of the process of teaching-service integration: learning through doing

Teaching-service integration is perceived by the study participants as a space conducive to the learning process, from the exchange of knowledge, in which both professors and students are benefited. The student is seen not only as someone who uses the service for his learning, but as the protagonist who contributes the same.

Commitment to form the SUS is acknowledged, recognizing the reality of the community and of the service, at the individual and collective level, inserting itself in the community. Just as health professionals are encouraged to resume their studies, the reality of services becomes a challenge and a process of self-evaluation for professors, who need to review their clinical and teaching practices in search of consonance with what occurs in services.

The approach of the university to the service is seen by professors as a form of effectiveness of the political and pedagogical proposal of the course, impossible to be performed without the participation of the health professionals and far from the real settings of the practice.

[...] we would not be able to maintain our pedagogical project of the course without having this relation with the network [of health care]. It would be impossible because we work a lot on the current logic, from what is happening. It is a proposal that is not easy either, because this planning and evaluation has to be joint and it demands more time, more energy [...]. (P2CA)

Relationship construction between teaching and service is gradual, and it is essential that the subjects of both segments be clear about the importance of this process and the policies that guarantee and strengthen it, so that the integration, in fact, occurs.

[...] is an action that has to be built on a daily basis. You have to build relationships, we believe that we have to have more general, institutional policies that allow us to be present with the students in the services. (P3CB)

The activities of teaching and research in the service space are understood as a moment of learning of the student and a devolution of this process to the service, from the activities of clinical practice with direct supervision of the professor and indirect supervision (supervised curricular internship). They are mentioned as a concern not to restrict the activity of teaching in the scope of the service to a student training practice.

They [research actors] carry out research bringing new data, which we may be working on and doing some intervention action. [...] we can draw a problem, it can be brought by them, by the community itself. Anyway, it is through this that we devise a strategy to improve that index [epidemiological or other statistical data]. (HP1CA)

Participants recognize that teaching-service integration experiences contribute to Permanent Education in Health (PEH), from the establishment of relations of exchange of knowledge, with the conduction of research and a process of self-evaluation of teaching and service. It is considered prior knowledge and updates, which makes the approximation of these two contexts necessary and complementary.

Moreover, teaching and service instances act as a lever of PEH movements, especially by strengthening the actors (of management, attention, teaching and social control), in the development of new practices of assistance, teaching, management, social participation and of a new way of operating health work.¹⁵

In the process of teaching-service integration, health services become teaching-learning spaces of work, which, in this research, is based on the epistemology of reflexive practice called, in this study, “pedagogical atelier in health^”.⁸ This means that the training of students and professionals should be based on the service itself, experiencing real situations and contrasting with the idealized reality.¹⁶

In this way, teaching-service integration becomes not only a moment that is limited to the recognition of the reality of services, of “know-how”, but mainly, it focuses on the unexpected circumstances that are present in the daily setting. This will open the doors to a critical, reflexive training that considers the historical and social processes, being thus committed to the health needs of the population.

In CB, the interviewed professors did not have, at the time of data collection, research or extension in development in the units in which they supervised, as well as health professionals were not currently included in research in partnership with the university. It should be noted, however, that both courses have approved projects in Pro-Health and Pet-Health.

Limits of the process of integration teaching-service: a policy instituted by the school and the service?

During clinical practice, students have learning objectives that involve both content related to the management of the basic unit, as well as the accomplishment of care practices.

In CB, the nursing course has a workbook with the objectives to be achieved, weekly, by the student during the supervised internship, which is given to the coordinator of the unit. This workbook, built in conjunction with health professionals, is periodically and jointly reviewed. However, some professionals, at the beginning of their work at the health unit, report difficulties in understanding the purpose of the internship.

In the course of the professional integration with the unit in which he operates and, given the annual presence of the course in the service, the purpose of the internship is becoming something understandable and valued by the server.

At first, I did not quite understand what they [students] came to do, what the [teaching] institution was proposing. In the first year that was only observed, we did not understand how it worked [...]. (HP2CB)

Integration between the teaching and the service faces limits related to the understanding and/or operationalization of this approach, being considered as an “overworked” when in reality could be assimilated as Permanent Education. Contradictory to the studied reality, art. 27 of Organic Law 8080/90 mentions that the public services that are part of the SUS comprise a field of practice focused on teaching and research, articulating interests of HEI and SUS, jointly.¹⁷

[...] what really happens in nursing is that they [students] end up being an extra manpower, unfortunately, because as we have a shortage of professionals [...]. It’s wrong, but it’s what happens. I believe that the trainee should be sharing knowledge with us, we are working at the same time that they are learning. (HP2CA)

Another unfavorable factor for the teaching-service integration is the absence of university activities in a continuous way, although in CB the same internship fields are maintained year after year and also the professor.

[...] in the probationary period, we have a much greater approximation, but then there are seven, eight months in the year without the internship. So, every time you have to rescue, recombine [...]. (P2CB).

Contrary to the contributions and exchanges provided by the teaching-service integration, it is considered that mistaken actions taken by education can weaken the link between the segments.

[...] I already had a student who made a mistake. So that causes a shudder. I spent time with the students who were prevented from giving vaccine [...]. Until you regain confidence and establish again, it takes some time [...]. (P2CB)

The role of the professor is emphasized in the operationalization of the teaching-service integration, according to the students’ speech, who perceive the need to approach the team, to acquire greater autonomy and to lean less on the professor figure.

I think the insertion period is the worst, breaking that bond of having a professor “holding our hand” all the time. We suffer a little at the beginning. If there was more time in the course without the professor, or with the professor more distance, even if he is in the unit, only with the team, it would be much better. (S1CB)

In CA, the organization of the fields to perform clinical practice activities in health services is performed between the nursing courses of the Municipality and the Municipal Health Office (MHO). In CB, the organization is carried out directly between the school and the coordinator of the basic health unit and, subsequently, the agreement with the local management was signed. It is noteworthy that CB has a partnership of more than 10 years with MHO.

Problems related to the release of health professionals for the participation of Permanent Education actions, emphatically in CA. When asked about the possibilities of carrying out Permanent Education actions (health education process through meaningful learning)⁸ and continued (more restricted purpose of updating, sometimes using traditional methodologies),² is described the bureaucratic difficulty of the institution in performing these actions outside the university.

These bureaucratic difficulties limit the actual implementation of the real objective image of ministerial policies to encourage teaching-service integration.

Empowerment is not understood as a part of the work, which is a pity! (P2CA). I think we are very far from what the Ministry proposes of an integration, of being able to sit together, plan together, evaluate together. (P4CA).

Health professionals who embrace students in the service suffer from a lack of dialogue between health professionals who embrace students and local health management. What transpires is the determination in place of dialogue and flexibility.

The unit coordinator knows that trainees will come, because it’s a determination! You do not have a question like, can they come? Do they [service] have space to give way to them [teaching]? Not! It’s a determination, you have to get intern. Not that we do not like it, we like it [...]. (HP2CA)

Similar difficulties were faced by the CB and overcome with the bond created by the local coordination of the units and the clarity about the importance of the teaching being carried out in the service.

In the past, we had many problems and just did not interrupt the internship because our link with the units is very consistent. Nowadays, it’s very tranquil that we have former students that understand what the goal is, the importance of that. In their training, this makes it easier. (P2CB)

Teaching-service integration, as a policy to be accomplished by the schools and service, is influenced by the dissonance of objectives of both, besides the overload of academy and service, both in the CA and CB, although there is commitment of both so that it to occur.

The objectives of the institutions are not the same. So to be able to reconcile the two things is a task that requires some effort, it does not happen naturally, but it is possible to do, and it has benefits for both sides. (P2CB)

Regarding the limits mentioned by the participants, it is understood that the proposal of teaching-service integration is not a strategy to reduce the overload of professionals who work in the services, at the risk of returning to the traditional technical strategies of teaching in health, and demand elimination. Teaching-service integration should establish horizontal relations of actions (including pedagogical proposal and delineation of curricular changes) and shared results arising from this relation.^18-19

An important pillar of teaching-service integration is the reflection process, which consists of an analysis of personal thoughts and actions, this means concentrating on the interaction with colleagues and the environment, to obtain a clearer picture of actions and behaviors.⁸ Reflection is a process of critical analysis of feelings and knowledge in order to lead to new perspectives on the practice of care or teaching.²⁰

The development of a teaching that aims to turn to a reflective practice needs to integrate the institutional context of health services, as well as the institutional context should focus on integration.⁸ It is reinforced that the sharing of knowledge among professionals involved in health production and teaching in this area consists of collective work, essential for mitigating possible resistance to change. In addition, it is convenient to include as a strategy, the self-assessment, considering not only the student’s training process, but also the activities performed by teaching in the service and vice versa, as expressed in the information of study participants.

However, academic productivism has to be considered. This is a result of the logic of the exploitation and accumulation of capitalism that, in its neoliberal perspective, is marked by the sickness of the workers, as well as by the precariousness of teaching and health care. It is required a work process that limits the time to perform the reflexive practice.¹⁹

Thus, it is observed that the teaching-service integration anchored in the epistemology of reflexive practice is a counter-hegemonic process. It departs from conformity or “consensus” by encompassing all educational practices and health care models, transforming education into praxis that breaks with the mystifying logic of capital. It is to recognize the origin of people’s health problems. It identifies problems that are not always contained in manuals and protocols.⁸

From the conception of pedagogical atelier in health, it is essential that the service, health managers and the community are involved in the research carried out by teaching in the practice setting. This prevents it from becoming not only a research participant, but an active contributor, uniting the research, intervention and evaluation of what is done.

Although the objective of clinical practice is presented in a team meeting, some professionals report the difficulty in visualizing the goals to be achieved by inserting the student into the service. It is noticed the need to continuously present the intentionality of the integration between teaching-service, especially when there is a turnover of health professionals in the units. The activity book used by the CB becomes an interesting strategy of planning the actions, which go beyond a teaching plan, but its implementation of what is desired, to systematize actions. However, this should be accessible to all professionals who work in the pedagogical atelier in health.

The lack of clarity about the activities carried out by teaching is not a peculiarity of this study. In similar cases, professionals recognize the presence of the university in the health unit, however they can not detail the activities performed.²¹ The exception is in the area of the process by the head of the unit, that is, the effective involvement of management.

In the scope of reorientation of training in health, researchers defend the “prism of training for the health area” as a representative figure of the construction and management of education within SUS. The ideology of this geometrical figure implies that each one of its faces establishes specific movements, in a process of interaction between interlocutors, with different points of view and understandings, in a constant flow and that forms a network of connections. This network necessarily involves the dialogue between representations of social control, health care, management and teaching, considering the unfolding of these segments (students, professors, workers, professionals, managers, users, supporters, among others).²²

In this direction, one of the challenges of teaching-service integration is the incorporation of more staff in the planning and evaluation of the objectives of integration, strengthening the role of the SUS as a health educator and giving opportunities to think about daily work and professional practices.²¹

The learning process is permanent and often encouraged by the day-to-day uncertainties of practice. Thus, mistakes cannot be considered as something that weakens the link between teaching and service, but to the awareness that error is part of the process of reflection on practice, being part of meaningful learning. The use of active teaching-learning methodologies provides spaces for the use of innovative and indispensable pedagogical frameworks for the promotion of changes, integrative and democratic practices.²³

Thus, it is not enough for teaching to be part of the service, but it is necessary to plan strategies that enable the student to learn, through action and doing, with a facilitator who can help him to broaden his perspective on reality, from reflection on the actions taken.⁸

There are distortions in the process of materialization of teaching-service integration and its causes are the most diverse, appearing strongly in the speeches the need for local policies between health management, professionals and academia to guarantee spaces such as pedagogical atelier in health. In CB, these problems appear less noticeable in the speeches, which can be understood due to their teaching path for such, it is their teaching trajectory, for more than 40 years and in partnership with the service, which has maintained the same fields of activity for more than 10 years, which may allow closer ties.

The implementation of local policies for teaching-service integration is essential for health education and assistance, as well as creating a link and defining the roles of the protagonists involved in this process, in order to develop clear guidelines to guide students during their clinical practice.²³ Approximation between teaching and health services can contribute to the qualification of professionals, professors and students, and vivifies the production of knowledge based on the needs of the community. To this end, it is fundamental to plan joint actions for quality of life and community assistance in a desire for feedback with an intersectoral partnership.²³

In this context, there is a need to involve the different segments that represent teaching and service in the scope of Pro-Health, based on the dialogue between the different subjects that represent management (university and service), care (professionals), (professors and students) and users, in order to compose solid networks that are involved and constitute lines of care. These central axes of actions integrated to the different levels of health care, aim to guarantee the integrated assistance flows, 24 integrated to the processes of attention, management and education, within the scope of SUS.²

Strengthening the bond between the protagonists needs to be a goal shared by all, as well as making misconceptions committed by teaching or service can be seen as an instrument of the reflection process, not as a punitive action.²⁵

The teaching-service integration analyzed from a reflective practice is provocative, since it requires an active posture, of captivation over the lived, of creating and re-creating actions, facing the state of inertia of some protagonists, in the activities that involve training and health work.

It is in practice, in the doing, that the professor is able to visualize what the student really can understand from the subject, being a strategy for the recovery of the objectives of certain action/theory.⁸

In this context, it is necessary that the professor be the facilitator of the process, being together with the student in the initial phases, but also encouraging so that it begins to integrate and gradually form a link with the multidisciplinary health team. Listening to what each individual or segment involved has to say and reflect on professional practice, initially permeated by values and meanings that are often encouraged/built in the academy itself and sometimes lost along the way. It is a movement of otherness, whose strategies allow for frequent interaction and fertile relationships between teaching and service.²

Final considerations

Participants perceive teaching-service integration as a fundamental process for the training of nurses focused on the need and recognition of reality and the needs of the population. The approach to the team becomes stronger in clinical practice, especially during the development of compulsory curricular internships, at which point the academic is directly supervised by the health professional.

The operationalization of teaching-service integration is dependent on agreements and alterity between teaching and service segments, and the perception and effective involvement of managers is an essential condition for their effectiveness. Thus, there is a need for institutional policies that guarantee integration between teaching and service, constitution of the pedagogical atelier in health, being fundamental for overcoming the difficulties, especially the raised, in view of the bureaucracy in relation to the organization of internships fields. It is suggested that new studies report the experience of adequacy of strategies of teaching integration with the service, according to the PNAB of 2017.

This study was limited to the reality of two courses in the southern region of Brazil. However, the in-depth information evidences the need for teaching and service to periodically reiterate the intentionality of participatory training, seeking to create permanent links that are not limited to the execution of practices, but also to its planning, sharing of the actions carried out and the responsibility to connect with the needs of the population.

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Correspondente Author

Daiana Kloh Khalaf

Email: daianakloh@gmail.com

Address: Av. Prefeito Lothário Meissner, 632 - Jardim Botânico, Curitiba - Paraná

ZIP CODE: 80210-170

Authors Contribuitions

1 – Daiana Kloh Khalaf

Conception and planning of the research Project, obtain, analize and interpret informations. Composition and critical revision.

2 – Kenya Schmidt Reibnit

Conception and planning of the research Project, obtain, analize and interpret informations. Composition and critical revision.

3 – Carine Vendruscolo

Conception and planning of the research Project, obtain, analize and interpret informations. Composition and critical revision.

4 – Margarete Maria de Lima

Composition and critical revision.

5 – Vanessa Bertoglio Comassetto Antunes de Oliveira

Composition and critical revision.

6 – Aline Bussolo Correa

Composition and critical revision.

Como citar este artigo

Khalaf DK, Reibnitz KS, Vendruscolo C, Lima MM, Oliveira VBCA, Correa AB. Teaching-service integration in the perception of its protagonists. Rev. Enferm. UFSM. 2019 [Acess at: 2019 jun 15];vol ex:1-20. DOI:https://doi.org/10.5902/2179769231464

[I] Enfermeira, Doutora em Enfermagem, Professora do Curso de Graduação em Enfermagem da Universidade Federal do Paraná (UFPR), Curitiba, Paraná, Brasil. E-mail: vancomassetto@hotmail.com ORCID: https://orcid.org/0000-0001-9140-2715