FACILITIES AND DIFFICULTIES IN PLANNING TRAINING-SERVICE INTEGRATION: A CASE STUDY

Sandra Marcia Soares Schmidt ¹, Vânia Marli Schubert Backes ¹, Maria do Horto Fontoura Cartana ², Maria de Lourdes Denardin Budó ³, Helena Carolina Noal ¹, Rosângela Marion da Silva ¹

¹ Universidade Federal de Santa Maria, Hospital Universitário de Santa Maria

² Universidade Federal de Santa Catarina, Departamento de Enfermagem

³ Universidade Federal de Santa Maria, Departamento de Enfermagem

ABSTRACT

Objective: identify the facilities and the difficulties in planning the teaching-service integration of the undergraduate courses in Nursing, Medical and Dental in the Primary Care Units of a county of southern Brazil. Method: it is a descriptive case study with qualitative approach. As a technique for data collection were used document analysis, semi-structured interviews and participant observation. The data underwent a thematic analysis and Atlas Ti 5.0 Software. Results: the results were discussed in two thematic categories: facilities in planning teaching-service integration and difficulties in planning Assistance Teaching Integration. It was possible to learn that there is a gap between the preconized in theory and displayed in practice. Planning the learning opportunities developed in the world of work and school is an urgent need for the process of formation of the future health workers.

Keywords: Health services; Higher Education; Teaching Care Integration, Training.

INTRODUCTION

The school world and the world of work strive to come closer so that the valuation of healthcare workers and, simultaneously the participation in the training of professionals capable of developing a humanized, high-quality and problem-solving care in the Public Health System (PHS) may occur. One could say that the courses and health services have been working in an integrated manner but they still have gaps in professional training, often dissociating theory from practice.

The process of teaching and learning must be linked to working universe and consider the needs required to the formation of health professionals, aiming at primary health care in the first place. Thus, it is essential to develop the skills of teamwork, of knowing how to communicate and act on different situations and, mainly, of learning how to learn.

In this sense, the professional experience made it possible to perceive some mismatch between the preconized profile for the future workers and it would take to train them, both in the school world, understood as the Higher Education Institutions, and the world of work, as the institutions that provide health care, in which students develop the practical activities of teaching. This mismatch also occurs due to the historical gap between academic education and the real needs of the practice scenarios.

The perception of this need is not new. Therefore, several efforts were or have been made to bring these two worlds together and thus to strengthen strategies for the construction of PHS. Among these efforts, stands out the arrangement of the development of human resources for the health sector for PHS as the National Health Conferences, the Assistance Teaching Integration Program and Incentive Program for Curricular Changes in Medical Courses¹.

In addition, the approval of Health undergraduate programs², in the period from 2001 to 2004, by the National Health Council of the National Curriculum Guidelines (NCGs), caused a process of implementation of new curricula in undergraduate courses in this area, adding to the Sanitary Reform Movement and the Brazilian educational movements. The NCGs insert innovative concepts in the educational process, such as common expertise among the 14 professions in healthcare, early participation in scenarios of practice, active learning methods, among others.

It is also worth mentioning the approach between the Ministry of Education and Ministry of Health, where one of the major joints resulted in the National Reorientation Program for Vocational Training in Health (Pro-Health), in order to encourage changes in the educational process, generation of knowledge and services to the population for a comprehensive approach of the health-disease process within the perspective of NCGs. Initially were included the courses of Nursing, Medicine and Dentistry, and later the other courses in the area of health.

The distance between the academic world and the actual delivery of health services is being identified as one of the responsible issues for the crisis in the health sector. These worlds are places of knowledge building for the future health professionals, in other words, they are places of learning, action-reflection-action. They are places that provide exchange of knowledge through experiences in which one learns from the other, favoring the construction, deconstruction and reconstruction of knowledge and practices, therefore, with the potential for the formation process. Thus, an urgent need that deserves attention from the school world and working world, as well as its management, is the commitment with this formation process of the future health workers, being necessary a mutual planning of the integration of education-service. For the success of a planning, you need clarity and rigor with which it is prepared and the ability of its management³.

In the intersection between the worlds of school and work, agreements and disagreements between students in the areas of health, teachers, health workers, managers, users, among others happen. These people often do not talk to one another.

However, to train professionals committed to the health of the population, it is necessary to make these "two worlds" dialogue, and take responsibility with training and assistance offered to the population. This is necessary because in these worlds expectations and actions of individuals are different, and the product of their work, too.

We have outlined as the objective of this study to identify the facilities and the difficulties in planning the teaching-service integration of the undergraduate courses in Nursing, Medicine and Dentistry in Primary Health Care Units.

METHOD

The study was conducted in a town in southern Brazil with approximately 264,000 inhabitants. The setting was a Federal Institution of Higher Education established as Special Autarchy and under the Ministry of Education and the Municipal Health Secretariat (SMS) of this municipality, in which there are 39 Primary Health Care Units. Among these, 16 are Health Strategies of the Family (HSF), and the others, basic healthcare units (BHU).

The method used was a descriptive case study with qualitative approach. This type of qualitative research aims at studying a social unit that analyzes in depth a real context in which the researcher has no control over the variables and seeks to grasp the reality in its totality.

Data collection was conducted from January to September 2007. As a technique for data collection were used participant observation, semi-structured interviews and documentary analysis. First, the analysis of documents was performed based on the Pedagogical Projects of the Courses (PPCs) in study and the Municipal Health Plan of the City.

The individuals for the participant observation were the students of Nursing, Medicine and Dentistry who were carrying out practical activities in primary care in a Health Unit or the ESF during the data collection. The chosen students were the ones who were enrolled in 3rd semester of Nursing, the 5th semester of Medicine and the 2nd semester of Dentistry for being the earliest semesters after the implantation of the DCNs in the higher level institution chosen for this study. The students selected were seven students of the 3rd semester of Nursing, eight students of the 5th semester of Medicine and fourteen students of the 2nd semester of Dentistry, who developed the practical activities during the period of data collection. The criteria for inclusion of students were: be participating in practical activities in primary care, and sign the Instrument of Informed Consent (IC). The exclusion criteria were: not being regularly enrolled in the course, and not take up the case.

The observation was made with students in practical scenarios, being guided by an instrument that allowed recording what was being observed, the description of activities, impressions and participation of the researcher. It is noteworthy that the observation was carried out in a Basic Health Unit with the medicine students; in an ESF with the Nursing students and in a school with the students of Dentistry, for they are the locals for development of the practices.

The individuals of the interviews were the coordinator of the Nucleus of SMS permanent Education and three coordinators, one for each course. The criterion of inclusion of these coordinators was to sign the Instrument of Informed Consent (IC). The exclusion criterion was not accepting to participate in the study.

We made the semi-structured interviews in accordance with prior appointment and signature of the IC. We chose to study Nursing, Medicine and Dentistry courses for being the ones in the area of health that are part of team working in Primary Health Care Units.

In a case study, data reliability can be ensured by the use of multiple sources of evidence and the significance of the findings and will have more quality if different techniques are used. Thus, the process of triangulation of data sources assured of the search of the results. One could say that triangulation of data is the convergence of results coming from different sources⁴.

Data was analyzed using content analysis and we used the thematic analysis technique⁵. After the organization of data into categories, we used the software Atlas Ti 5.0 (Qualitative Research and Solutions) to assist in data coding. This software is a program used as a tool for qualitative analysis of textual data, graphics, audio and video. It is able to manage knowledge by transforming loose data into useful, relevant and flexible information in a systematic way. It allows the introduction of qualitative data already entered and organized by the researcher. Thus, this software allows the organization and processing of data using codes that were used in the categories. It is important to mention that in a case study, there is not a specific way to analyze the results, and most of the data analysis is performed concomitantly with the collection work.

We emphasize that ethical principles have been kept to ensure the rights of people to participate in research involving human beings and we also point out that the study has taken into account the principles proposed by Resolution 196/96 of the National Health Council⁶. To ensure the anonymity of the interviews, we used the letter S (Subject) followed by an Arabic numeral.

The research was approved by the Ethics Committee in Research of the Federal Higher Education Institution of the municipality under number of the Certificate of Presentation for Ethical Appreciation (CPEA) 0042.0.243.000-07 and number of the process 23081.002790/2007-95.

RESULTS

Records referring to the data collected were hired from observations, interviews and documents. For the process of analysis and formation of the categories several readings of the collected data were needed, from which emerged the following categories: a) facility in the planning of teaching-service integration, and b) Difficulties in planning the teaching-service integration.

Presented below are the categories:

a) Facility in the planning of teaching-service integration

About the facilities in the planning of the teaching-service integration, we highlight the willingness of professional achievements, pronounced by the coordinator of the Municipal Health Secretary:

[...] the easy part is that I have always come across people who are open, available and willing to do the the right thing and not complain of what is being asked. We know that network professionals sometimes receive students with no project but often in partnership, in need, "I do not need them here, I'll receive," but I think it is an educational problem that over time we will achieve [...] (S4)

Another facility in the planning of this integration is to visualize the satisfaction of professionals and students, referred by one of the course coordinators:

[...]I have visited five or six positions that exist here. Students are happy, serving the professionals, happy with them. [...] With all the difficulties we have carried on. (S2)

The working world offers multiple learning opportunities and alternatives for future health care workers, but it is also a complex space, with lots of information and many professionals with many different interests and attitudes in health care and with several problems to be faced daily, both in the resolution of material and human resources, among others. However, for taking advantage of opportunities and the achievement of the learning process, there must be an organization of joint actions between these worlds.

b) Difficulties in the planning of teaching-service integration

Initially, contact was made with the coordinator of the Municipal Health Secretariat, responsible for the affairs of the teaching/service of higher education institutions with the Health Care Units, to understand how this planning is done. The fragment of speech below elucidates the fact:

[...] we have created standards for granting training field [...] the educational institutions would have make possible [...] one of these items of the norms would be the sending of the project 30 days in advance so that I could send the memo to the unit and the unit would answer me, I would respond to the educational institution serving the need of both. I do the mediation of this process [...]. (S4)

Nevertheless, the coordinator of the Municipal Health Secretariat is optimistic about the situation:

[...] I think that in time things will flow in a very satisfying way [...] projects do not come on time, but they come. There are some which have not yet arrived and that I know are on the network. But it's okay, I believe that one day they will arrive [...] the idea is that the project is not for one or another unit, that the project is for the practical activities developed by the course in all the units they want [...]. (S4)

The report highlights the impaired communication between the City Department of Health and Higher Education Institution about the forwarding of the standards. In addition to this, some difficulties were also identified as the profile of professionals in the working and school world and the need for continuation of activities during vacation.

Regarding the profile of professionals of the working and school world, the fragment says.

[...] how can we will, for example, want the student to follow the model of practice, if it is not the one we're really looking forward through curricular directives? I wonder if that professional who is at the basic unit, is really a professional who is following these guidelines we're talking about, serving the individual, seeking integrality? [...] We are a model, either positive or negative in the sense of what we pass to the student. We are training a professional, whether he has the skills and competencies. You have to conquer your own space, so all you have to do is a job and plan this job [...]. (S1)

[...] There are teachers, professionals who work in the educational area and are graduated and have a biomedical, assistentialist, rehabilitator, and well fragmented thought. There are professionals who are in the network who have this same vision, but there are professionals who are both in the network and in educational institutions and have a much more open and more generalist view, far more in relation to the promotion and prevention of health [...] and I think that teaching and service in a way, get intertwined, especially in this kind of vision [...]. (S4)

[...] One of the most complicated things we face at the course, is the fact of teachers going to teach in the basic network [...]. (S3)

Another difficulty pointed out concerns the need for continuation of activities during vacation:

[...] Institutions were very careful in raising a demand and in the months of vacation or in the months in which those disciplines were not practiced, that demand belonged to the unit, which cannot always keep these periods. This fact generates a negative impact. For that reason some professionals are often afraid of receiving students [...]. (S4)

The interruption of the activities during vacations allows the breaking of the bond of the service to the community, factor emphasized by another coordinator:

[...] We do have difficulties [...] but in order to be there in the community, we must have a bond with them, an approach [...]. (S1)

Faced with the reported difficulties, it is necessary to highlight the activities described in the National Curriculum Guidelines which are common to Nursing, Medicine and Dentistry courses such as: ensure the integrality of care; know how to work in a multidisciplinary and interdisciplinary team; develop individual and collective care; and work at all levels of health care, integrating programs of promotion, maintenance, prevention, protection and restoration of health. Professionals need to be responsible with users and future professionals.

DISCUSSION

Working with people willing to do things right and view the satisfaction of professionals and students have been identified as facilities in the planning of teaching-service integration. The Health Care Services are fields for the teaching and research, so they are places for teaching-learning that express the indissolubility of the roles of management and training within SUS⁷.

Considering the characteristics of the school world and working world it is necessary the interaction with several people from Higher Education Institutions and the Municipal Health Department (teachers, course coordinators and students, managers of the Municipal Health Department, coordinators of practical activities and health workers) with distinct knowledge and power.

For the organization of activities in the working and school world, it takes teamwork, participation in training, permanent education for professionals, and the cooperation of other professionals in scientific production. Some authors deem necessary a policy of permanent education in the process of health work in the perspective of reflection and updating of practical activities⁸. Thus, it is clear that the relationship between teaching and service is still being built in the collective and negotiating spaces. It is important to emphasize the articulation and integration between the sectors of health and education by people who are currently performing some role or being represented.

As for the difficulties, we highlight the profile of professionals in the working and school world, the need for continuity of activities during vacation time and impaired communication as in cases of non-compliance with the submission of projects of activities by undergraduate courses in a timely manner, difficulty faced even before the integration of students in a practical field, a fact also observed in contact with students of the three undergraduate courses.

It is observed that the planning of teaching-service integration between the working world and school world needs to be revised within each course. So that there is a shared planning between these "worlds", we believe it is essential the mobilization of people with defined goals and responsibilities, with interaction and dialogue and the creation of collective spaces in which we may assess and reevaluate the development of the proposals planned .

It is still very common the training of future health professionals based on the use of traditional methodologies such as the separate study of body and mind, knowledge in specialized fields in search of technical efficiency. This fragmentation of knowledge is also evident in the subdivisions of university centers and departments, and courses, in watertight disciplines, which has implications in the teaching-learning process. Often, there is the reproduction of knowledge, in which the teacher assumes the role of content transmitter, and the students, of their retainer and repeater, that is, taking a passive attitude⁹.

Constructing some work in health cannot be based only on what the curricular guidelines say regarding health courses, or in the formulation of scholars' or institutional leaders proposals. We should also listen to the dissatisfactions, reflections and dreams of students, teachers, health workers and social control, those who experience on the day by day the difficulties and overcoming initiatives.¹⁰ Increasingly we need to build strategies for approach and institutionalization of the world of work with the world of school with the same goals.

In one of the observations with the students a certain detachment and differences became evident between theory and practice. They noted, besides the expectation of the name of the discipline which was not corresponded, that there is emphasis by teachers about the importance of teamwork and that it is not seen in practice. These situations, which mobilize students to reflect on the theoretical and the real, need to be rescued by teachers who have also the duty of following the practical activities.

While the world of school aims at teaching what is right, the world of work needs to answer questions according to the demand of care in a real context. However the existing health policies form somecomplex triangle of difficult convergences. Therefore, the planning and communication between the two worlds need to be built of many encounters and spaces in which there can be dialogue between people.

This construction, in the school world, has as a starting point the changing process in professional graduation with the approval of the Law of Directives and Bases of Higher Education in 1996, and the preparation of NCGs in 2001, which redirect a degree in all professions. It is reinforced the need of existing some plan between the world of school and work for the training process in SUS, strengthening its implementation. Thus, the analysis of PPPs enabled us to realize that these have been reformulated, following the resolutions of the National Education Council (NEC) and the National Health Council (NHC).

The curricula in higher education institutions must be respected, ensuring flexibility and providing quality in teaching, according to the Resolutions of the National Health Council for Nursing, Medicine and Dentistry.² These resolutions include the guidelines to be observed in the curricula of each course and describe the skills and general and specific competences for these courses, which look much alike, since they have been prepared for the needs of SUS.

In this context, the active methodology, in which the student is the protagonist, co-responsible for his career and which encourages active participation, is essential; the teacher is a facilitator of experiences of "aprendência", assuming a supporting role, offering meaningful opportunities to consent and enhance student's ability to reconvene in reality.¹¹ The active methodologies provide the development of interaction of teachers and students, placing the future of the healthcare professional as a subject of learning, supported by the teacher as facilitator and mediator of this process, regardless of the methodology used or the path taken to the process of teaching and learning.

The development of integration of the world of school and community takes place from the need to create a demand for service, which enables practical activities for students and facilitates the learning process. However, reflecting on how to continue activities on vacation is important both to meet the needs of the community, and to strengthen the commitment of the world of school and the community, minimizing possible discomforts.

What is important in a planning is its application and not the kind of planning that is going to be used, whereas for the success of a plan is needed the perceptibility and accuracy with which it is developed and the capacity of its management. In this sense, we must reframe the word planning, understanding its importance and necessity for the realization of a proposal.

Scholars^10,12 have complementary perspectives concerning the role of planning for the institutions. They point out that planning should no longer be seen as a bureaucratic function, formalist and authoritarian, it must be taken as a means of work rescuing, overcoming alienation, to reincorporate the existence; planning has a dialogical role that contributes to the communicative action in groups.

Planning is part of the work process and has the potential of transforming human relations when conducted through dialogue. Another important aspect to be considered when assembling a planning is the commitment of those involved with the success of the plan, not leaving the implementation under the sole responsibility of those who proposed or coordinated. Joint planning learning-service is not new; it is a proposal that began in the National Health Conference, which strengthens the importance of joint planning between the world of work and the world of school for the identification of learning opportunities in these worlds and their use by all those involved.

One can imagine the planning between teaching-service using the Wheel Method or the Paideia Method.¹³ This method incorporates the concept of Paideia Method support as a methodology that seeks to reformulate the traditional management mechanisms, a complementary manner to the implementation of a planning, coordination, supervision and evaluation of a job.

This support involves knowing that management is the product of interaction among people and management functions are exercised among subjects with different degrees of knowledge and power. The process of listening analysis, interpretation and operational intervention can be addressed from different collective areas or with different methodological resources.¹⁴ A major challenge of the Paideia Method is to think of collective management not only as a democratic space in institutions, but also as a space that is educational, therapeutical, of critical reflection, of subjectivity production and construction of the subjects.

Thus, the observation made with students from the course of Dentistry revealed that the goals of a discipline according to NCDS disagreed with opportunities to students. In this sense, Paideia Support outlines a series of resources to deal with these relationships among subjects, valuing the potential of those involved, the interest of each one and democratic ways to coordinate and plan the work, namely the creation of a collective space so that the joint management may happen^13,15. The most Important is that "the constitution of subjects, of social and institution needs, is the product of power relations, the use of knowledge and methods of circulation of affection"^13:90.

CONCLUSION

The study has enabled us identify as facilities in the planning of teaching-service integration in undergraduate courses in Nursing, Medicine and Dentistry, work with people willing to do what is right and view the satisfaction of professionals and students; We may quote as difficulties the impaired communication, the profile of professionals in the school and work world and the need for continuation of activities during holidays.

To solve these difficulties, it is important the communication between the world of work and school, in which you can talk about the opportunities offered by the world of work and contributions to the world of school can provide for the development of activities, for that it takes a joint planning of the activities offered and the activities to be developed.

In contact with students, it was possible to identify that all three courses develop their activities in different locations, with commitment, responsibility and participation of teachers. However, there is a mismatch between the preconized on the theory and displayed in practice, that is, there is no collective space of co-management between the world of school and work, so that together we can plan these activities, where there a collaboration between these worlds, which would be desirable.

The results of this study represent slices of focused problematics, without the intention of treating it in its entirety. There is a need for further studies on the formation process of courses in the area of health in Higher Education Institutions of the South.

To be changes, it is necessary, firstly, that the world of school starts encouraging the ability of reflection and critical thinking of students; second, that the world of work provides for future health workers opportunities to develop these capacities. In addition, people in these worlds need to interact and contribute to the growth of both.

Therefore, it is in the process of training that we need, besides the knowledge of the specifics laid down in the curriculum, provide the discussions held in the Sanitary Reform movement, which today is being contemplated in the Covenant on defense of SUS as a base to fight for the Right to Health, assured in the text of the Constitution.

REFERENCES

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12 TESTA, M. Pensar en salud. 3. ed. Buenos Aires: Lugar Editorial, 2004.

13 CAMPOS, G. W S. Saúde paidéia. São Paulo: Hucitec, 2003.

14 CAMPOS, G. W. S. Um método para análise e co-gestão de coletivos. São Paulo: Hucitec, 2000.

15 CAMPOS, G. W. S. O trabalho em saúde e a perspectiva Paidéia. Unidade de Produção. Departamentos dos serviços de saúde organizados segundo lógica interdisciplinar e modo de produção da atenção. 2007 [cited 2007 Dez 2]. Disponível em: <www.ensp.fiocruz.br/biblioteca/dados/txt_145834601.ppt>. Acesso em: 21 maio 2010.

Contribution of the authors: Bibliographic Research: Schmidt, Backes. Data Collection: Schmidt. Conception and design: Schmidt, Backes, Cartana, Budó, Noal, Silva. Analysis and interpretation: Schmidt, Backes, Cartana, Budó, Noal, Silva. Critical Review of the article: Schmidt, Backes, Cartana, Budó, Noal, Silva; Final approval of the article: Schmidt,  Noal, Silva.