ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

Reliving the debate concerning nursing education: from where we departed and to where we are going

Reviviendo el debate de la formación en Enfermería: de dónde partimos y a dónde vamos

Revisitando o debate da formação em Enfermagem: de onde partimos e para onde vamos

Jouhanna do Carmo Menegaz¹; Daiana Kloh²; Hilário Mattioli Neto³; Jussara Gue Martini⁴; Flávia Regina de Souza Ramos⁵; Vânia Marlil Schubert Backes⁶

¹ RN, Master student Universidade Federal de Santa Catarina UFSC, Brazil. email: jouhannamenegaz@hotmail.com.

²RN, Master student UFSC, Brazil. email: daianakloh@gmail.com.

³RN, Master student UFSC, Brazil. email: hhyl@ig.com.br.

⁴RN, PHD. Professor UFSC, Brazil. email: jussarague@gmail.com.

⁵RN, PHD. Professor UFSC, Brazil. email: flaviar@ccs.ufsc.br.

⁶RN, PHD. Professor UFSC, Brazil. email: oivania@nfr.ufsc.br.

Receipt date: Jun 26, 2012. Approval date: May 8, 2013.

Article linked to research: Mudanças na formação do enfermeiro: necessidade de reflexão sobre onde estamos e para onde vamos.

Subventions: none.

Conflicts of interest: none.

How to cite this article: Menegaz JC, Kloh D, Neto HM, Martini JG, Ramos FRS, Backes VMS. Reliving the debate concerning nursing education: from where we departed and to where we are going. Invest Educ Enferm. 2013;31(3): 395-405.

ABSTRACT

Objective. To identify the perception of both students and professors from a graduate nursing program in the South of Brazil concerning the historical process of nursing education in the country. Methodology. Qualitative, exploratory-descriptive study. Data were collected from professors using semi-structured interviews and focus groups with 12 students, analyzed using Minayo's operational proposal. The following categories emerged: 'from where we departed'; 'transition process'; and 'to where we are going'. Results. The participants showed knowledge concerning the process that permeates the education of Brazilian nurses from the establishment of the first school and determination of national curricular guidelines, highlighting challenges and future prospects. Conclusion. There is advancement toward the reorientation of educating more critical, creative nurses aligned with the demands of the Brazilian Unified Health System.

Key words: education, nursing; unified health system; human resources formation.

RESUMEN

Objetivo.Conocer la percepción de los alumnos y de los profesores de un programa de posgrado en enfermería del sur de Brasil acerca del proceso histórico de formación en enfermería en el mismo país. Metodología. Investigación cualitativa, exploratoria-descriptiva que utilizó como técnicas de recolección de los datos la entrevista semiestruturada con 4 profesores y grupos focales con 12 alumnos que fueron analizados por la propuesta operativa de Minayo. De este proceso emergieron las categorías de 'dónde partimos', el proceso de transición y el 'a dónde vamos'. Resultados. Los participantes mostraron el reconocimiento de los procesos que permean la formación del enfermero brasileño desde la creación de la primera escuela hasta la determinación de las directrices curriculares nacionales, destacándose los desafíos y futuras perspectivas. Conclusión. Se avanza hacia la reorientación de la formación en enfermeros más críticos, creativos y conectados con las demandas del Sistema Único de Salud.

Palabras clave: educación en enfermería; sistema único de salud; formación de recursos humanos

RESUMO

Objetivo. Conhecer a percepção dos alunos e dos professores de um programa de pós-graduação em enfermaria do sul do Brasil a respeito do processo histórico de formação em enfermagem no mesmo país. Metodologia. Investigação qualitativa, exploratória-descritiva que utilizou como técnicas de recolha dos dados a entrevista semiestruturada com 4 professores e grupos focais com 12 alunos que foram analisados pela proposta operativa de Minayo. Deste processo emergiram as categorias de 'onde partimos', o processo de transição e o 'a onde vamos'. Resultados. Os participantes mostraram o reconhecimento dos processos que permeiam a formação do enfermeiro brasileiro desde a criação da primeira escola até a determinação das diretrizes curriculares nacionais, destacando-se os desafios e futuras perspectivas. Conclusão. Está-se avançando para a reorientação da formação em enfermeiros mais críticos, criativos e conectados às demandas do Sistema Único de Saúde(SUS).

Palavras chaves: educação em enfermagem; sistema único de saúde; formação de recursos humanos.

INTRODUCTION

Society, given its dynamic nature, constantly needs to transform and adapt to the configuration of the State, public policies and the job market. When such configuration indicates elements that make it essential to abandon one condition and achieve another that is desired, there is often a need to discuss the role of education in each context. The Unified Health System (SUS) was established in Brazil, through Law No. 8080 in 1990, due to the construction and mobilization of diverse stakeholders engaged in the Sanitary Reform movement, considerably changing the ways health is understood, managed and promoted. This new social and political social configuration impacted the organization of labor and, consequently, the education of health professionals. Nonetheless, as the reconfiguration and adaptation of the services to a new model of management and care organization was a priority, affirmative actions concerning the reorientation of education for the new configuration were postponed.

A movement for change only began to unfold with the National Education Bases and Guidelines Law in 1996, which proposes a new model for undergraduate education in Brazil requiring programs to establish national guidelines. It impelled and finally acknowledged a need already perceived in the education of health professionals. This directive was allied with the responsibility to organize education within the health sector and led the Ministry of Health and Ministry of Education to create broader committees involving different professions to discuss the guidelines for each profession. Such guidelines began to be individually published in 2001 and were the initial thrust of a series of actions and programs, among which were the Program to Encourage Changes in Medical Schools (PROMED), Aprender-SUS, the Health Education Reorientation Program (PRO-SAUDE), and the Education for Health Work Program (PET-SAUDE), among other possible local and regional initiatives, many of which are currently being developed.

Even though the Brazilian State formally took the initiative only from 1997-98 on, some professions had already envisioned the need to discuss the education of health professionals within the movement triggered by the SUS and the accumulated insight gained from having already advanced discussions internally among their peers. This was the case of the Nursing field, which could then intervene as a protagonist in the process. The National Curricular Guidelines for Nursing Undergraduate Programs were published by the National Council of Education and by the Board of Higher Education on November 3, 2001 proposing to graduate generalist nurses, substantially changing the previous educational curricula and tuning professional education in accord with the SUS, heeding a historical claim of social movements concerning education being organized by the State, through the Ministry of Health.

In a period just over ten years after the National Curricular Guidelines were approved, nursing researchers updated their focus and objects of study and began to contemplate the challenges faced by schools, professors and the professional organization itself, as well as their impacts and ongoing movements, or began to critically analyze this new political and institutional context^{1- 7}, including new true discourses and ways of being professional.⁸ One would expect that priority would be given to primary health care (PHC) and nursing education in their mutual relationships^9-11, but also to focus on traditional themes, such as ethical education, which were re-appropriated into the new nursing context and into the context of other health professions.¹² In summary, the growing investment of nursing in the investigation of education could be already perceived by the expansion of research groups with this privileged mission, mainly associated with graduate nursing programs,^13,14 though new and common concerns have broadened interest and new studies and research lines with different focuses emerged.

The National Curricular Guidelines for Nursing Undergraduate Programs represents advancement in relation to different elements of change, among which are replacing job-oriented education with society-oriented education. On the other hand, given the heterogeneous configuration of Brazilian higher education and the daily need to overcome large and historically knotty issues, it is an immense challenge to overcome the conception of health as being the absence of disease, replacing polarizations such as individual/collective and biological/social by interpenetration and transversality, replacing professor-centered teaching practices with student-centered learning practices, and overcoming the fragmented disciplinary model to build integrated curricula and link theory and practice, among other challenges.¹⁵

Another interesting element, which makes the scenario even more complex, is the reinforcement and breadth of university autonomy based on the National Education Bases and Guidelines law from 1996. It allows the adoption of the national curricular guidelines for nursing undergraduate programs by the various higher education institutions to vary in terms of understating demands and alternatives or even the extent of changes, creating a very diversified scenario. Since the current status is a reflex of the past and understanding the current status helps build the future, this study's objective was to identify the perception of nursing students and professors of a graduate nursing program in the South of Brazil concerning the historical process of nursing education. Considering that these individuals are important actors in the process of change that currently takes place in Brazilian Nursing education, the totality of their perceptions is one of the elements that can reveal the complexity of the subject, aid in envisioning challenges and ability to reflect upon their own experiences. These may or may not be similar in other contexts, but do motivate future studies in broadened contexts.

METHODOLOGY

This is a qualitative study with an exploratory-descriptive approach. The study's participants were four professors from the nursing department and graduate program and 12 master's students from a university in the south of Brazil. The participants were intentionally selected and both professors and students were named after flowers in order to maintain confidentiality. The inclusion criteria for the faculty participants were: acknowledged empirical and scientific experience in the field of education, being a member of a research group studying the subject, and/or having considerable involvement in the process of replacing the university's minimum curriculum to national curricular guidelines. The inclusion criterion for the students was: being enrolled in a course related to the theme administered for the master's program by the nursing graduate program during the data collection period at the university under study.

Data were collected at two different points in time using different techniques. First, semi-structured interviews were held with the professors and recorded with a digital camera, then a focus group was organized and a questionnaire was applied to the students. The discussion in the focus group was conducted with the aid of videos addressing the trajectory of professional education in the nursing field and the questionnaire was used at the end of the group discussion so that important reflections were not omitted. Data resulting from the interviews, questionnaires and focal groups were transcribed and analyzed using the operational analysis proposed by Minayo¹⁶, which consists of uncovering the core of meanings that compose communication, and the presence or frequency of meanings as the object of study. From this process emerged three broad categories: where we started; process of transition; and where we are going.

The investigation followed the ethical principles determined in Resolution No. 196/96, National Council of Health and was approved by the Institutional Review Board (Process No. 2037/2011).

RESULTS

The professors and students graduated in different states and from schools with different proposals, which greatly enriched the discussion. Even though these peculiarities could lead to substantial differences, we perceived an acknowledgement and agreement in terms of the identification of the milestones in the progress of this debate and changes in nursing education in Brazil. The categories that follow present a rationale grounded on a historical acknowledgment of the conditions and transformations taking place in Brazilian nursing education.

Where we started

This category shows that the participants recognize the beginning of the professional education of nurses in Brazil and identify some of its historical landmarks. Hence, there is an acknowledgement concerning the establishment of the first school in the country and the context that demanded it, as well as the first school run by nurses and its teaching method: ... mainly determined by a political and economic context concerning the sanitation of port facilities; that is the first school we recognize as the first nursing school, Alfredo Pinto, at the State University of Rio de Janeiro. Teaching was still done by physicians. At the beginning of the 20^th century the first school exclusively run by nurses was established, with a strong hierarchical, disciplinary connotation along the lines of Florence (Gerbera).

There is, in this process of acknowledging nursing education prior to the curricular guidelines, a reinforcement of the perception of a hierarchical relationship on the part of the professor with the student. The minimum curriculum and its implications for education were also acknowledged in the reports of professors and students: The professor as protagonist (...) student being submissive, receiving information (...) teaching was based on the need to evaluate knowledge. Therefore, all the nursing education processes follow this pattern up to about the mid-80s when a re-discussion concerning the health model process in Brazil was initiated. Up to the establishment of the national curricular guidelines for nursing graduate programs and this discussion concerning the implementation of a new curriculum in Brazil, education was based on what is called minimum curriculum, which determined a minimum number of hours, the courses offered, because it was a totally disciplinary curriculum (...) totally static (Gerbera)

Process of Transition

This category shows the understanding of professors and students concerning important elements and facts related to the historical process when debates concerning, and with a sense of change in, professor-centered nursing education with a strong disciplinary base, as previously mentioned, started to take place. The first landmark is related to the beginning of broad discussions concerning education in the health field that was strongly encouraged during the military dictatorship, during the movement of the sanitary reform, showing that the debate concerning education in general as well as within the profession has started long ago: (...) the military dictatorship, the movement for direct elections, the movement for health at the 8^th conference, already linked to the definitions of the Alma Ata conference in 1976, is a whole process that is important to acknowledge so we don't get the impression that suddenly someone decided to change everything. It's not that, it's a development, an unfolding of events, of changes in the political, economic, socio-cultural spheres (Lily). Another important landmark noted by the participants in relation to redirecting nursing education refers to the national education bases and guidelines law: with the new law, there was no minimum curriculum anymore; there were only guidelines telling which direction to go, but each does his own (Gerbera).

Other important events that took place later were mentioned in the this transition process as important elements that would support the coming transformations, as the cooperation established by the ministries of health and education and the establishment of a national system to assess higher education: (...) set up a joint decree between the Ministry of Health and the Ministry of Education to establish cooperation, when all the projects that now encourage education along the lines of the SUS emerged (Sunflower). In '98, '99 the discussion concerning the higher education national assessment system, SINAES, starts, concomitantly with the national teaching assessment (Lily).

As relevant actions indicated by the participants, we highlight the creation of the Secretariat of Health Work and Education Management and all the programs and actions it coordinated, among them PRO-SAUDE in 2005 and PET-SAUDE in 2009. In summary, the participants show an understanding that links different elements in the context of Brazilian public policies to the process of the organization of the debate concerning nursing education, showing they understand it within a broader context and emphasizing the idea of transition as an expression of changes that have been designed, negotiated, gradually conquered and are in continuing redesign.

In regard to their understanding of the role played by the guidelines, there are perceptions there is a shift of focus and dynamics, showing a view that the national curricular guidelines are close to what is desired for health practices from the perspective of the SUS: (...) approximates education to the country's health needs, to the SUS health needs, a concern that professionals had to have this principle, that health is a right, health has to be accessible to all, a duty of the State (Sunflower).

Despite this context of a positive perception of the role the national curricular guidelines have to play, some barriers were observed in the consolidation process. Among these, some testimonies make reference to the heterogeneity of Brazilian higher education with a strong presence of private education and weak control from the State, which generates a series of repercussions and distortions in the incorporation of guidelines, especially the relationship between teaching and quality. (...) we have many nursing undergraduate programs in Brazil; there are about 2,000 programs. If we consider whether there are excellent programs, there are very serious institutions concerned with quality of education; but there are also institutions and programs where nursing is just another program without much visibility or priority (Rose).

There is, however, a perception among the participants that this difficulty in incorporating guidelines to a greater or lesser extent, even if more evident in private schools, is not restricted to them but is also true in other institutions. This issue of the SUS within schools is something that not everyone has understood; I don't think that is something the schools have already bought, I guess that private schools have a deficiency (Wildflower). Regardless of the nature of the institution, there is an understanding that, in general, there are differences in investments in and understanding of the guidelines and the movement of professional reorientation on the part of schools and discrepancies that possibly hinder its consolidation. One of these discrepancies refers to a view that the reorientation of education and the SUS passes through a teaching process mainly focused on PHC: It is important that we think from the perspective of education for the SUS as the country's unified health system and that it is not only PHC. It is composed of all the levels of care (Lily).

Another difficulty mentioned is related to the fact that the faculty does not know the program's political pedagogical project and often ignore the essence of the proposal to reorient education in the health field as expressed in the national curricular guidelines: You meet with the professors and they don't know the program has a project, let alone what the project is about (Lily). In this process, there are also difficulties from both the professors and students in dealing with these new proposals that encourage students' autonomy and creativity, which reinforces the need for a space to qualify professors and enable discussions between students and professors to understand and engage in the process of educational change: I try to pay close attention and work with this way of bringing to the student, discussing with the student (Orchid); we wanted to have classes but didn't want the professor to go there, give us a text and discuss it, we'd say: this professor must know nothing; he wants us to read because he has no idea about its content, so it was very difficult for us (Daisy).

In addition to these points, though still related to the schools, the need for institutional support to implement changes was highlighted and exemplifies the need to establish a greater workload and the continuous education of the faculty to consolidate such changes: it requires structure from the school I believe, because the professor works with a workload, which has to be taken into account; it cannot be something I do for love or because I think is nice (Carnation); (...) since education fundamentally depends on professors, there is no way to change education without changing the professors' mindset, so this pedagogical education of professors has also been a challenge (Gerbera).

Where we are going

This category reveals a positive perception of the study's participants in relation to the national curricular guidelines. After highlighting persistent challenges, optimistic testimonies were presented, which can demonstrate the advancements already achieved with this new proposal of nursing education, both in relation to the understanding of education according to the SUS and to the professional profile of nurses: we'd see an abyss between us and the SUS (...) we didn't feel like we were part of the system (...) it was very distant from us, from our experience as undergraduate students, as professionals, and now we start to feel like an integral part of it and also responsible for this system. (Narcissus)

When the participants express their idea of the future, they point out elements that refer to the profile and role of nurses in the collective context of health, indicating areas of practice, complex and joint competencies, in addition to values and principles that should regulate or guide such practice: prepared and focused to work at all levels of healthcare. They will be more active in classroom, and will be part of their own construction of knowledge (Daisy).The participants' reports express a desire that the guidelines and reorientation of nursing education be consolidated, including overcoming the elements they reported as being obstacles in this transition process: to train a professional capable of working with average, high and low complexity; capable of understanding the integration among these different levels of healthcare delivered in the network, integrality, universal access, that is, all the guidelines, the system's principles (Lily); a critical professional, who, during the undergraduate program, reflects upon education, working conditions, learns the importance of working within a multidisciplinary team (Celosia). Nonetheless, for this to happen, the participants indicate more time is needed, as well as a collective disposition and commitment: 20, 30 years is too little for us to change a way of education that has been like this for years. More traditional, imposing education, so I guess it's a long way, but I believe that we are all willing to change this scenario (Narcissus).

DISCUSSION

It is relevant, when considering the starting point of institutional nursing education in Brazilian schools, to take into account the understanding of the faculty and students concerning its landmarks. It is believed that awareness of the circumstances that were present at the time of creating the first schools and the establishment of teaching models is important to assessing our strengths and weaknesses, and is one of the cornerstones for reflection based on the problematization of reality. In this sense, an important point to note, in addition to those expressed by the participants, is related to the fact that the emergence of the first school is concomitant with the creation of the first health departments and public health agencies in the Brazilian State, a result of an incipient recognition of State responsibility in providing health to the population, even though this perceived responsibility was limited to a perspective of sanitation and to the objectives of industrial development.¹⁷

It is interesting to note that, even though the first nursing school run by nurses was created in 1923, nursing teaching came to be regulated in Brazil only in 1949 through Law No. 775, due to an organization of nursing professionals intermediated by the Brazilian Association of Graduate Nurses, which in 1954 became the Brazilian Association of Nursing (ABEn) as we know today.¹ In practice, this regulation reinforces the rationale of job-oriented education, which considering the context of the healthcare at the time, was based on a biomedical, hospital-centered rationale to serve the health care model offered by the Institutes of Retirement and Pensions (IAP's). Also, due to a greater demand for nursing professionals, this Law also required every university center or medical school to offer a nursing program.¹⁸ One study¹⁹ highlights the fact that the proposition contained in this law was mainly based on the American Curriculum Guide, since in general, the American nursing teaching model greatly influenced not only Brazilian higher education but also nursing education.

Since then, nursing teaching has changed to follow the changes in the Brazilian educational legislation, but remains tied to the biomedical model. According to the national education bases and guidelines law from 1961, a minimum curriculum for undergraduate programs was incorporated by nursing education in 1962 through process No. 271/62, the Federal Council of Education. The curriculum into effect since then proposed, among other aspects, that the program take place in the time span of three school years, that there will be no nursing courses in Public Health, or Human and Social sciences, and that nursing education would emphasize the biological sciences, disease, and healing measures. The ABEn, aware this requirement was not sufficient, did not meet the interests of the profession and did not play its role in the context of health services, wrote an official letter (No. 115 on October 27^th 1962) to the federal council of education requesting it to halt the process, but was not successful.¹⁷

Nursing professionals at this point in history started to perceive that teaching based on this model was no longer able to meet the country's health needs, an element that together with sanitary reform, led the State to organize education in the health field. Such education would occur in a broader dimension, based on principles that currently underpin the SUS, such as universality and integrality, for instance.²⁰ This discussion on nursing education has been a constant in the profession and schools; however, the desired changes were not politically feasible. The concrete reorientation of nursing education has gained force within Brazil and in the international scenario as seen in Lily's testimony.

The SUS has greatly strengthened this movement and the national education bases and guidelines law from 1996 provides a real opportunity to initiate transformations and discussions within the State, as acknowledged by the participants. As appropriately noted by Sunflower, there is momentum for discussions and actions to develop proposals capable of meeting a long repressed and crucial need. These discussions develop both in internal forums and in committees cooperating in a partnership between the Ministries of Health and Education.¹⁰ The development of policies for the education of human resources occurred concomitantly in this period, which culminates in the NOB/RH0-SUS in 1996. It is in this context that nursing professionals, through the ABEn, create a space for discussion: the National Seminar of Guidelines for Nursing Education in Brazil (SENADEn) greatly contributed to the developments in the profession.²¹

All this movement takes a slow, transitional process with elements and difficulties acknowledged by the study's participants. They show understanding that the curricular proposals and pedagogical models need to be understood, as they have meaning and intentionality, never detached from a conception of society and education and are, therefore, very significant for the curricular changes encouraged by the national curricular guidelines.²² Professors and students perceive that the current analysis of nursing education requires one to look both to the past and to the present, is strongly aligned with the SUS process of construction, to the SUS's theoretical and political perspective, and to the way the role of nurses has been designed in the context of health services. Hence, when the proposal of a minimum curriculum is considered outdated and disconnected from this intentionality, we start from this relatively shared historical and political bias that secures the demands for the effective reorientation of education.

The process of constructing the national curricular guidelines has incorporated the need to organize education according to the SUS and brings with it the understanding that, in a country as diverse as Brazil, there is no space for a closed, predetermined type of education. There should be a possibility to educate according to each regional reality. There were many discussions to achieve the document's final redaction, and there were many challenges after its publication because, even though there is no longer a demand to reach consensus, there is a demand to win over schools, promote understanding of the guidelines and implement them. Nonetheless, even though professors and students have such an understanding, they point out the difficulties faced in this process that, at the same time, confer autonomy and flexibility, but which may hinder the implementation of the proposal. One of the perceived difficulties was the large expansion of private higher education, which resulted in a large expansion in the number of undergraduate nursing programs. There was a considerable increase in the number of private nursing schools in the 1990s, especially in the wealthiest regions, such as the South and Southeast. This study shows a greater demand for nursing professionals after the implementation of the SUS, which would result in the proliferation of schools.²³

Aiming to curb this unbridled expansion of nursing programs, which would cause a drop in the quality of Brazilian higher education,²⁴ assessments became a fundamental element to properly implement the guidelines. There is currently a national system to assess higher education, the SINAES, which is transforming itself together with Brazilian education.

This process aids the search for quality teaching but is still challenged to curb disparities and overcome a series of difficulties observed in schools and professors, as Lily's report shows. The participants, however, recognize that despite private education's greater tendency of instability, there are positive aspects and weaknesses in both private and public universities. Hence, there is a need to be more flexible in relation to this rationale. One study⁵ suggests that private schools are ahead in terms of the programs' curricula and conception, while public schools are ahead in terms of work regimen and faculty qualification. This is another issue noted by the participants as an element that hinders the consolidation of the reorientation of nursing education.

Another important point related to the transition process concerns the professors' pedagogical posture and their ability to more broadly focus on public policies at all levels of healthcare, not only in relation to PHC. We understand that in order to qualify nurses to work in accordance with the SUS, schools need to take into account and enable students to have experiences in all these teaching spaces linking teaching, research and community services during the educational process, enabling students to work and understand the complexity of the health system and the integrality of care.⁹ Schools also need to encourage professors to constantly update their qualifications, providing them the conditions to develop their abilities and the knowledge required to contribute to this process of change, since they are an essential element in this process.

The testimonies also express the need to re-discuss pedagogical practices in elementary, middle and high schools so that teachers more easily accept active methodologies and more dialogical proposals and, then, these do not become difficult during undergraduate programs.²⁵ The testimonies show relevant aspects that integrate a true collaboration network of responsible and active joint actions that continually promote changes facilitating the SUS and benefits society. There is an acknowledgment that nursing education is in a moment of transition where some advancements had already been consolidated and others are still in process.⁶

Conclusion. This study enabled identifying and problematizing important aspects concerning the perceptions held by nursing graduate students and professors concerning nursing education in Brazil in its historical dimension. The continuous process of change and reflection has the potential to mobilize more critical work aligned with professional policies of the education field and in the organization of the health field. The participants are optimistic because they believe that the path at hand enables glimpsing a promising future for professional practice precisely because changes are based on important shared values and commitments. In spite of some barriers, there is a collective recognition concerning the need to reorient professional nursing education and that reorientation is already in progress.

Despite the potential and actual advancement expressed by the national curricular guidelines for nursing undergraduate programs, it is important to note in this context that the guidelines will not enact the changes required in the educational system, professors and students, by themselves. These are an important tool but should be contextualized and modeled according to local specificity.

We believe that even though this has been a theme present in discussions and academic studies in recent years, it is important to further encourage discussions and analyses, and discuss the reality of the situation based on the historical process in the most diverse spaces and contexts to achieve the desired transformations and awaken, through reflection, a collaborative spirit among those involved, enabling these movements of change to be collectively constructed. Even though these movements do not mobilize everyone, they seem to manifest a common desire. Perceiving the ongoing changes is also recognizing and questioning where they are going to lead, what future can already be envisioned, or even that not everything is guaranteed. To overcome ingrained teaching practices, the time of maturation and the consolidation of new projects is an essential and necessary condition for the profession to advance.

REFERENCES

1. Fernandes JD, Vale EG. Ensino de Graduação em Enfermagem: a contribuição da Associação Brasileira de Enfermagem. Rev Bras Enferm. 2006; 59(1):417-22.         [ Links ]

2. Marques CMS, Egry EY. As competências profissionais em saúde e as políticas ministeriais. Rev Esc Enferm USP. 2011; 45(1):187-93.         [ Links ]

3. Moura A. et al. SENADEn: expressão política da Educação em Enfermagem. Rev Bras Enferm. 2006; 59(esp.): 442-53.         [ Links ]

4. Renovato RD, et al. As identidades dos enfermeiros em cenários de mudanças curriculares no ensino da enfermagem. Trab Educ Saúde. 2009; 7(2):231-48.         [ Links ]

5. Lopes Neto D, Teixeira E, Vale EG, Cunha FS, Xavier IM, Fernandes JD et al. Aderência dos cursos de graduação em enfermagem às Diretrizes Curriculares Nacionais. Rev. bras. Enferm. 2007; 60(6):627-34.         [ Links ]

6. Corbellini VL, Santos BRL, Ojeda BS, Gerhart LM, Eidt OR, Stein SC et al. Nexos e desafios na formação profissional do enfermeiro. Rev. Bras. Enferm. 2010; 63(4):555-60.         [ Links ]

7. Ito EE, et al. O ensino de enfermagem e as diretrizes curriculares nacionais : utopias x realidade. Rev Esc Enferm USP. 2006; 40(4):570-5.         [ Links ]

8. Niemeyer F, Silva KS, Kruse MHL. Diretrizes curriculares de enfermagem: governando corpos de enfermeiras. Texto Contexto - Enferm. 2010; 19(4):767-73.         [ Links ]

9. Silva MJ, Souza EM, Freitas CL. Formação em enfermagem: interface entre as diretrizes curriculares e os conteúdos de atenção básica. Rev Bras Enferm. 2011; 64(2):315-21.         [ Links ]

10. Costa RKS, Miranda FAN. Sistema Único de Saúde e da família na formação acadêmica do enfermeiro. Rev Bras Enferm. 2009; 62(2):300-4.         [ Links ]

11. Montenegro LC, Brito MJM. Aspectos que facilitam ou dificultam a formação de enfermeiro em atendimento primário à saúde. Invest Educ Enferm. 2011; 29(2):238-47.         [ Links ]

12. Ramos FRS. O Discurso da bioética na formação do sujeito trabalhador da saúde. Trab Educ Saúde. 2005; 5(1):51-78.         [ Links ]

13. Lino MM, Backes VMS, Ferraz F, Reibnitz KS, Martini JG. Análise da produção científica dos grupos de pesquisa em educação em enfermagem da região sul do Brasil. Texto Contexto - Enferm. 2010; 19(2):265-73.         [ Links ]

14. Schveitzer MC, Backes VMS, Lino MM, Canever BP, Gomes DC. Grupos de pesquisa em educação em enfermagem: caracterização de três regiões brasileiras. Texto Contexto - Enferm. 2011; 20(spe):117-23.         [ Links ]

15. Fernandes JD, Xavier IM, MIPF Ceribelli, Bianco MHC, Maeda D, Rodrigues MVC. Diretrizes curriculares e estratégias para implantação de uma nova proposta pedagógica. Rev Esc Enferm USP. 2005; 39(4):443-9.         [ Links ]

16. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12^nd ed. São Paulo: Hucitec; 2010. P.327-54.         [ Links ]

17. Haddad AE. A trajetória dos cursos de graduação na área da saúde: 1991-2004. Brasília: Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira; 2006.         [ Links ]

18. Fernandes JD, Silva RMO, Calhau LC. Educação em enfermagem no Brasil e na Bahia: o ontem, o hoje e o amanhã. Enfermagem em Foco. 2011; 2(1):63-7.         [ Links ]

19. Angerami ELS, Gomes DLS, Mishima SM, Hayashida M, Ribeiro CMM, Reis JN. Estudo comparativo da nomenclatura das matérias e disciplinas do currículo mínimo com a utilizada pelas escolas de enfermagem da região sudeste - Brasil. Rev Latino Am Enferm. 1996; 4(1):31-46.         [ Links ]

20. Fernandes JD, Sadigurski D, Silva RMO, Amorim AB, Teixeira GAS, Araújo MCF. Ensino da enfermagem psiquiátrica/saúde mental: sua interface com a Reforma Psiquiátrica e diretrizes curriculares nacionais. Ver Esc Enferm USP. 2009; 43(4):962-8.         [ Links ]

21. Xavier ML, Batista SS. Associação Brasileira de Enfermagem no contexto da reforma educacional de 1996. Rev. Bras. Enferm. 2010;63(2):257-63.         [ Links ]

22. Optiz SP, Martins JT, Telles Filho PCP, Silva AEBC, Teixeira TCA. O currículo integrado na graduação em enfermagem: entre o ethos tradicional e o de ruptura. Rev Gaúcha Enferm. 2008; 29(2):314-9.         [ Links ]

23. Brasil. Dinâmica das graduações em saúde no Brasil: subsídios para uma política de recursos humanos. Brasília: Ministério da Saúde; 2006. P.409.         [ Links ]

24. Lopes Neto D, Teixeira E, Vale EG, Cunha FS, Xavier IM, Fernandes JD, et al. Um olhar sobre as avaliações de Cursos de Graduação em Enfermagem. Rev Bras Enferm. 2008; 61(1):46-53.         [ Links ]

25. Teófilo TJS, Dias MAS. Concepções de discentes e docentes acerca de metodologia de ensino aprendizagem: análise do caso do curso de enfermagem da Universidade Estadual Vale do Acaraú em Sobral-Ceará. Interface. 2009; 13(30):137-51.         [ Links ]