ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

doi:10.17533/udea.iee.v33n3a14

Education for the unified health system: what do good professors do from the perspective of students?

Formación para el Sistema único de salud: lo que hacen los buenos profesores en la percepción de los estudiantes

Formação para o sistema único de saúde: o que fazem bons professores na percepção dos estudantes?

Jouhanna do Carmo Menegaz¹; Vânia Marli Schubert Backes²

¹RN, MsN, Doctoral Student. Federal University of Santa Catarina -UFSC, Brazil. email:menegaz.jouhanna@posgrad.ufsc.br.

²RN, PhD. Professor, UFSC, Brazil. email:vania.backes@ufsc.br.

Receipt date: October 20, 2014. Approval date: April 15, 2015.

Article linked to research: Practices of good nursing, medical and odontology professors from the perspectives of students.

Subventions: none.

Conflicts of interest: none.

ABSTRACT

Objective.to analyze the educational practices for the Unified Health System performed by good professors, from the perspective of nursing, medical and odontology students, based on the Shulman's concepts of knowledge of educational ends, purposes, values ​​and their historical and philosophical grounds, at a university in southern Brazil. Methods. A qualitative study with an exploratory and analytical approach in which the participants were graduating students, interviewed with the aid of vignettes, between October of 2011 and January of 2012. Data were analyzed based on thematic analysis. Results. it was observed that good professors educate for the Unified Health System through the promotion of teamwork, interdisciplinary practices, good communication, leadership exercises, and promotion of a student's desire to be an agent of change for the sake of improvement and guaranteeing the right to health. Conclusion. the students attribute to professors the responsibility for the performance of these practices. Despite their consistency with the Brazilian curriculum guidelines, the professors that perform them are seen as a minority.

Key words: unified health system; faculty; staff development; students, nursing; students, medical; students, dental.

RESUMEN

Objetivo.Analizar las prácticas relacionadas con la formación para el Sistema único de Salud -SUS- realizadas por los "buenos profesores" según la percepción de los estudiantes de enfermería, medicina y odontología de una universidad del sur de Brasil. Metodología. Estudio cualitativo con abordaje exploratorio-analítico en el cual se entrevistaron 16 estudiantes que finalizaban sus estudios. Los datos fueron analizados temáticamente. Resultados. Se observó que los buenos profesores forman a sus estidiantes para el SUS mediante el fomento del trabajo en equipo, la prácticas interdisciplinares, la buena comunicación, el ejercicio del liderazgo; además, promueven en ellos el deseo de ser un agente de cambio en pro del mejoramiento y garantía del derecho a la salud. Conclusión. A pesar de consonancia de estos resultados con las directrices curriculares brasileras, los profesores que las realizan son señalados como una minoría.

Palabras clave: sistema único de salud; docentes; desarrollo de personal; estudiantes de enfermeira; estudiantes de medicina; estudiantes de odontologia.

RESUMO

Objetivo.nalisarcom referência no conceito de conhecimento dos objetivos, finalidades, valores educativos e seus fundamentos histórico-filosóficos de Shulman práticas relacionadas à formação para o Sistema único de Saúde realizadas por bons professores na percepção de estudantes de enfermagem, medicina e odontologia de uma universidade do sul do Brasil. Metodologia. Estudo qualitativo com abordagem exploratório-analítica no qual foram participantes estudantes concluintes entrevistados com auxílio de vinhetas no período de outubro a janeiro de 2012. Os dados foram analisados com base na análise temática. Resultados. Observou-se que bons professores formam para o Sistema único de Saúde através do fomento do trabalho em equipe, práticas interdisciplinares, boa comunicação, exercício da liderança e fomentam desejo no estudante de constituir-se um agente de mudança em prol de melhorias e garantia do direito à saúde. Conclusão. Osestudantes imputam aos docentes a responsabilidade pela condução destas práticas. Apesar da consonância destas com as diretrizes curriculares brasileiras, os professores que as realizam são apontados como minoria.

Palavras chave: sistema único de saúde; docentes; formação de recursos humanos; estudantes de enfermagem; estudantes de medicina; estudantes de odontologia.

INTRODUCTION

Over a decade after publication of the national curriculum guidelines, the concrete start of a movement for reorientation and arrangement of education for the Unified Health System (SUS),¹ the Brazilian health care system, has moved beyond a professional educational profile fragmented into disciplines with a predominant promotion of technical skills to a triad consisting of knowledge, skills and attitudes. This movement is expressed by competencies that articulate education in health; this is a sum of efforts of the Ministries of Education and Health, through initiatives and programs, so that health education constitutes a strategic element for the consolidation of SUS.

Despite the observed advances,² there are still two questions about which there is little work, and only a few initiatives have been undertaken. Of these questions, we would like to seize especially the education of professors, who are key players in the process of change and have pedagogical disabilities in the health field,^3,4 little knowledge about the Brazilian national curriculum guidelines for undergraduate education in health, and sometimes, exhibit a resistance to the new educational model.⁵ These findings alarm us, since it is inconceivable to think of education, especially in a background of change, without considering the role and contribution of the professors, as well as the implications of a dissonant understanding and/or deficient pedagogical education. In the Brazilian educational system, enacted by the Law of Guidelines and Bases of National Education, there is the statement that the professor training for higher education should predominantly occur in master's and doctoral courses.⁶ Considering this statement, and the setting of teaching in health, questions and challenges are presented to the researchers.

Given the current profile of the Brazilian academic master's and doctoral courses, with an emphasis on the education of researchers,⁷ would it not be partly a responsibility of the educational system itself to train professors who are pedagogically unprepared and disconnected from the understanding of the educational challenges? Specifically regarding education in health, as a turning point, would professorswithout an initial and continuing pedagogical training, with little involvement in the discussion about the relationship between education and SUS, be able to promote the professional profile desired by society? Once we recognize this deficiency, how is it reflected in education and, given this recognition, what should our attitude be?

The relevance of professor training for educational success is defended and highlighted by studies in which the teaching practice of excellence is supported, particularly through the professor's mastery of some knowledge categories called a knowledge base, namely: content knowledge; general pedagogical knowledge; pedagogical content knowledge; curriculum knowledge; knowledge of learners and their characteristics; knowledge of educational context; and knowledge of educational ends, purposes, values ​​and their historical and philosophical grounds.⁸ The expression of mastery of these types of knowledge from various sources such as the academic background, the educational context and materials, the use of research and practical experience itself manifest articulately in one's teaching practice, supported by what the author⁸ calls the Model of Pedagogical Reasoning and Action. This model, divided into six phases, namely, comprehension, transformation, instruction, evaluation, reflection and new comprehensions, outlines the reflexive movement that supports the teaching practice.

Considering the scenario of changes in health care education, we understand that having professors develop knowledge of educational ends, purposes, values and their historical and philosophical grounds is particularly important in this moment, without disregarding the defense of the development and global expression of all listed knowledge base⁸. This is a knowledge category that simultaneously expresses the professors'understanding of his desired professional profile, his optimal performance space, and the historical and political process that has brought education to the current moment.

The teaching practice is the expression, either consciously or not, of the professor's reasoning process. Despite inefficiencies in the basic training of professors, and a lack of determination of inducing policies for professor training with the aim of understanding the professor role in the context of education for SUS, i.e., promoting the development of knowledge of educational ends, purposes, values ​​and their historical and philosophical grounds, the professors interact, reflect and act in this context, and students in general notice them when they understand the ongoing processes of change, since they are the primary target of all interventions and inducing policies. Therefore, we aimed to analyze the educational practices for the Unified Health System performed by good professors, from the perspective of nursing, medical and odontology students, based on Shulman's concept of knowledge of educational ends, purposes, values ​​and their historical and philosophical grounds, at a university in southern Brazil.

METHODOLOGY

This was a qualitative study with an exploratory and analytical approach performed in the nursing, medical and odontology courses at a public university in southern Brazil. The study participants were 16 graduating students, six from the nursing course, five from the medical course, and five from the odontology course. The subject selection was intentional, because the researchers wished to get statements of students with a trajectory in the course, and the sample was gathered through networking by using the snowball technique. After obtaining the course coordinators'consent for the study, we requested contact with the class representatives, a gateway to the contact with the other students. In the contact with the representative via e-mail, we presented the study and invited him to participate. Upon acceptance, a face-to-face meeting was set up for the interview. At the end of the interview, the class representative was asked to recommend two other colleagues that would also like to contribute to the study, in his opinion. These colleagues were contacted and invited to participate, and, likewise, were then asked to indicate two colleagues. Theoretical data saturation was established to define the end of participants inclusion.

All participants were individually interviewed, in a reserved place and time according to their preference, from October of 2011 to January of 2012, using a focused interview composed of vignettes and qualitative indicators constructed from previous studies.⁹ The vignette was a fictional story on printed paper provided to the participant, who was then asked to talk about his impressions.

At the beginning of the interview, the participant was instructed to have as a reference for his answers the best professor or members that he had had during the course. This instruction is justified because, when one understands what is good, which is a value judgment based on a certain world view, we could have simultaneous access to the student's perception on teaching practice and on his own concept of teaching. In addition to the support provided by the indicators of other studies, two elements provided the basis for the construction of the vignette and the script of the interview: the concept of knowledge of educational ends, purposes, educational values ​​and their historical and philosophical grounds⁸ fundamentals, and the description of the six general competencies for the education of health care professionals as described in the national curriculum guidelines, namely: health care, decision making, communication, leadership, administration and management and continuing education. This composition is justified by the need to situate Shulman's concept on the Brazilian educational reality.

For data analysis, we used thematic analysis,¹⁰ which has three stages: pre-analysis, material exploration, treatment and interpretation of the obtained results. From this integrative analytic movement, the following categories emerged: stimulus for teaching-service integration and multidisciplinary and interdisciplinary work; stimulus for autonomy, communication, participation and leadership; and stimulus for the development of a transforming social and professional practice, which we present in the results. This work is part of a larger study entitled 'Practices of good nursing, medical and odontology professors from the perspectives of the students', which abided by the ethical guidelines of Resolution 196/96 and was approved by the Research Ethics Committee under Protocol N. 2317/2011. In this text, the statements of the students can be identified by the initial letters (N, M, O), with the sequence number of interviews according to the course (1-6) and the overall record number that corresponds to the statement (R accompanied by a number).

RESULTS

Stimulus for teaching-service integration and multidisciplinary and interdisciplinary work

In general, the students pointed out that their best professors have good integration with the team in the clinical services, an aspect highlighted especially by nursing students. This facilitates their inclusion and involvement in activities, giving them more space and openness to the team. The medical students also emphasized that good professorsare good at teamwork at the university and in the clinical services, setting an example for the students of 'how to do it': We must be seen as part of the team and not as students who are there to learn and will go away a week, a month later. There must be this articulation. And the team must also be prepared for the fact that a group leaves, but another one comes soon, so the professors must have a good relationship with the team to welcome new students. (N1R187)

The students express marked difficulty in integrating with teams, especially in articulating with other professionals, professors and students that sometimes share the internship sectors, highlighting in their statements the impact that poor integration with professional and multidisciplinary teams and students from other areas has on education: When we did home visiting, I went with my dentist. I've never done it with the nurse, the physician. And one thing that perhaps could be done, I don't know how it works, is all health care areas, everyone going to the basic unit, get the students and do something together, with a requirement that everyone is together, the nutrition team, the odontology team, the nursing team, the medical team. Everyone goes. I know that everyone goes because I see it, but I don't know if you do something with the medical team, with the nutrition team, we have no contact. I didn't see any, and I knew that my unit did home visiting, then maybe that's a flaw in odontology, I can't say. I don't have a clue of how it is working together. (O1R123)

For odontology students it is essential that the professor start this process of approach, as the student, upon entering the course, does not understand that this is something important. The nursing students point out as a possible reason for the gap between students'and professionals'valuing or devaluing the work of some at the expense of others' work, which must be demystified by the professor. This, from the students'perspective, helps with integration between courses, enhances teamwork and helps students to better see how the work is or should be in the health care service, since this understanding of superiority, especially felt with regard to the physicians, among other issues, impairs communication within the team, something that should occur naturally and swithout squeamishness.

Stimulus for autonomy, communication, participation and leadership

Stimulus for participation in the various SUS construction spaces and the development of good communication and leadership are seen as practices of good professors and as essential elements of enhancement for SUS consolidation. However, the perception of this stimulus in the practices of professors was expressed by a few participants as rare moments. There was a perception that there is little participation and, when it occurs, the professors stimulate issues concerning participation in forums, which are political spaces of the disciplines of nursing, medicine and odontology, and that there is not much stimulus for participation in a broader sense, and spaces that go beyond the unit and care scenarios such as the health council, for example: I also highlighted the dialogue with the health council, with the managers, with the community, it's rare. We have it in theory, learn what the health council is, in fact most learn what the health council is, I find it strange to be in a medical or nursing school, well… I'll talk about my reality… to be in a medical school to know that there is a health council, know what it is, and worse, to know what SUS exactly is. It's not content that comes before college, but it remains theoretical. I've never participated in anything in the health council, in the community, here. Dialogue with the community happens, but it happens during consultations, I think, because that is the dialogue with the community. There are few times when we have this dialogue in a meeting, as well (M2R17).

In the opinion of nursing students, the practice of good professors is to let them act more autonomously, making them feel as if they were already exercising their professional role, their leadership, communicating with other professionals. The medical and odontology students also value autonomy and believe that this space is important for their professional training, but they all emphasize that this occurs just a little: I think we are still very dependent on the professor, will I make this decision? Then we ask the professor advising us in the case. What would be the best way? The best way is to do it is this way or that?. (N2R205)

Stimulus for the development of a transforming social and professional practice

This category evidences how the students understand their social role as professionals from the professor stimulus, both in the sense of co-responsibility for the consolidation of SUS and in the direction of transformation of health services to guarantee the citizen's right to universality, equity and integrality. For the nursing students, good professors highlight and encourage students to always leave a legacy after performing their activities, thereby contributing to the improvement of the service. They also emphasize the potential for change that lies in the hands of health professionals¹¹ if they accept engagement in activities beyond the health facility. The other courses did not highlight this practice: The professor has the ability to stimulate us to suddenly improve, add some knowledge to the unit or to the basic care unit. I think the professor does a lot. In addition to your learning there, you are doing something in return, not a vague internship where we only take, where only we receive benefits, you also leave something and contribute to that unit, and the professor is very responsible for it. (N2R220)

The faculty showing commitment and valuing of SUS as a public health policy is also mentioned as an important element. There were statements from the medical students that this practice by their professorsis new. For the medical students, the good professors encouraged them to engage not only with the service, but also individually, by establishing a relationship with the patient, indicating the dimension of his ethical and professional responsibility.¹² In the Odontology course there were no significant demonstrations of this thought: It occurred to me that in the health service there is no way to work without getting involved with things. There's no way you go there, perform your working hours from 8:00 to 6:00 if you don't get involved with people who work there with you, and that you welcome. I think that's the essence of our profession, that's why I emphasized 'get involved' because we also don't have much of that. As our training is theoretical and practical, but in practice we are not frequently taught to engage with people, follow-up with the patient, sit next to him, get close. If it were my family, how would I want it to happen? I think this is essential, it should have been highlighted more, more often, from the beginning of the course, because we learn otherwise, at least in medicine. We can't get too involved, we have to keep a distance, we must establish the doctor-patient relationship in a way, of course, that is sympathetic, empathetic, but not necessarily close." (M4R90)

DISCUSSION

From the students'perception, good professorsvalue mutiprofessional teamwork, enable the exercise of autonomy, leadership and communication, and convey to the students an understanding about their contribution and role in the SUS context. Good professorstoday do not simply do what good professors would do, but what all professors should do. Although this study was performed taking into perspective the students'perception about good professors and not the whole, the reported practices were explicitly highlighted as being the minority, still being developed in different measures in the courses. It still seems to be a difficulty for the professors to have a pedagogical practice that allows the student to understand an ongoing process of change. In this regard, we emphasize the lack of development of integration among courses as a major obstacle to the success of reorientation of health education within SUS.

An important aspect to consider about the students'perception is the low report of the presence of knowledge of educational ends, purposes, educational values ​​and their historical and philosophical grounds by the group of professors. This suggests that, although changes are desired within the Brazilian health education, individual work continues being taught to students, with little communication, integration with the teams, and only small stimulus for autonomy, which in summary is expressed out of a context stimulated by the inducing policies of health education and by the aspects highlighted in the national curriculum guidelines.

Specifically with regard to the nursing students'perception, there is greater awareness of the presence of knowledge of educational ends, purposes, educational values ​​ and their historical and philosophical grounds by professors who demonstrate appreciation for the professional in the health care teams, which therefore facilitates the integration and experience of students in the internship fields. There is also the perception that the promotion of student autonomy is manifested by freedom of action and noticed by the importance of contributing towards the service, a sign of the presence of the category of basic knowledge within Shulman's teaching.

The practices identified by students as those of good professorslead us to important elements expressed in the curriculum guidelines, especially in general skills, which are the current drivers of health education. If we make a comparison with Shulman's referential, we can state that the agreement between teaching practice and that recommended by the guidelines demonstrates an understanding of educational ends, purposes, values ​​ and historical philosophical grounds by these professor considered to be the good ones. We can highlight that the presence of this knowledge base category demonstrates the professors'understanding of the educational moment in which we live, the intentionality of educational guidelines for a given historical moment from the concept of knowledge of educational ends, purposes, values, historical and philosophical grounds. In the case of Brazilian health professors, the perception by students that this knowledge base category is present refers to the perception that they are present in teaching the elements that characterize the new era of health policy, SUS, and new imbricated concepts of health and care that SUS provides, and that are drivers of education.

The prominence and recognition for teamwork, and especially for the integration between teaching and service in clinical practice¹³ is something that often appears in studies related to changes in health education, added to the defense of the necessary integration with the community, since the services are not located in a virtual space, but are circumscribed, loaded with culture and specificities. Therefore, it would be questionable to consider the transformation of education without integration, teaching, service and community.⁵ However, despite the recognition by the students that these are important issues, it still seems to them that we are far from a genuine articulation.

The students'perceptions about their professorsendorse the view that the promotion of multidisciplinary work is still one of the great challenges in health education,¹⁴ and this cannot be considered by us as a minor challenge. Since most health policies and actions today reside in a collaborative work, this lack of articulation is problematic, since it is highly unlikely that without teamwork one is able to ensure completeness, fairness, social participation, among other doctrinal and organizational SUS principles. We seem to recognize this quite clearly, however, our intervention is still timid. It is common that many disciplines share the same internship places, yet do not interact.¹⁵ More common has been understanding that this is natural. The students demonstrate understanding of the importance of working together with other disciplines, but make it clear that it does not occur frequently and this is a loss.

Despite the statement that it is difficult to integrate students and professionals from other areas, most emphatically expressed by students of the odontology course, the nursing and medical students also reported that their experiences are punctual. The fact that they are punctual makes them stand out as practices of good professors and not as a common practice of the course. It should be noted that the lack of integration is not just about the services, but also concerns the lack of articulation within the schools themselves, thereby nullifying a great potential for interdisciplinary and multidisciplinary articulation in health education.¹⁶ How can we work together with other disciplines if we teach them to work alone? It is rare to conduct coordinated actions among peers and colleagues from other areas, leaving the specificity/specialty, just as there are limitations of the educational actions to the physical space of the unit. These pedagogical decisions in the current context can limit the student's understanding of his role as a professional and citizen, as we have seen in the second category when it comes to political participation.

The students'perception that a good professors understands that the healthcare team works collectively, and that every professional has knowledge, responsibilities and areas of expertise, which together enable health care quality, helps demystify old territorial disputes among professional categories. The professors are twice the models for students: professional models of conduct and models of authority, by being 'the' professor. Their actions certainly have the potential to transform the scenarios of schools and services. Apart from these issues, it was noted that students want to be free to experience the services, communicate, stand out, lead, conduct their learning and their performance.¹⁷ They seem to want to extricate themselves from doctrinal teaching, which certainly should not be considered as a minor finding. Quite the opposite; they go towards the development of important skills such as decision-making and leadership, and the professor who encourages students in this regard has possibly clarified that the desired professional profile is of the most independent, creative and critical professional. This professor, as signaled by Shulman,⁸ has clear ends, purposes, values, historical and philosophical grounds of professional education in health.

In this context of support for autonomy, participation and leadership of students, understood as a good teaching practice, it is surprisingly not accompanied by any significant mention of political participation. With the exception of acting on health councils, which was timidly indicated,^11,18 the students do not characterize political stimulus or action as a good teaching practice. It is important to consider the understanding of the role and encouragement of political activity, leadership of the students for SUS consolidation, in the wake of the detention by the professors of the knowledge of the educational ends, purposes, values ​​ and their historical and philosophical grounds. This is because, despite the already achieved progress, there still remain a number of challenges¹⁹ that can only be overcome through the organization and political participation of citizens and health professionals.

Considering the historical characteristics of teaching and the professor's and student's role, these are certainly not the simplest tasks. However, it is important that the professor seeks the full measure of following up without hindering, setting free without lacking in help. The professor should encourage the student's empowerment,²⁰ and therefore will need to revisit his pedagogical practices and his understanding of the relationships between them,²¹ since this reorientation movement of education requires from all a new attitude and understanding.

It is necessary that we have an urgent debate on professor training in health, and the development of a knowledge base for teaching so that the educational activities are directed toward the professor segment. It seems that the vast majority of professors lack understanding about what it means to educate for the SUS. Although the present study brings interesting contributions, it should be noted that it is limited, since it only considers the students'perception of their good professors, and not the whole set of professors. One must also highlight the study's limitations related to its being performed in just one institution of higher education. To complete this gap it would be interesting to investigate what sources were used to construct the knowledge base of these professors, especially how their knowledge of educational ends, purposes, values ​​and historical and philosophical grounds was developed, since the problem of lack of pedagogical training in the lato and stricto sensu courses is increasingly present in the current scientific literature.

Finally, we highlight the relevance of Shulman's knowledge base for teaching, because although it is not in evidence in our analysis, we have noticed the presence of other categories of a knowledge base, for example, the mention of pedagogical practices of professors. In this sense, we highlight the importance of developing other Brazilian studies in other educational institutions, supported by this theoretical framework, so that more aspects are explored, since it remains infrequently used and can provide contributions.

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