Abstract

Teacher Education in Healthcare: impossible neutrality

Throughout the long and disrupted process of Brazil’s Unified Health System – SUS building ‒ which began right after the 1988 Federal Constitution was enacted, a period of permanent dispute surrounding different projects for society and public health ‒ the issue of team training raised increasing concerns, especially due to the large number of workers who were poorly qualified or even unqualified¹1 . Lima J, Matta G, organizadores. Estado, sociedade e formação profissional em saúde: contradições e desafios em 20 anos de SUS. Rio de Janeiro: Fiocruz; 2008..

We must consider SUS worker training within the political scenario in Brazil in which formal achievements of past decades were not fully guaranteed. Maintaining and expanding those achievements requires a permanent struggle. With the aim of thinking socially about worker training, public schools of professional education in health still resist, linking their programs to local demands of the population. However, professional education in this area is an essentially private activity.

The assessment we discuss in this paper used as its subjects the students who attended a teacher training program, who already had healthcare degrees and who taught at public, charity and private schools in São Paulo state from 2010 to 2012. Essentially this is an assessment of results achieved by participants according to the intended profile at the end of the Teacher Training Program in Professional Technical Education in Healthcare, developed by the Escola de Governo of Escola Nacional de Saúde Pública Sergio Arouca-ENSP, of Fundação Oswaldo Cruz-FIOCRUZ, at a non-degree, specialist level^(dd() This research has been supported by Fundação do Desenvolvimento Administrativo (FUNDAP). Institutions that participated in training include: São Paulo State University (USP) – Nursing School – Department of Professional Orientation; São Paulo State University/Ribeirão Preto Campus – Nursing School; School of Medicine of São José do Rio Preto (FAMERP) – Nursing Department; School of Medicine of Marília (FAMEMA) – Nursing Department; Federal University of São Carlos (UFSCAR) - Center for Biological and Health Sciences – Graduate Program in Nursing; Paulista State University (UNESP) – Botucatu Campus – Nursing Department.⁾.

The training program incorporates democratic values and principles of the Brazilian sanitary movement as conceptual frameworks, adopting the history of social struggles for healthcare in Brazil as a syllabus foundation, in order to support the complex analysis of the sector’s reality and of the historical process of public health defense. To the people who completed the program, that is, individuals who had degrees in Biology, Biomedicine, Nursing, Pharmacy, Physical Therapy, Speech Therapy, Medicine, Veterinarian Medicine, Nutrition, Dentistry, Psychology, Social Service and Occupational Therapy and work at professional education institutions within the SUS, this training awarded the title of teaching specialists in professional technical education at high school level in healthcare.

In summary, one can say that this training, which is not neutral, prioritizes reflective and critical thinking about teaching activities conducted at professional education schools that train SUS workers. It also prioritizes offering the groundwork for building other activities in this area, without ignoring, on the one hand, that healthcare work is strongly defined by technical division and, on the other hand, that effective transformations in health and education realities require transformations in the social model. Therefore, unlike other programs, this teacher training under assessment does not ignore class differences, “as if the mere fact that one occupies a teaching position would exempt one from having values, concepts and class commitments”²2 . Kuenzer A. A formação de professores para o ensino médio: velhos problemas, novos desafios. Educ Soc. 2011; 32(116):667-88..

Assessment: meanings, assumptions and methodological aspects

In this country, despite progress made in recent decades, there are still not enough studies about assessment methodologies and processes³3 . Arretche M. Dossiê agenda de pesquisa em políticas públicas. Rev Bras Cienc Soc. 2003; 18(51):7-9., especially when assessed policies distance themselves from the search for productivity, a model that has been copied from the merchandise production world, according to which quantitative indicators are uniformly applied and translated into goals that ignore the reality which public policies are part of⁴4 . Lima L. Investigação e investigadores em educação: anotações críticas. Sísifo [Internet]. 2010 [acesso 2012 Maio 5]; 12:63-72. Disponível em: http://sisifo.fpce.ul.pt
http://sisifo.fpce.ul.pt... .

Within the context of State Reform, assessment gained a core position as a management tool in the 1990s, turning into a priority area for multilateral cooperation, in order to achieve a new efficiency and quality profile in the public sector. Acknowledging the existence of tensions and conflicts in the struggle for uniformity in defining the meaning and the assessment models, especially in the social field, we notice that the idea of quality combined with productivity reinvigorated in the last few years the technicality that marked teacher education research in the 1970s⁵5 . Gatti B. Formação de professores, pesquisa e problemas metodológicos. Contrapontos. 2003; 3(3):381-92.. Under this perspective, one understands that all phenomena are subject to direct observation, measurement, experimentation and testing.

Studies in the field of assessment are showing gaps in developed proposals by understanding that the subject of investigation can be entirely controlled, by not evidencing the theoretical assumptions used, or also by the difficulty of building indicators of social quality. Considering those limitations and considering the multiple meanings that involve the concept of quality, this paper returns to the notion of social quality coined in the field of Brazilian education from 1997 onward, whose origins are in the deliberations of the II National Education Congress (CONED) held in Belo Horizonte, Minas Gerais, Brazil. Education was defended as a tool of comprehensive training and struggle for citizenship rights and social emancipation, preparing people and society for the responsibility of collectively developing an inclusion and social quality project for the country, which means prioritizing the struggle for health, in our view.

The concept of teacher education with social quality, whose meaning is still under discussion⁶6 . Frigotto G. A qualidade da educação básica no Brasil: um contraponto à concepção hegemônica. In: Bertussi G, coordenador. Anuário Educativo Brasileiro. São Paulo: Cortez; 2011. p. 15-28.

7 . Dourado L, Oliveira J. A qualidade da educação: perspectivas e desafios: Cad Cedes. 2009; 29(78):201-15.^-88 . Fonseca M. O Projeto Político-Pedagógico e o Plano de Desenvolvimento da escola: duas concepções antagônicas de gestão escolar. Cad Cedes. 2003; 23(61):302-18., goes beyond learning the required contents to gain knowledge about subjects that traditionally form syllabi. This includes a concern in providing the tools for students to think, reflect, question and take a stand on life and the reality where they work, which requires an appropriation of historically produced knowledge.

The assessment in question considered the category totality as central, in an attempt to understand connections and tensions between results achieved by teacher education students and structural and situational conditioning factors in the researched reality^(e), which were able to limit or encourage the development of proposals with social quality for all. It is worth noting that this consideration does not mean ignoring the rich diversity that characterizes healthcare reality. Quite the contrary: if that which is diverse results from a reality on a equal basis, it offers a wealth of possible choices for student-teachers.

Escaping the false quantitative/qualitative antagonism, we chose to combine approaches and techniques in order to build comprehensive interpretations of the analyzed reality, constructed by historical, political, economical and cultural dimensions. All the instruments we used were directed by created indicators, and here it is worth noting that indicators “even when they are very strong, [...] they signal certain trends, but do not offer absolute certainty with respect to the results of any given action or process”⁹9 . Minayo MC, Assis S, Souza E. Avaliação por triangulação de métodos: abordagens de programas sociais. Rio de Janeiro: Fiocruz; 2005. (p. 106). In this construction, we also considered the meaning of assessment proposed by the developed teacher education. It values the process of a growing view of the world, of one’s understanding of reality, of producing what is new, of assessing a given reality.

Therefore, assessment indicators were defined bearing in mind six attitudes/commitments expected after completing the education program: I. Ability to link healthcare and education specific issues to social and historical conditioning factors of reality; II Commitment with healthcare as a right, with health social needs, to users as the subjects of rights, to students as subjects who produce culture; III. Ability to understand the meaning of permanent collective struggle for a State policy that is committed to SUS users; IV. A personal construction of a critical and emancipatory attitude with respect to ruling hegemonic values in healthcare today; V. Ability to offer students possibilities for individual and collective construction of a critical and emancipatory perspective, committed with SUS values, adopted from the Brazilian sanitary movement; VI. Ability to use one’s intellectual, social and ethical independence to choose and develop pedagogical practices based on people’s and populations’ healthcare needs.

The profile of subjects who took part in the assessment

It is certain that workers in general have limited possibilities in mercantilist societies. It is also true that education work, as well as healthcare work, has its specific characteristics and potentials. This is because the acts of teaching or caring for people are inseparable from their consumption by human beings. In summary, one can say that teaching work in healthcare can reaffirm fragmentation, subordination aspects; it can cave in to market pressures for an education that will ensure faster profits to those who pay for the labor force; however it can also mediate the interests of the majority of the population.

Although there are no sufficient available data on professional teacher trainers in healthcare or about the specific nature of their work, one may say that worker training is not a professional priority for most nurses, physicians, nutritionists, physical therapists, pharmacists, etc. Teaching is regarded as an extra activity; public school teachers often have not passed civil service examinations; there is not always a career plan or a wage floor, as in basic education; and teaching work is not necessarily valued.

Paradoxically, technical professional education is strongly regulated today both by the Ministry of Education and the State Boards of Education. In the specific case of São Paulo state, for instance, one cannot be a professional education trainer in all areas without a university degree (in teaching) or without attending a similar program. Regulatory bodies require schools to provide the same documentation as other programs, including a political-pedagogical syllabus and a program plan. Having that in mind, the debate over teacher training in professional education in healthcare cannot be postponed.

It is worth noting that the offer of teaching programs in healthcare is declining. On the other hand, programs such as Medicine and Dentistry do not include teacher education, and it is up to degree holders in those fields to look for pedagogical complementation in order to work as teachers in professional education schools. Therefore, based on the traditional models of their own education, healthcare professionals who take up teaching must learn how to do it as they go, without critical thinking about the meaning of teaching workers in the realm of public health¹⁰10 . Ludke L, Cutolo LR. Formação de docentes para o SUS: um desafio sanitário e pedagógico. Sau Transf Soc. 2010; 1(1):88-98..

Participants of the assessment are healthcare professionals and teachers, simultaneously. A few characteristics of those subjects contribute to the analysis of results achieved at the end of their teacher education program. Broadly speaking, one can say that there is much in common between Program students. This allows us to indicate with reasonable certainty the profile of professional education in healthcare in São Paulo state, as reported below:

Nursing degree holders are predominant, as are women under 40 years old and married women. About half of them worked primarily at the public healthcare network. Most professionals worked in hospitals, followed closely by those who worked in basic care. From what we noticed in focus groups statements, the option for teaching is also an alternative for a lack of jobs in healthcare, although there are limited opportunities for teachers as well.

Nearly half of the participants said they only had one job when the research was conducted, although the percentage of individuals who reported having two or more jobs is also relevant. In any case, the weekly hours of working of student-teachers suggest that their ability to dedicate to the Program as desired may have been limited significantly, since a third of them worked over 40 hours per week, as shown in Graph 1. Furthermore, we noticed that some individuals worked in different cities which were not always close to one another, or belonged to different networks (municipal, state), frequently as the only healthcare professional on duty.

The research also asked about participants’ family income. More than a third earned between R$ 2,489.00 and R$ 3,732.00. When added to previous categories, 66% of all participants had a family income of up to R$ 3,732.00^(f). In focus groups, we noticed that participants felt overwhelmed and often had other high school level jobs for which they passed a civil service examination before they achieved their university degrees in healthcare.

Most student-teachers were religious, with a predominance of Catholics, evangelicals and spiritists. The significant religiousness of student-teachers is a reality which cannot be ignored. This is because for religions in general, emancipation arises especially from an inward transformation, while outside reality is very difficult to change. This concept is worlds apart from the Program’s purpose, not only in terms of how one perceives objective reality, but also about the possibilities of changing it.

Data show that student-teachers were very rarely involved in any kind of collective movement, something that is encouraged by their training: 12.8% took part in trade unions and/or social movements, cultural and religious activities, while only 2.9% were in a political party. In focus groups, we noticed that participation in social movements could translate most of the times into some kind of voluntary or religious activity. There are also few references to participation in local healthcare councils, marked by disillusionment with how council members are chosen, that is, based on political-partisan criteria, according to the subjects of this assessment. On the other hand, lack of participation by student-teachers, especially in trade unions, is related to a common feeling that current administrations are not committed with their more immediate interests and also to lack of time.

With respect to teachers at professional education schools, there are a number of different situations: healthcare professionals formally hired by charity institutions and with part of their working hours dedicated to teaching at schools of the above-mentioned institutions; professionals who were specially recruited to teach one or two courses and who were paid by the hour; and less frequently government-employed and contract-employed professionals hired for teaching. However, we noticed that most of them had no formal links with institutions. The devaluation of the teaching profession was frequently discussed in focus groups. In addition to the issue of employment contracts and pay, student-teachers highlighted how little social value was ascribed to teaching.

Although valuing and training SUS teams remains as one of the main challenges in the field of public healthcare committed with the social needs of the population, this sector’s training traditions, mostly private when it comes to worker training, often disregards that one defines healthcare and human education practices precisely in the organization of social life, with all its conflicts and contradictions.

Assessment: issues and tensions observed

Within the scope of this paper, we outline below the issues and tensions we observed. The assessment focused on results achieved by student-teachers in relation to the expected profile at the end of the training process. To that end, we defined six expected commitments/attitudes at the end of the Program as indicators. Among others, we prioritized the ability to link healthcare issues with conditioning factors of the social-historical reality and to understand the meaning of the collective struggle for a State policy that is committed with SUS users.

In focus groups, people insistently highlighted their concern with social rights that were not guaranteed and poor quality of services offered by the SUS. Likewise, individuals frequently expressed commitment with users as subjects with rights. However, what effectively drew the attention in focus groups were reports on how most participants started to value SUS student-workers after their teacher training.

On the other hand, frustration, angst and indignation were reported by student-teachers in focus groups when faced with healthcare work situations and in schools. This shows tensions between potentials for transformation and existing limitations, restricting possibilities for creative and collective intervention guided by ethics and justice. This suffering is caused by the difference between what student-teachers know they could do and what they are actually able to do under the objective conditions they work, aggravated by new forms of labor materialization¹¹11 . Dejours C. A banalização da injustiça social. Rio de Janeiro: FGV; 2005.^,1212 . Kuenzer A. Sob a reestruturação produtiva, enfermeiros se encontram no sofrimento do trabalho. Trab Educ Saude. 2004; 2:239-65..

The results of our assessment, in general terms, point to how difficult it is for student-teachers to overcome unilateral views about the reality where they work. Indeed, most of them have a critical take on how the SUS is being organized since its inception in cities and in their region, about progress and limitations of this construction and about daily challenges faced by teams in healthcare services and by teachers in professional training schools. However, most of the time they do not mention the need for healthcare workers and services to adopt a broad perspective when analyzing the issue of health and not only the disease, incorporating the greatest possible amount of knowledge from other areas. Therefore, many times the prevailing view is that health problems in their cities/regions are caused only by the local government, by political-partisan issues, by teams, especially physicians, or also by users themselves, who do not act on prevention.

In a stricter and deeper analysis of the issue, other dimensions of the problem would have to be considered, in addition to education for healthy habits, such as unemployment, inadequate labor conditions of the Brazilian population, precarious work relations, lack of proper housing, unsatisfactory transportation and the deprivation of the right to education at higher levels, which affects most of that population. Such issues are emphatically addressed throughout the training. Understanding the reality “means going beyond looks; it means capturing what is hidden and this justifies the scientific undertaking”¹³13 . Saviani D. Problemas sociais e problemas de aprendizagem. In: Saviani D. Educação e questões da atualidade. São Paulo: Cortez; 1991. p. 41-55. (p. 44).

Other issues and tensions were observed with respect to the inclusion of teachers in professional education schools. There are, for instance, elements to be considered with respect to the effective participation of teachers in the construction/modernization of political-pedagogical projects and in drafting course plans. Although we expected projects to be drafted already, due to the prescriptions of the Educational Guidelines and Framework Law - LDB (Law Number 9,394/96) and later the local education systems, it would be advisable that those projects were submitted to frequent modernization with comprehensive participation from teachers, students and staff, in addition to the external community.

However, this almost never happens. According to Table 1, 14.7% of student-teachers noted that the political-pedagogical syllabus was not even made available by the school.It is important to reaffirm that the political-pedagogical syllabus is a theoretical-practical document drafted collectively by the school’s stakeholders. It records the political and philosophical foundations in which the community believes and wishes to put in practice; it sets their values and principles; it systematizes the indicators for good education; in addition, it identifies the social and historical roles of responsibility of the school¹⁴14 . Silva MA. Do projeto político do BM ao projeto político-pedagógico da escola pública brasileira. Cad Cedes. 2003; 23(61):283-301.. However, in schools, in general, discussions about the political-pedagogical syllabus seem to be hibernating, showing a clear step back taken by participatory management, especially in public institutions.

Teachers’ lack of participation also occurs in relation to building course plans, in which teaching goals and contents are outlined, since only 5% of people interviewed were in charge of developing/updating those plans. The possibilities of teacher participation are often limited to the class diary, that is, to developing a class plan and choosing tools to assess students. Most people we interviewed took part or were in charge of such activities. In light of the above, one cannot help but think about the possibility that the precarious nature of those workers’ relationship with schools may define their limited participation in the directions of decisions made about professional education^(g).

Finally, we will briefly discuss challenges encountered with respect to students' Final Program Paper (TCC), which is mandatory in non-degree graduate courses. We all know that writing is difficult for students, especially because of the limitations of the basic education they received. This reality is experienced on a daily basis in Brazilian universities. For instance, it is notoriously difficult for students to show that they master the construction mechanisms of written language at level of formality and accuracy that is compatible with the academic setting in the perspective of writing texts with cohesion and coherence.

In addition to that limitation, TCCs made it even clearer that it was difficult for student-teachers to make a broad analysis of the reality. They once again offered partial views of healthcare and education problems, despite there being other structural conditioning and situational factors involved in that reality. Concrete labor and study conditions, the program’s total course hours and the time they spent on their TCC are all elements that must be taken into account in other training opportunities.

Final considerations

Without the intention of exhausting the topic discussed herein, we can list elements for new investigations. First, we should highlight the potential for teacher training in professional education, within the scope of the SUS. Training itself will not solve this country’s health problems or define itself as a condition for workers to keep aligned with the market’s needs. Rather, we support consistent training targeting a world analysis and critical action, different, therefore, from training processes committed with the existing social order and where teachers are not in a situation of tension, but rather accommodation. “Citizens are on one side and teachers are on the other. However, the main element in teachers’ human condition is the citizen”¹⁵15 . Fernandes F. A formação política e o trabalho do professor. In: Catani D. Universidade, escola e formação de professores. São Paulo: Brasiliense; 1986. p. 15-27. (p. 21).

Expected abilities and assessment indicators translate comprehensive commitment and attitudes considering Brazil’s reality, concrete life and working conditions of student-teachers, as well as the characteristics of the higher education they received, in which health and education are often seen as aspects isolated from the social whole and public health is seen as an accessory content.

Limitations regarding observed results cannot help but take that reality into account. Quite the contrary; one must think about conditions under which expected attitudes and commitment can be made by all with social quality, in order to break with limited concepts about the relationship between society, health and education. According to those concepts, which some authors label naive, social problems require educational solutions only. This position captures the relationships between health, education and society through the immediately visible pathway, believing that things are as they are presented before us¹⁶16 . Gasparin JL. Uma didática para a pedagogia histórico-crítica. Campinas: Autores Associados; 2005.

17 . Saviani D. Educação: do senso comum à consciência filosófica. Campinas: Autores Associados; 2000.^-1818 . Pinto VA. Sete lições sobre educação de adultos. São Paulo: Cortez; 1982..

Finally, we highlight that the organization of teaching work in the schools involved contributes to limiting expected results, since one of the pillars of teacher training was collective work and effective participation of teachers in the school’s future direction, while several academic activities along those lines were proposed throughout the training process. We also consider that a transformative collective project, combined with a number of changes in the healthcare sector, requires deeper transformations in other sectors, in the State, in society and in institutions.

Data we found indicate that the most favorable space for collective discussion is that of public schools, followed by charity schools. On the other hand, private schools had more obstructions to our research, according to participants. However, it is worth noting that the greatest hurdle with respect to actual participation of student-teachers in schools is the type of employment relationship. Student-teachers with a formal relationship both at public and private or charity schools participated more than those who do not have any formal connections with the school, because of how much time they were able to dedicate to the school.

One must acknowledge that, in addition to the Program, individuals’ professional history, teaching experience and other previous education may have contributed at different levels to whether student-teachers showed the expected commitments and attitudes or not. In any case, the results described here are rich enough to encourage reflection on critical proposals for teacher training.

Finally, we must remember that in 2013 Brazil commemorated the 25^th anniversary of its Federal Constitution and the universal right to health, which resulted from struggles of the sanitary movement, especially in the 1980s, a period of novel strengthening of people’s organization and social progress in the country. The right to health means that the State will guarantee universal and equal access to actions and services that promote, protect and restore health to all people nationwide, leading to the full development of human beings. This also requires dignified housing, income, food and education conditions, among others¹⁹19 . Fundação Oswaldo Cruz. Escola Nacional de Saúde Sergio Arouca. Formação docente em educação profissional técnica na área da saúde: o SUS e os processos de trabalho em saúde. In: Pinto H, coordenador. Rio de Janeiro: Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública Sergio Arouca; 2009..

References

Publication Dates

History