Abstract

Introduction

The training of health professionals remains a critical area the reorganization of work in the health field process. However, since the implementation of the Family Health Program, the political discourse government has changed, and we identify that the managers of the Unified System Health (SUS) begin to intervene politically in ordination training health.

Policies on education and training of health professionals always been focused on those inserted or insertion phase in services. Among the interventions of the Ministry of Health (MS) to fulfill their constitutional role of officer of health education stand out some initiatives such as VerSUS, and AprenderSUS EnsinaSUS from 2003 to 2005 and the Pro-Health I, II Pro-Health and PET-Health later¹1 Dias HS, Lima LD, Teixeira M. A trajetória da política nacional de reorientação da formação profissional em saúde no SUS. Cienc Saude Colet. 2013; 18(6):1613-24.. These initiatives consistent with the need for modification of health practices and pedagogical practices in the training process, which requires an articulation between the SUS, in its three spheres of government and institutions forming.

A strategy used to redirect the training stands out, since 2005, the National Program for Reorientation of Professional Training Health (Pro-Health) which aims to induce the transformation of health education in Brazil²2 Ministério da Saúde. Ministério da Educação. Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde: objetivos, implementação e desenvolvimento. Brasília (DF): MS, MEC; 2007.^,33 Portaria Interministerial nº 3.019, de 26 de novembro de 2007. Dispõe sobre o Programa nacional de reorientação da formação profissional em saúde – Pró-Saúde para os cursos de graduação da área da saúde. Diário Oficial da União. 05 Out 2007.. In 2008, in the formulation of the second Pro-Health, it assumes as a strategic priority by the Labor Education Program for Health (PET-HEALTH), inspired by the Tutorial Education Program Ministry of Education. This way the PET HEALTH was created as a strategy intersectoral directed not only to the training of health professionals, but also to strengthen primary health care, redirecting the practices of professionals that work in the Family Health Strategy²2 Ministério da Saúde. Ministério da Educação. Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde: objetivos, implementação e desenvolvimento. Brasília (DF): MS, MEC; 2007.^,33 Portaria Interministerial nº 3.019, de 26 de novembro de 2007. Dispõe sobre o Programa nacional de reorientação da formação profissional em saúde – Pró-Saúde para os cursos de graduação da área da saúde. Diário Oficial da União. 05 Out 2007.. The PET-HEALTH is based education through work and provides grants for tutors, teachers in public universities and private and preceptors, professional family health strategy, in addition to undergraduate courses in the field of health⁴4 Haddad AE, Campos FE, Freitas MSBF, Brenelli SL, Passarella TM, Ribeiro TCV. Programa de Educação pelo trabalho para a saúde – PET-Saúde. Cad ABEM. 2009;5:6-12..

Another strategy that integrates the Education Policy for the SUS is the Project Experiences and Internships Reality SUS – VER-SUS / Brazil, built in partnership between the Ministry of Health and the Student Movement in this area, with the main objective to give students the experience and experimentation of everyday of service systems SUS⁵5 Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Ver – SUS Brasil: cadernos de textos. Brasília (DF): MS; 2004.network. This project promotes the meeting between students of various courses degree in health throughout Brazil on stage experiences in the management of Unified Health System and enables the exchange between students.

Another version of PET - Health / Health Care Networks (PET- Health / Networking), was also launched in 2013, proposing an approximation of Higher Education Institutions (IES) with the more complex levels of care health, seeking to strengthen the most complex levels of the system health. This strategy presents itself as instrument qualification service of health professionals, enhancement and promotion of networks health care, work initiation and training of students of undergraduate courses in health⁶6 Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Secretaria de Atenção à Saúde. Edital nº 14, de 08 de março de 2013. Edital para o Programa de Educação pelo Trabalho para a Saúde - PET-Saúde/Redes de Atenção à Saúde (PET-Saúde/Redes). Diário Oficial da União. 11 Mar 2013..

Such governmental demonstrate that strategies to achieve necessary for the proper functioning of the SUS changes, investments in physical fitness of the service network, in technology, in medicine, for if alone are insufficient, without being added to this, the large investment changing practices of SUS workers and policy formation and technique of future health professionals.

In this context, this research started questioning how the students of the undergraduate experience in health strategies training.

The objective of this paper is to analyze the meaning assigned by students of undergraduate health care experiences in the areas of formation of the strategies of reorientation of health education the perspective of the SUS: PET-HEALTH and Internship Experiences SUS.

Methodology

It is a nature qualitative exploratory research. The qualitative research aims to deepen the universe meanings of actions, experiences and human relationships, including the internal dynamics of specific groups, institutions and actors, allowing reveal social processes⁷7 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12a ed. São Paulo: Hucitec; 2010.. And to allow an approximation of the researcher to the research object, its meaning and the context of reality⁸8 Gil AC. Métodos e técnicas de pesquisa social. 6a ed. São Paulo: Atlas; 2008., as in the case of reorientation training strategies in health experienced by students undergraduate.

In the state of Bahia existed when the fieldwork was done, seven higher education institutions (IES) public, two federal and four State: Universidade Federal da Bahia (UFBA), Universidade Estadual de Feira de Santana (UEFS), Universidade do Estado da Bahia (UNEB) Universidade Estadual do Sudoeste da Bahia (UESB), Universidade Estadual de Santa Cruz (UESC), and Universidade Federal do Recôncavo Baiano (UFRB).

Thus, the selected subjects were students of graduation health of public IES in Bahia, including an institution of public higher education in Pernambuco, the Universidade Federal do Vale do São Francisco (UNIVASF), because one of the campus of this situation IES in the town of Juazeiro, Bahia. The subjects were 12 students in the area of health institutions of public higher education in Bahia and Pernambuco.

It was used, as criteria for inclusion, students who participated PET-HEALTH at least for a year or Internship Experiences in SUS at least in one of its editions; be a student of undergraduate courses in health and be enrolled in undergraduate degree in selected one of the IES. Exclusion criteria was adopted: students with institutional and / or off-registration of PET HEALTH performance by unsatisfactory. We emphasize that the respondents who participated in the PET-HEALTH were in its first version (family health, surveillance, and alcohol drugs), because this study preceded the implementation period of the PET-HEALTH / NETWORKS, launched in 2013.

Of those interviewed, all participated in the Internship Experiences SUS and six participated in both strategies, PET-HEALTH and Stage Experiences of the SUS.

Data collection was operated during the monthly meetings of the Course Training of Mediators of Learning for the 5^th edition of the Stage Experiences in SUS in Salvador, Bahia, promoted by the School State of Public Health, Department of Health of the State of Bahia. The technique used for data collection was a semi-structured interview. Analysis of the material extracted from the interviews was performed using thematic analysis based on Bardin⁹9 Bardin L. Análise de conteúdo. 4a ed. Lisboa: Edições 70; 2009. and Minayo⁷7 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12a ed. São Paulo: Hucitec; 2010. method.

After the pre-analysis with organization of the data collected, and reading the interviews, material exploration and thematic analysis itself, the content of the interviews was divided into the following central categories: strategies for training as a source of interaction and learning; the experience strategies causes changes in the way think of health and education; strategies for retraining and new ways of seeing the SUS. For buth the research was approved by the Research Ethics Committee (CAAE: 0186.0.059.000-11) respecting the Resolution 196/96 of the National Health Council, when it developed the current fieldwork (10).

Results and discussion

Strategies for training as a source of interaction and learning

Understanding of students participate in the PET strategies - Health and Internship Experiences SUS had a positive meaning. The experience, according to respondents, enables learning topics that are not covered in the courses. Moreover, the experiences with the approach allow the daily services and practices of workers of different areas, allowing the identification and expansion of consciousness with student SUS policy, its value and importance to a country like Brazil. The experience also provided the exchange between students varied courses health, which does not happen in the formal spaces of practices courses and internships in health. This is an identified gap in formation process in the university: a precarious existence or nonexistence of a training process that enables the joint development work health, given that the nature of this is to be shared between different professionals and workers.

The motivation of students to participate in training strategies for SUS was related to the expectation that such projects could bring them a real SUS, in different local contexts, expanding its training, as say the health training goes beyond the walls of the university.

“I wanted to acquire knowledge in the same area, may have skills, meet new realities, because when you're in college, we get too attached to the stages that the university provides, and not have as much opportunity to get out to other regions, to have contact with other students”. (Ent.4)

According to the students, the experience in the health services was a source of reflective learning, expanding the understanding about the use of the same lessons learned in the university internal space and the need that they allow the professional practice with the aim of meeting the demands and needs of individuals who seek health services. Students said they understand that these experiences allow understand how services and a network of health care are structured, and whether or not they have conditions to meet the needs of individuals and communities, as well as the structural factors that limit results in the production of health actions and services.

The resulting experience is a conscious knowledge of their limits; an interim and related mutants set, insofar as it - the experience - not only discusses the cognitive registration of a subject, but also your senses, perceptions and emotions¹¹11 Capazzolo AA, Imbrizi JM, Liberman F, Mendes R. Experiência, produção de conhecimento e formação em saúde. Interface (Botucatu). 2013; 17(45):357-70..

The term experience encompasses both ways of experiencing and living. For Freud, it is at the same time experience immediately lived, that is, not presumed, not merely heard but direct and personally performed; while it is a lasting and meaningful experience¹²12 Barretta JPF. O conceito de vivência em Freud e Husserl. Psicol USP (São Paulo). 2010; 21(1):47-78..

Taking this into consideration we can say that through the experience of the students was possible to achieve a theory-articulation practice. In addition, sets up a mutual learning from experiments Earlier different individuals through the sharing of knowledge, because the strategies work in discussion groups.

For Henriques^13:152 "the time of immersion of the student in everyday services could bring very rich resources for learning and care the organization of work processes and management".

Respondents assert that participation in one or both strategies provided open communication channels between the students from different courses in the area of health. Through dialogue and interventions in an integrated way was it possible to share knowledge and practices of its core expertise, and experiences in applying them.

The work on health requires the participation of different actors. In field of public health, some thoughts have been produced about teamwork as a way to modify the model of health care. The communication is considered the common denominator of teamwork. The experiences of the respondents reaffirm that when there communication there is interaction in the collective work, where there is less inequality between different jobs and their agents and, therefore, greater integration into the team occurs¹⁴14 Pedduzi M. Equipe multiprofissional de saúde: conceito e tipologia. Rev Saude Publica. 2001; 35(1):103-9..

As teamwork is built on interaction, as nearest the status of ethical-social individual agents, the greater the possibilities to interact in situations free of coercion and submission, the search for consensus on the purpose and manner of performing the work¹⁴14 Pedduzi M. Equipe multiprofissional de saúde: conceito e tipologia. Rev Saude Publica. 2001; 35(1):103-9..

In interviews, the interdisciplinarity was also highlighted as a factor that values and integrates teamwork in health and contributes to training of new professionals to work towards the consolidation of SUS.

“many people think that interdisciplinarity is to join a lot of students from different courses in one place, and it is not. You can only interdisciplinary offering various services, with aggregation of several professionals, but have to have dialogue between these professionals, discuss clinical cases together. And these strategies can promote dialogue among students of various health courses”. (Ent.1)

“is very good, because you see, discuss, interdisciplinary experiences. You talk to people from other regions, people of different courses, different ages, different semesters, of different institutions. You do not get to its closed head only in your university”. (Ent.7)

Students point out that interdisciplinarity promoted by training strategies contributes to expanding the world view, to expansion of discussions on issues related to health in that provided the interaction of students from different courses, trainings and educational realities.

The interdisciplinary approach and work in multidisciplinary team are often not exploited by educational institutions, whose teaching is still based on disciplines. The disciplines are organizational categories of scientific knowledge which are based on the specialization of labor¹⁵15 Moretti-Pires RO. Complexidade em saúde da família e formação do futuro profissional de saúde. Interface (Botucatu). 2009; 13(30):153-66., the which contradicts own policy of higher education expressed in the Guidelines National Curriculum for higher education in the health field.

University education has problems dating back to the origin of scientific thought, configuring it as positivist paradigm to be overcome, with all its implications of political and epistemological nature¹⁶16 Campos FE, Aguiar RAT, Belisario SA. A formação superior dos profissionais de saúde. In: Giovanella L, organizadora. Políticas e sistemas de saúde no Brasil. Rio de Janeiro: Fiocruz; 2008. p. 1011- 34.. The teaching of disciplines, specializing knowledge, can´t always give the real dimension of social space occupied by a particular profession.

Training can´t take as reference only efficient search evidence to the diagnosis, care, treatment, prognosis, and etiology prophylaxis of diseases and disorders. Should seek to develop conditions meeting the health needs of individuals and populations, the sector management and social control in health, resizing the development of people's autonomy to the condition of influence in policymaking care¹⁷17 Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65..

The experience in strategies causes changes in thinking health and forming

We highlight the design of these programs cause changes in thinking of the students. Some feel more prepared professionally after participation in training strategies PET- Health and Internship Experiences. Such experiences also awaken a vision positive work in the public health system.

“I think it is an extremely interesting initiative because it goes far beyond what we see in college, they use reality, the dynamics of the SUS as a source of learning”. (Ent.6)

“I am very passionate about the SUS. In fact, more sprouted in me a seed of struggle for me to spend for other students it was possible a differentiated training through EVSUS and PET-HEALTH”. (Ent.4)

The diversification of learning scenarios as one of strategies for curriculum transformation and approach the students with everyday life of people, develops critical awareness in students about the problems of the population¹⁸18 Silva MAM, Amaral JHL, Senna MIB, Ferreira EF. O Pró-Saúde e o incentivo à inclusão de espaços diferenciados de aprendizagem nos cursos de odontologia no Brasil. Interface (Botucatu). 2012; 16(42):707-17..

The integration of students in the strategies makes that they know the causes different scenarios of professional work. Furthermore, it allows the learning of other fields of work, occupations, which helps future provision of comprehensive care and allows us to understand which activities that are specific to each profession, which ones are complementary and shared.

“It is an articulator space of professional enrichment for the student, which allows you to view the context of practice, analyzing the profiles of professionals to understand a little of the demand and the system, how it works”. (Ent.9)

“I began to realize that within the public health policies within the execution of the SUS, there was a great need for action for social assistance, within teams. So is the action of social assistance to users and to the staff at inter and multidisciplinary work units”. (Ent.6)

Depending on the perception that the student has about the strategies, this may impact on your life in such a way, even including, affecting your academic performance, their social relations and attitudes.

According to respondents, after participation they wish share with other students what was experienced in trying to also produce changes in those who had no opportunity to participate.

“I want to take to university as a way to revolutionize. When I returned the internship experience I motivated myself to put me in the student union, the student movement, I see myself as a social actor to change both training within the university and as a health professional” (Ent.2)

The student role is also one of the strong point of these strategies, particularly in Stage Experiences SUS. The conduct of activities by the students themselves establish a closer relationship and dialogue between them and professionals thus learning occurs more peaceful and effective manner because no hierarchy is established between those involved.

“the depth that the experience provides is you can listen to other professionals in training as well as you, and not have that hierarchical question you have fear of speaking. When you're on the teacher you measure your words. The question you're there with equal is the main experience of living [EVSUS], you can talk, you can actually manifest, say what you think”. (Ent.7)

“I think very good this wave of mediators are students. You inserts yourself increasingly. You pass not only your vision, but the idea of leadership when you see who is organizing”. (Ent.8)

In this process, the student is no longer seen as an object of learning and becomes its subject, one who learns with each other what their social group produces, such as values and self-knowledge¹⁹19 Secretaria de Saúde. Superintendência de Recursos Humanos da Saúde. Escola Estadual de Saúde Pública. Estágio de Vivências no SUS: o cotidiano do SUS enquanto princípio educativo. Salvador: SESAB; 2009.. Thus, the learning facilitator is a key element that must meet the role in stimulating critical thinking among other students from a concrete reality. This paper is subsidized, a theoretical perspective practice, Mediator Training Course and Learning for Internship Experiences in SUS.

Another highlight for the students was the opportunity to work in groups and the encouragement of collective construction in the teaching-apendizagem process.

“This stage provides the contact with other people, work in a group, listening to the opinions of others. You can also build and form an opinion, and try to see the best for the world in general, for the population, patient and client”. (Ent.12)

Students also revealed that the opportunity to participate in new strategies for reorienting the training produced feelings different between them. The feelings were provided hope, passion, struggle to discouragement, protest and anguish:

“It gives an anguish that you will hear lectures, studying and you see it's so hard to change the minds of professionals who are conformed to the way of their work and talk to us when you enter the system you will see that you will end up settling. People with completely shaped, molded, that the system will not change” (Ent.5)

“mind the highest intention and willingness was known elsewhere, another system to keep believing that you can still work out, when you see things right, it creates the hope that can still be changed”. (Ent.6)

For the respondents, the encounter with the population and professionals active in services was unsettling. In these spaces, they were stimulated to try new emotions, to rethink the reality relating it to the practical experience and comparing it with the worldview already prepared.

Among the proposals of the Pro-Health, the encouragement of active interaction with the student population and health professionals should occur since the beginning of the training process, allowing work on problems real, and assuming increased responsibilities, consistent with their level of autonomy³3 Portaria Interministerial nº 3.019, de 26 de novembro de 2007. Dispõe sobre o Programa nacional de reorientação da formação profissional em saúde – Pró-Saúde para os cursos de graduação da área da saúde. Diário Oficial da União. 05 Out 2007.^,1818 Silva MAM, Amaral JHL, Senna MIB, Ferreira EF. O Pró-Saúde e o incentivo à inclusão de espaços diferenciados de aprendizagem nos cursos de odontologia no Brasil. Interface (Botucatu). 2012; 16(42):707-17..

Strategies for retraining and new ways of seeing the SUS

Students consider that strategies were significant insofar as they cause sensitization in defense of the SUS and on work processes of their professions. Interests in strategies reverberate in the lives of respondents.

Recognizing that in the academic plan the logic that has guided educational movements is still significantly displaced, from both epidemiological reality as the healthcare purposes as initiated by the SUS. In practice exercises significant influence on the future planning of health professionals²⁰20 Feuerwerker LCM. Além do discurso de mudança na educação médica: processos e resultados. São Paulo: Hucitec; 2002., the experiences of students cause a critical this displacement between teaching and service. The respondents recognize that the development of the professional profile must be consistent with the needs of the SUS and that depend on both teaching at the university as the service experience.

Another issue that must be emphasized is that the respondents think that advance the knowledge of the SUS and health policies is needed for the improvement of health care. To that, they consider it important to expand the teachings offered in the matrices curriculum, taking advantage of new experiences in different contexts and various strategies.

“The experience itself both EVSUS, as some curricular components focused on public health and the PETs which allows us to analyze the profile of professional we will be, and hence, since graduating from already developing a more suitable profile for SUS needs”. (Ent.9)

The understanding of various learning scenarios and the subsequent professional practice leads students to reflect on the future workplace, the purpose of the course and the path that will be traversed to achieve their goals.

For one interviewee, the Stage Experiences in SUS also awakens reflections on the importance of health management.

“Stage makes us mature, and made me think, reflect on management, know specifically manage my course that has no discipline focused on health management, my role in this area as a student and professional future health”. (Ent.2)

The interviewee from one of the topics discussed, in this case the health management, realized the gap that leaves the university in its training on the topic.

The interviewees' statements showed that participation in training strategies encourages students to approach the management arrangements and the possibility of becoming manager in the future. However, recognize that they need further clarification on the subject, given that his graduation in no specific courses in health management.

“I am in 3rd semester and I had no contact with the SUS, the only contacts that had been provided by PET and by EVSUS and this allows an early contact with the SUS” (Ent.1)

“actually EVSUS for me was one more proof that I really like to wear the shirt ... I see no downside and I think the design is very good”. (Ent.9)

Another relevant aspect and identified in the speeches of undergraduates are refers to the change of view on the SUS since before many of the experiences had a theoretical conception of the system based on image relayed by print and broadcast media.

“[..] for me, it was a modification about what was the SUS, I had a vision that the SUS was just chaos, it was you get a unit or hospital stay hours and still waiting to be treated poorly, expect the goodwill employees to attend you or the doctor that don’t look to you”. (Ent.5)

“the vision about the SUS has changed a lot, because when we think, we have the view of the media, newspaper, the row of SUS, the people who are being detained in unsuitable, without blanket, beds we think: "this SUS is so bad. "(Ent.8)

These discuss show the image of the SUS in the society. This image is influenced by the information disseminated by the media, even for students in the health field. Show that some students had an image of SUS restricted to that which is propagated by the media, which can also indicate the elementary discussion of the public system in content of health education at the university.

Through the strategies of reorientation training for the SUS, students face up the ideal SUS and the real SUS. This contributes to a new representation of the SUS, concrete, political and indeed experienced through their daily lives.

Conclusion

For students of undergraduate health care of Bahia and Pernambuco, the participation in new strategies for reorienting the training health from the perspective of SUS (PET HEALTH and-the Internship Experiences SUS) was considered as spaces for meaningful learning, allowing an understanding of their professional place of experimentation and interdisciplinary work. And we note that there was a difference in perception between students who participated in the VERSUS and PET those who participated only the PET, despite strategies occur at different national times and settings.

They recognize that the interaction between service and education causes approach with the reality of health services, awakening them, to in the future, take up the work in the public health system.

Students consider that the strategies enable learning expanded topics, and that curricular activities at the university does not can contemplate.

The living in the new spaces health training encourages multidisciplinary and interdisciplinary approach that is considered one of the more meaningful learning, and facilitates the work subsequent to training.

Operating strategies, students feel part of the process teaching and learning through the use of methodologies that encourage participation and joint action and not hierarchical, allowing them to be protagonists of this process.

Participation causes reflections about the function of the university that, beyond technical and scientific qualification, is also to stimulate development of critical, ethical and social spirit. Early insertion of students in the experiences enables a reconstruction of what is beyond the SUS the imaginary common sense built by the media, frankly contrary to this public policy.

In the end, we can conclude that this such learning strategies allow us to state that the process of teaching and learning can and should break through the fragmentation of knowledge and health practices, allowing to identify correlations between the knowledge, the complexity of life and the health problems of the population. Such experiences should be expanded and its operational strategies introduced us whenever consistent with the objectives of the curriculum areas and public health training ordered by SUS university.

References

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