Abstracts

Brief explanation and introduction to the text

In 2010, the Botucatu Medical School (BMS) was selected in the public notice no. 24/2010 of the Coordination for the Improvement of Higher Education Personnel (Capes, as per its acronym in Portuguese), in a partnership between this institution and the Brazilian Ministry of Health (MH). This initiative, devised in the scope of the Brazilian Program for Teaching and Research Support in Strategic Areas (PRONAP, as per its acronym in Portuguese), designed a series of policies and inducing actions, carried out by the Brazilian Ministries of Health and Education, to consolidate the Unified Health System (SUS, as per its acronym in Portuguese). This process aimed to promote and expand the training of professors and development of research about teaching in different health areas, in existing and consolidated graduate programs. The proposal of the Pró-ensino na Saúde public notice was inserted in the Brazilian Policy for Health Professionals Training, which began to be implemented in 2003 in the MH. The projects could be suggested by groups of professors and researchers from public and nonprofit private institutions¹1. Ministério da Educação (BR). Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Diretoria de Programas e Bolsas no país – DPB. Coordenação Geral de Programas Estratégicos – CGPE. Coordenação de Indução e Inovação – CII. Pró-Ensino na Saúde: Edital Nº 024/2010. Brasília: MEC; 2010.,²2. Ministério da Educação (BR). Programa atua na consolidação da formação dos profissionais da saúde. Brasília: CAPES; 2014..

The projects had to be developed between 2011 and 2016, and their execution should last five years at most. It was assumed that, by encouraging the creation of branches or concentration areas on teaching in graduate programs, it would be possible to improve teaching training in graduate courses, and, consequently, contribute to progressing changes in health undergraduate courses, especially during the expansion in the number of vacancies and degree programs that the country was experiencing.

The public notice took in account that, despite the diversity of topics referring to health teaching, priority would be given to the following thematic areas: health teaching management; curriculum teaching-learning processes in health undergraduate and graduate courses; evaluation in health teaching; teaching training and development in the health field; integration between universities and health services; integration policies between health, education, and science and technology; and face-to-face and online technologies in health teaching¹1. Ministério da Educação (BR). Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Diretoria de Programas e Bolsas no país – DPB. Coordenação Geral de Programas Estratégicos – CGPE. Coordenação de Indução e Inovação – CII. Pró-Ensino na Saúde: Edital Nº 024/2010. Brasília: MEC; 2010..

The selected project “Integration between universities, health services, and communities at the BMS: setting up new training and research practices” had the objective to develop and consolidate support to research and teaching in the health field by improving undergraduate and graduate teaching, thus contributing to expanding, strengthening and qualifying the development of research, knowledge production, and training in the “integration between universities and health services” thematic area. The project intended to train masters and doctors involved in the creation of health graduate courses by carrying out studies that problematized their practices in the SUS formation process.

The development of research on undergraduate teaching in primary health care (PHC) was the object of these investigations, and professors, healthcare professionals, and students involved in teaching processes oriented to SUS training challenged themselves to examine the professional training obtained through PHC practice. The initiative was planned to increase the understanding of the insertion of students in basic health units and basic family health units, under the professional supervision of a professor-tutor; curricular integration between medical and nursing courses, and between these and the family health multiprofessional residency program; bonding with local communities, health teams, and social equipment of the areas covered by health units; development of activities with insertion in health work practices; prioritization of activities with social relevance, based on problem-solving, in the context of each territory; expansion of the dialogue healthcare professionals establish with themselves, population, and managers; development of teaching and learning activities to help consolidate SUS; and pedagogical training and innovations coordinated with education through work, changes in BMS teaching practices, and national reforms and proposals, including the relationship with and development of the Brazilian curricular guidelines (BCG).

The objectives of the present paper were to report the experience of BMS in the development of research, knowledge production, and training in health teaching, and present the results of the investigations carried out after the selection of the institution in the Capes Pró-ensino na Saúde public notice.

Authors that dialogue with the following studied themes made up the theoretical framework: problem-solving education in the health field; problem-solving methodology; community teaching; integration between university, service, and community; continuing education of professors and healthcare professionals; and interprofessional education in the health field.

The present paper is a report of an exploratory project, which can be denominated so for bringing up problems with little accumulated and systematized knowledge, such as healthcare workers as professors, interprofessional education in PHC in higher education, and home visits in the training of doctors. The nature of the approach reveals that it is an intervention study, whose main goal was to build knowledge to impact changes in health training, marked by the commitment to propose the investigation of problems identified in the teaching practice to establish actions to tackle the issues in a participative way.

It is important to stress that, although the focuses of the studies were the development and evaluation of a set of implemented subjects, as in a case study, some investigations did not limit their scope to the analysis of this methodological method, and elaborated on other models of PHC teaching and dialogued with Brazilian experiences in the teaching-service integration.

The participation of BMS in Pró-ensino na Saúde

Since its implementation in 1963, BMS has been involved in questions concerning medical education and its renewal movements, offering an education that values the active role of students in the learning process, with moments of integration between theory and practice. It is experiencing the beginning of the cooperation between teaching and services, with the participation of several departments and subjects.

In the past three decades, BMS has promoted actions to suit its teaching to the health needs of the population, and meet BCG. In 1989, it implemented the undergraduate nursing course, with a curriculum that incorporated the proposal of training in different healthcare levels.

In 2001, the school instituted the Pedagogical Support Center, first to back up the need to change the curriculum of undergraduate medical courses, and later to extend the measure to nursing courses. The conception of the center presented the following objectives: to formulate a proposal for continuing evaluation of medical teaching, to offer technical support to changes oriented to improve teaching, to promote teaching training focused on the learning of methodological innovations, to develop research on medical education, and to expand teaching spaces in SUS. The idea was to simultaneously support external demands, such as the necessary adaptation to BCG, and internal requirements, for instance a larger academic production on health teaching.

The Secretariat for Work and Education Management in Health, created in 2003, added to the process of curriculum change in BMS by supporting initiatives that aimed to coordinate the management and service network with professional training institutions, focusing on comprehensiveness and continuing education.

An innovative educational activity was proposed in BMS in 2003, as a direct result of the participation in these programs: the University-Service-Community Interaction (IUSC, as per its acronym in Portuguese). Originally implemented as a complementary activity, it became a set of regular and mandatory subjects of the medical undergraduate course in 2007, and of the nursing course in 2008, introducing both degrees in interprofessional training.

The subjects called IUSC I, II, and III are taken from the first to the third year of the course in the medical school and in the two first years of the nursing course. Consequently, PHC pervades the two courses in all their years; in these cases, in the form of interdisciplinary, interdepartmental and interprofessional subjects. In the first year, there is a valorization of territory study and family follow-up, with emphasis on the development of community life, communication and narratives. The second year focuses on dialogic education in communities, and follow-up of the same families, with a focus on their health and community-related questions. The third year emphasizes expanded clinical medicine. The whole project is based on education through work and is developed in small groups of students inserted in a PHC territory.

There are approximately 120 students each year, 90 in the medical course and 30 in the nursing one. To develop activities, they are split into two mixed groups, under the supervision of a professor-tutor.

The activities of these subjects take place in partnership with the Botucatu Municipal Health Secretariat and community leaders, and have been offered with the participation of professors from BMS and professionals from the PHC network, designated professors-tutors, who have different backgrounds in the healthcare and education areas. This deliberate choice had the objective to provide students with the interprofessional interaction in different teaching scenarios. Consequently, professors and PHC professionals work together in teaching, in a process of continuing education. This outline underwent several restarts and reviews during the work developed in the subjects, and prompted the need for constant negotiation with BMS and the Botucatu Municipal Health Secretariat.

Despite the importance of the expertise and variety of professionals in the board of professors-tutors of IUSC, it is undeniable that these facts rose reflection and conflict at BMS since the implementation of the subjects.

The design of these subjects, and the need for a critical and reflective look at them and similar experiences in other higher education institutions made clear the necessity to carry out studies, knowledge production, and training in health teaching in the interface between universities and health services at BMS.

Following this path, a group of professors-researchers saw the Pró-ensino na Saúde public notice as an opportunity to promote the valuing of research on PHC teaching. Concurrently, it was noticed that the project could boost new studies about pedagogical training, teaching practice, and quality of teaching in PHC.

Systematizing and socializing the present manuscript resulted in knowledge and appropriation of this know-how, this way to ponder the routine of health teaching and education through work, originating questions, and creating and improving collective constructs between professors, students, workers, managers, and users. Given this scenario, the authors of the present study invite readers to read, criticize, assemble, and disassemble the products of this research project.

Pró-ensino na Saúde at BMS: producing research, training, education, and health

The project discussed in the present paper belonged to the Development and Analysis of Technologies and Processes for Training of Healthcare Professionals line of research of the graduate program in collective health of BMS.

Taking into account that PHC teaching practices deal with an ethnical-technical-political project to train professionals to work at SUS guided by care comprehensiveness and teamwork, Chart 1 lists the objectives and main findings obtained in investigations resulting from Pró-ensino na Saúde, followed by excerpts to illustrate their potentialities.

The studies listed in Chart 1 originated six academic master’s degrees and six doctorates that were published as books and scientific papers, and disseminated in scientific conferences, among other forms.

The professional training, teaching methods, and PHC teaching themes were investigated from different perspectives, from the point of view of medical and nursing undergraduate students to healthcare professionals, such as doctors, nurses, dental surgeons, health community agents, nursing technicians and/or aides, and coordinators of health courses and subjects/modules related to primary care.

All the studies reported in the present paper were approved by the BMS Research Ethics Committee, in accordance with resolution no. 466/2012, which instituted guidelines and norms that regulate human research¹³13. Ministério da Saúde (BR). Resolução CNS 466, de 12 de Dezembro de 2012. Diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Brasília: Ministério da Saúde; 2012.. The majority of the investigations were qualitative, and sought to understand the examined experiences and the perceptions associated with them, by agents involved in the processes and relationships established between interlocutors¹⁴14. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12a ed. São Paulo: Hucitec; 2010..

The instruments used to collect data were mostly semi-structured interviews, documentary analysis, focus groups, and questionnaires. Data organization, on the contrary, was carried out in multiple ways, such as the content analysis method proposed by Bardin¹⁵15. Bardin L. Análise de conteúdo. 4a ed. Lisboa: Edições 70; 2011., the creation of categories set in meaning and sense nuclei with analysis by a historical-cultural approach, and Vigotski’s explanation method¹⁶16. Vigotski LS. A construção do pensamento e da linguagem. 2a ed. São Paulo: Martins Fontes; 2001..

Overall, the studies posited the important role of teaching institutions in the training of future healthcare professionals, and the relevance of teaching methods that potentiate the teaching-learning process, such as interprofessional education and the problem-solving methodology. Additionally, the relationship between PHC services, teaching institutions, and undergraduate health students stood out as one of the most prevalent topics.

Nevertheless, it is known that Brazilian higher education institutions still apply the traditional and hegemonic teaching model, which compartmentalizes knowledge, and leads to professional silos, and inefficient and little resolutive teamwork. Their practice setting is a care model focused on disease and subordinateness of health professionals to the medical work¹⁷17. Costa MV. A educação interprofissional no contexto brasileiro: algumas reflexões. Interface (Botucatu). 2016; 20(56):197-8..

Given this panorama, and the need to change professional training to achieve a better integration of teaching with health services and improve the relationship between different health professionals, interprofessional education has been pointed as a tool that can promote alteration in teaching settings toward efficient practices to cope with social and health problems¹⁸18. Barr H, Koppel I, Reeves S, Hammick M, Freeth D. Effective interprofissional education: arguments, assumption & evidence. London: Blackwell; 2005., ¹⁹19. Carpenter J, Dickinson H. Interprofessional education and training. 2a ed. Bristol: The Policy Press; 2016..

In 2010, the World Health Organization issued a report entitled Framework for action on interprofessional education and collaborative practice, which pointed that interprofessional education happens “when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes”²⁰20. World Health Organization. Framework for action on interprofessional education and collaborative practice. Geneva: WHO; 2010.. (p. 7)

Taking into consideration that few Brazilian institutions use interprofessional education as a basis for the teaching-learning process to promote a future collaborative practice between healthcare professionals¹⁷17. Costa MV. A educação interprofissional no contexto brasileiro: algumas reflexões. Interface (Botucatu). 2016; 20(56):197-8., this teaching tool was the topic of one of the studies, in which students saw colleagues from different backgrounds as a source of learning, leading to a greater collaboration between students in activities at BMS¹¹11. Santos LC. A educação interprofissional na graduação de Medicina e Enfermagem: vivências e percepções de alunos [dissertação]. Botucatu: Universidade Estadual Paulista; 2015..

This investigation disclosed the perception of shared work as an important way to reach care comprehensiveness, although the stereotypes of professions have been mentioned as barriers in interpersonal relationships. It was also possible to identify professors-tutors as the people who mediated or limited learning, for having a professional training different from the students’, and as a fundamental key in the mediation of the whole teaching-learning process²¹21. Berbel NAN. A metodologia da problematização em três versões no contexto da didática e da formação de professores. Rev Dialogo Educ. 2012; 12(35):101-18..

Student knowledge sharing takes place in these subjects not just through the interprofessional practice, but also the problematizing education, used as a teaching method that enables students to be co-responsible for their learning and to be trained to work as professionals that can formulate solutions when faced with problems²¹21. Berbel NAN. A metodologia da problematização em três versões no contexto da didática e da formação de professores. Rev Dialogo Educ. 2012; 12(35):101-18..

Working on problematization involves discovery, autonomy and initiative resulting from provocations that encourage thinking and prepare students to have a critical consciousness. In addition, it allows a new interpretation of the world, which guides on its transformation²¹21. Berbel NAN. A metodologia da problematização em três versões no contexto da didática e da formação de professores. Rev Dialogo Educ. 2012; 12(35):101-18..

Another study showed that, through the activities developed with communities in the set of subjects, students could understand the power of education as a social transformation tool, and recognize the tensions resulting from dealing with problematizing teaching practices. The investigation highlighted the presence of constructive and questioning dialogues among the people involved and the bet in transformative actions⁷7. Villardi ML. A problematização em educação em saúde: percepções dos professores tutores e alunos [tese]. Botucatu: Universidade Estadual Paulista; 2014..

Students indicated that after they took the subject they began to value health education as a transformation vehicle and construe it as crucial to every healthcare professional⁷7. Villardi ML. A problematização em educação em saúde: percepções dos professores tutores e alunos [tese]. Botucatu: Universidade Estadual Paulista; 2014.:

Students also stressed that performing activities with communities favored a problematizing health practice⁷7. Villardi ML. A problematização em educação em saúde: percepções dos professores tutores e alunos [tese]. Botucatu: Universidade Estadual Paulista; 2014.:

At this point, it is necessary to emphasize praxis as one of the central topics of the problematization methodology, because students have the opportunity to surpass their spontaneous point of view and evolve toward a reflective, informed, and creative professional consciousness²³23. Costa NMSC. Formação pedagógica de professores de medicina. Rev Lat Am Enfermagem. 2010; 18(1):102-8.. It is fundamental to stress the role of professors-tutors in the subjects as people who coordinate health services with universities, taking into account that they try to keep an equal, democratic, and socially built relationship with students, mediated by the use of teaching tools (problematization and interprofessional education)²²22. Barr H, Low H. Introducing Interprofessional Education. Fareham: CAIPE; 2013..

This relationship is clear in one of the investigations mentioned in the present paper, through the following report:

The pedagogical training of professors must be inserted in the movements of creation and building of a new consciousness. To achieve that, it is usually necessary to make emerge the ‘whys’ and ‘hows’ of being a professor, based on a collective and continuous reflection process about the personal experience, providing thus an aware teaching action that develops the potentiality of professors to search for solutions and optimize capacities by conjugating beliefs, values, and knowledge²³23. Costa NMSC. Formação pedagógica de professores de medicina. Rev Lat Am Enfermagem. 2010; 18(1):102-8..

This study, dedicated to examining the role of professors-tutors, made clear the recognition of the existence of a work that aimed to provide students with knowledge, and empower them to play their part as educators with more confidence³3. Manoel CM. A experiência multiprofissional e interdisciplinar da interação universidade-serviços-comunidade: o olhar e o trabalho do professor tutor [tese]. Botucatu: Universidade Estadual Paulista; 2012.. Professors should have the opportunity to be protagonists in their work, that is, to be free to make decisions and define alternatives for their teaching activities²⁴24. Cunha MI. O professor universitário na transição de paradigmas. Araraquara: Junqueira & Marin; 1998..

It is noteworthy that these policies enabled teaching institutions to adjust their practices to make them compatible with SUS principles and guidelines that allowed their coordination with health services.

In that sense and taking into account the relevance of these policies, one of the topics prioritized as the subject of one of the studies looked at the role of 2001 BCG when curricular changes are posed. This investigation identified in three medical schools in the state of São Paulo the depreciation of PHC in medical courses, the tensions between universities and services to perform teaching in communities, and the distance between the academic standpoint and the teaching practice⁹9. Bravo VAA. Explorando o ensino médico na atenção primária à saúde de diferentes escolas médicas do estado de São Paulo [tese]. Botucatu: Universidade Estadual Paulista; 2014., which contradicts what health undergraduate BCG establishes to be a “contextualized practice” in different teaching settings since the beginning of training²⁵25. Feuerwerker LCM, Cecílio LCO. O hospital e a formação em saúde: desafios atuais. Cienc Saude Colet. 2007; 12(4):965-71..

Another study about community teaching and the interaction between services and universities analyzed tensions and potentialities of the relationship between medical and nursing undergraduate students and PHC workers in healthcare services⁴4. Pinto TR. A atenção primária à saúde e o ensino: tensionamentos e potencialidades nas práticas pedagógico-assistenciais [tese]. Botucatu: Universidade Estadual Paulista; 2013.,²⁶26. Pinto TR, Cyrino EG. Profissionais de saúde como professores: tensões e potências nas práticas de ensino na atenção primária à saúde. São Paulo: Cultura Acadêmica; 2014..

The main positive aspects pointed by professionals were: the richness of the contact with students, which encourages them to search for new knowledge; the achieved learning, which qualifies them and enables them to expand care practices in new care branches; the incentive they receive to break out of convenience and consolidated conduct standards; and the gratification they feel for contributing to training future professionals, fitter to work on SUS⁴4. Pinto TR. A atenção primária à saúde e o ensino: tensionamentos e potencialidades nas práticas pedagógico-assistenciais [tese]. Botucatu: Universidade Estadual Paulista; 2013.,²⁶26. Pinto TR, Cyrino EG. Profissionais de saúde como professores: tensões e potências nas práticas de ensino na atenção primária à saúde. São Paulo: Cultura Acadêmica; 2014..

Despite the overall positive feedback, the publications presented elements that still need to be explored and refined by the proposal coordinators, in the spheres of both university and service management and coordination. A few examples of aspects that should be improved are: need to better adjust the activities between teaching institutions and services, in consonance with the local specificities; better planning and organization of conjoint actions with teams, taking into consideration the reality of each territory; and the importance to carry on the proposals over time, instead of executing them sporadically⁴4. Pinto TR. A atenção primária à saúde e o ensino: tensionamentos e potencialidades nas práticas pedagógico-assistenciais [tese]. Botucatu: Universidade Estadual Paulista; 2013.,²⁶26. Pinto TR, Cyrino EG. Profissionais de saúde como professores: tensões e potências nas práticas de ensino na atenção primária à saúde. São Paulo: Cultura Acadêmica; 2014..

Final considerations

The scientific production examined in the present paper showed how Pró-ensino na Saúde was powerful and strategic in the fulfillment of the objective to make health professionals more prepared to meet the health demands of the population, and develop team and collaborative work. The project originated academic research in priority areas for health work on SUS, and helped qualify graduate students in the collective health field, with a focus on professional training. It allowed for partnerships between several subjects and spaces involved in the professional training of students regarding community teaching, and also offered an opportunity to discuss the use of active teaching methodologies that could better train doctors and nurses.

The making of knowledge in different moments of community teaching caused the interaction between universities, services, and communities to get stronger, in the form of student training, a greater appropriation of the theme by professors, and the continuing education of the professionals involved.

It is possible to state that the integration experiences adopted by BMS and promoted by the IUSC subjects over time are currently recognized and legitimized by different professionals in several settings.

References

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