Abstract

Introduction

The education framework of the physiotherapist as a health professional was gradually constituted as the profession itself evolved¹1 Espindola DS, Borenstein MS. Evolução histórica da fisioterapia: da massagem ao reconhecimento profissional (1894-2010). Fisioter Bras. 2011; 12(5):389-94.. The first teaching models emerged in Brazil in the middle of the 19^th century²2 Marques AP, Sanches EL. Origem e evolução da Fisioterapia: aspectos históricos e legais. Rev Fisioter Univ São Paulo. 1994; 1(1):5-10.. Initially, education was not provided by teaching institutions³3 Oliveira VRC. A história dos currículos de Fisioterapia: a construção de uma identidade profissional [dissertação]. Goiânia: Pontifícia Universidade Católica de Goiás; 2002. and merely prepared workers to help physicians in rehabilitation, mainly of children with poliomyelitis, soldiers with orthopedic, neurological and spinal cord sequelae from the First and Second World Wars, and people who had had occupational accidents⁴4 Teixeira RC, Muniz JWC, Nazaré DL. O currículo para a formação do fisioterapeuta e sua construção histórica. Cad Educ Saude Fisioter. 2017; 4(7):27-39.^,55 Koetz LCE, Périco E, Grave MQ. Distribuição geográfica da formação em fisioterapia no Brasil: crescimento desordenado e desigualdade regional. Trab Educ Saude. 2017; 15(3):917-30..

The first proposal regarding a minimum curriculum for Physiotherapy education dates back to 1964⁵5 Koetz LCE, Périco E, Grave MQ. Distribuição geográfica da formação em fisioterapia no Brasil: crescimento desordenado e desigualdade regional. Trab Educ Saude. 2017; 15(3):917-30.. In 1969⁶6 Brasil. Câmara dos Deputados. Decreto-Lei nº 938, de 13 de Outubro de 1969. Prevê sobre as profissões de fisioterapeuta e terapeuta ocupacional, e dá outras providências. Diário Oficial da União. 14 Out 1969., the Brazilian government determined that it is necessary to undergo university education to become a physiotherapist, which qualified the provided care and increased the number of courses in Brazil. Back then, only short-term courses were offered and the curriculum was composed of basic and specific subjects that valued the medical profession. In 1983, a new minimum curriculum for undergraduate courses was instituted. Its approach was predominantly curative, disease-centered, and restricted to hospitals and rehabilitation services²2 Marques AP, Sanches EL. Origem e evolução da Fisioterapia: aspectos históricos e legais. Rev Fisioter Univ São Paulo. 1994; 1(1):5-10.^,55 Koetz LCE, Périco E, Grave MQ. Distribuição geográfica da formação em fisioterapia no Brasil: crescimento desordenado e desigualdade regional. Trab Educ Saude. 2017; 15(3):917-30.^,77 Bispo Junior JP. Fisioterapia e saúde coletiva: desafios e novas responsabilidades profissionais. Cienc Saude Colet. 2010; 15 Supl 1:1627-36..

In a shift from massage therapy to physical rehabilitation, actions related to health promotion and disease prevention¹1 Espindola DS, Borenstein MS. Evolução histórica da fisioterapia: da massagem ao reconhecimento profissional (1894-2010). Fisioter Bras. 2011; 12(5):389-94.^,55 Koetz LCE, Périco E, Grave MQ. Distribuição geográfica da formação em fisioterapia no Brasil: crescimento desordenado e desigualdade regional. Trab Educ Saude. 2017; 15(3):917-30. started to be discussed in the field of Physiotherapy, in the spheres of education and work.

Curricular restructurings were driven by Brazil’s 1996 National Education Law, by discussions promoted by entities representing the profession, and by the establishment, in 2002, of the National Curricular Guidelines (DCN). Following the restructurings, the physiotherapist started to work in all levels of healthcare, in the perspective of comprehensive care, having autonomy in the decision-making process and communicating with users, families and the other health professionals⁵5 Koetz LCE, Périco E, Grave MQ. Distribuição geográfica da formação em fisioterapia no Brasil: crescimento desordenado e desigualdade regional. Trab Educ Saude. 2017; 15(3):917-30.^,88 Brasil. Conselho Nacional de Educação. Câmara de Educação Superior. Resolução nº 4, de 19 de Fevereiro de 2002. Institui as Diretrizes Curriculares Nacionais do curso de graduação em Fisioterapia. Brasília: Conselho Nacional de Educação; 2002.. Breaking with the focus on disease and based on an expanded concept of health, the DCN have brought the perspective of Physiotherapy education connected with the Brazilian National Health System (SUS)⁸8 Brasil. Conselho Nacional de Educação. Câmara de Educação Superior. Resolução nº 4, de 19 de Fevereiro de 2002. Institui as Diretrizes Curriculares Nacionais do curso de graduação em Fisioterapia. Brasília: Conselho Nacional de Educação; 2002.

9 Bertoncello D, Pivetta HMF. Diretrizes curriculares nacionais para a graduação em Fisioterapia: reflexões necessárias. Cad Educ Saude Fisioter. 2015; 2(4):71-84.^-1010 Schwingel G, Koetz LCE. A Fisioterapia e o SUS: reflexões sobre a formação e o papel do fisioterapeuta na equipe de saúde. Bol Saude. 2008; 22(2):151-60.. Thus, the care provided by the physiotherapist is no longer exclusively individualized and based on individual decisions, as group practices and collective, interdisciplinary/interprofessional decisions with the participation of users have been incorporated¹1 Espindola DS, Borenstein MS. Evolução histórica da fisioterapia: da massagem ao reconhecimento profissional (1894-2010). Fisioter Bras. 2011; 12(5):389-94.^,1111 Lourido BP, Rocha VM. Fisioterapia comunitaria: el camino desde de la conceptualización a la intervención con la comuni-dad. Fisioterapia. 2008; 30:244-50..

In Primary Health Care (PHC) - the strategic axis of SUS to consolidate the universal-equitable-comprehensive model of healthcare provision for the Brazilian population¹²12 Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saude Debate. 2018; 42 Esp 1:208-23. -, physiotherapists are not included in the basic team of the Family Health Strategy (FHS), but they can integrate the amplified teams of FHS or compose, with other professions, the Family Health Support Center (NASF)¹³13 Tavares LRC, Costa JLR, Oishi J, Driusso P. Inserção da fisioterapia na atenção primária à saúde: análise do cadastro nacional de estabelecimentos de saúde em 2010. Fisioter Pesqui. 2018; 25(1):9-19.

14 Braghini CC, Ferretti F, Ferraz L. Physiotherapist’s role in the NASF: perception of coordinators and staff. Fisioter Mov. 2016; 29(4):767-76.^-1515 Batiston AP, Bonilha LAS, Pierette F, Medeiros AA, Duenha C, Grosseman S, et al. Implantação de uma nova proposta pedagógica para o estágio supervisionado em fisioterapia na atenção básica: relato de experiência. Cad Educ Saude Fisioter. 2017; 4(8):48-55.. Such action is still limited to a few professionals and is marked by important regional differences¹³13 Tavares LRC, Costa JLR, Oishi J, Driusso P. Inserção da fisioterapia na atenção primária à saúde: análise do cadastro nacional de estabelecimentos de saúde em 2010. Fisioter Pesqui. 2018; 25(1):9-19..

In the context of changes in education and health policies, and in view of the recent – and ongoing - historical conception of the profession⁵5 Koetz LCE, Périco E, Grave MQ. Distribuição geográfica da formação em fisioterapia no Brasil: crescimento desordenado e desigualdade regional. Trab Educ Saude. 2017; 15(3):917-30., connecting the teaching of Physiotherapy to SUS has become a tendency marked by advances and challenges¹⁵15 Batiston AP, Bonilha LAS, Pierette F, Medeiros AA, Duenha C, Grosseman S, et al. Implantação de uma nova proposta pedagógica para o estágio supervisionado em fisioterapia na atenção básica: relato de experiência. Cad Educ Saude Fisioter. 2017; 4(8):48-55.

16 Ferreira ALPP, Rezende M. Reflections on the production of the formation of physiotherapy in the context of SUS. Fisioter Mov. 2016; 29(1):37-44.

17 Formiga NFB, Ribeiro KSQS. Inserção do fisioterapeuta na atenção básica: uma analogia entre experiências acadêmicas e a proposta dos Núcleos de Apoio à Saúde da Família (NASF). Rev Bras Cienc Saude. 2012; 16(2):113-22.

18 Silva LWS, Souza M, Souza TO, Souza TF. Contexto do cuidado fisioterapêutico: reveses e vieses na inserção comunitária à atenção domiciliar. Rev Kairós Gerontol. 2013; 16(3):79-101.

19 Bin CR, Diamante C. Formação em Fisioterapia: como a saúde coletiva está inserida nas instituições públicas de ensino superior do Paraná. Cad Educ Saude Fisioter. 2020; 7(13):e071304.

20 Rangel Neto NC, Aguiar AC. A Atenção Primária à Saúde nos cursos de graduação em Fisioterapia no município do Rio de Janeiro. Trab Educ Saude. 2018; 16(3):1403-20.

21 Silva DJ, Da Ros MA. Inserção de profissionais de Fisioterapia na equipe de saúde da família e Sistema Único de Saúde: desafios na formação. Cienc Saude Colet. 2007; 12(6):1673-81.^-2222 Medeiros PA, Pivetta HMF, Mayer MS. Contribuições da visita domiciliar na formação em fisioterapia. Trab Educ Saude. 2012; 10(3):407-26..

PHC has become a practice setting for teaching in the area of health that enables students to recognize the healthcare networks in SUS and to expand the knowledge of their profession, as well as that of the other professions²³23 Ely LI, Toassi RFC. Integração entre currículos na educação de profissionais da saúde: a potência para educação interprofissional na graduação. Interface (Botucatu). 2018; 22 Supl 2:1563-75.^,2424 Toassi RFC, Olsson TO, Lewgoy AMB, Bueno D, Peduzzi M. Ensino da graduação em cenários da atenção primária: espaço para aprendizagem interprofissional. Trab Educ Saude. 2020; 18(2):e0026798.. It allows students to have contact with the needs and routines of families and with multiprofessional teamwork¹⁰10 Schwingel G, Koetz LCE. A Fisioterapia e o SUS: reflexões sobre a formação e o papel do fisioterapeuta na equipe de saúde. Bol Saude. 2008; 22(2):151-60.^,2323 Ely LI, Toassi RFC. Integração entre currículos na educação de profissionais da saúde: a potência para educação interprofissional na graduação. Interface (Botucatu). 2018; 22 Supl 2:1563-75.

24 Toassi RFC, Olsson TO, Lewgoy AMB, Bueno D, Peduzzi M. Ensino da graduação em cenários da atenção primária: espaço para aprendizagem interprofissional. Trab Educ Saude. 2020; 18(2):e0026798.^-2525 Carvalho DFF, Siqueira-Batista R. Fisioterapia e Saúde da Família: inserção, processo de trabalho e conflitos. Vittalle Rev Cienc Saude. 2017; 29(2):135-45., enabling them to understand the inclusion and action of the physiotherapist in the sphere of PHC¹⁵15 Batiston AP, Bonilha LAS, Pierette F, Medeiros AA, Duenha C, Grosseman S, et al. Implantação de uma nova proposta pedagógica para o estágio supervisionado em fisioterapia na atenção básica: relato de experiência. Cad Educ Saude Fisioter. 2017; 4(8):48-55.^,2525 Carvalho DFF, Siqueira-Batista R. Fisioterapia e Saúde da Família: inserção, processo de trabalho e conflitos. Vittalle Rev Cienc Saude. 2017; 29(2):135-45..

This study aimed to understand the meaning of the experience of the undergraduate Physiotherapy curricular internship in PHC practice settings. The internship was the concrete and human phenomenon that was studied, related to the lived world²⁶26 Merleau-Ponty M. Fenomenologia da percepção. 3a ed. São Paulo: Martins Fontes; 2006. of students, supervisors, health professionals, and users.

Methodology

This is a qualitative research characterized as a case study²⁷27 Yin R. Estudo de caso: planejamento e métodos. 4a ed. Porto Alegre: Bookman; 2010.. The intention was to generate in-depth knowledge about the phenomenon of curricular internship in PHC practice settings, which is part of the undergraduate Physiotherapy course of a non-profit university located in the South region of Brazil, revealing the multiplicity of perceptions and singularities of the contextualized reality²⁷27 Yin R. Estudo de caso: planejamento e métodos. 4a ed. Porto Alegre: Bookman; 2010..

Inaugurated in 2002, the course analyzed here offers 50 seats per year, has a total of 4,250 hours and lasts five years (10 semesters). Students have curricular internships in the last year of the course, divided into hospital, outpatient and Collective Health practices. The internship in Public Health is the only one whose number of hours is distributed among the nine and tenth semesters of the course (155 hours in each semester). In this internship, students perform activities with individual, family and collective/community approaches. The practice settings have been permanently agreed with the city’s Health Department and include the Regional University Clinic for Education and Health, a Social Welfare Society, the Psychosocial Care Center for Adults, and two Family Health Units/PHC. The supervisor is a physiotherapist hired by the University to accompany students during their internship in the health services. The supervisor has no employment relationship with the health service and does not teach at the University. In PHC, students are received by the coordinator of the Health Unit and by the Community Health Agents (CHA), who organize home visits and collective activities considering the needs of users in the territory. NASF does not have a physiotherapist in its composition. The present study analyzes the PHC internship where the main researcher was the supervisor, which enabled her to observe the investigated phenomenon²⁸28 Universidade do Vale do Taquari - Univates. Resolução nº 142, de 13 Novembro de 2018. Projeto Pedagógico do curso de Fisioterapia. Lajeado: Univates; 2018..

Intentional sampling was performed and the sample was constituted by Physiotherapy students, internship supervisors, health professionals, and PHC users (Frame 1).

Sample size was determined by the criterion of saturation²⁹29 Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: de procedimentos para constatar saturação teórica. Cad Saude Publica. 2011; 27(2):389-94., considering repeated themes and ideas and correlating the density of the interviews’ content with the research objective.

Individual semi-structured interviews guided by a script were conducted in 2019 by one single researcher, each lasting 45 minutes on average (Frame 2). Fieldwork was carried out during seven months, enabling the researchers to analyze what was singular in the case under study and understand the context and historicity in which it unfolded.

The interviews were audio recorded and transcribed. The transcriptions were sent to the interviewees so that they could check their content, looking for modifications and/or additions.

The textual material was analyzed by thematic content analysis³⁰30 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011., supported by the software ATLAS.ti (Visual Qualitative Data Analysis). Initially, the free-floating reading of the material was performed, enabling the researchers to delve into the content of the produced narratives. There were no categories defined a priori. The corpus was identified by units of analysis and coded, initially, by generating themes (PHC in the curriculum, internship activities/experiences, relationship between interns, teams and users, learnings, challenges and perspectives). These themes, guided by the research problem/objective and by the theoretical framework, were grouped into emerging categories³⁰30 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011..

The study was approved by the Research Ethics Committees of the Federal University of Rio Grande do Sul (Opinion no. 3.282.318) and of the researched university (Opinion no. 3.336.109). To preserve the identity of the participants, letters followed by numbers were used to code the identification of students (E1 to E4), supervisor (S1), Health Unit coordinator (C1), CHA (A1 to A6), and users (U1 to U8).

Results and discussion

Four undergraduate students, one physiotherapist who supervised the internship in PHC, one nurse who was the coordinator of the PHC Unit, six CHA and eight users participated in the research (n = 20).

The three categories of analysis (Frame 3) do not express an individual description; rather, they intend to represent the meaning unit³⁰30 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011. that composes the studied phenomenon in the perception of students, supervisors, health professionals and users, who act, interact and suffer the action of the world where they live in a phenomenological perspective²⁶26 Merleau-Ponty M. Fenomenologia da percepção. 3a ed. São Paulo: Martins Fontes; 2006..

PHC as a practice setting in the education of physiotherapists: from the beginning of the course to the internship

Curricular placements in PHC have been described in the literature as an advance in the education of physiotherapists in Brazil¹⁵15 Batiston AP, Bonilha LAS, Pierette F, Medeiros AA, Duenha C, Grosseman S, et al. Implantação de uma nova proposta pedagógica para o estágio supervisionado em fisioterapia na atenção básica: relato de experiência. Cad Educ Saude Fisioter. 2017; 4(8):48-55.

16 Ferreira ALPP, Rezende M. Reflections on the production of the formation of physiotherapy in the context of SUS. Fisioter Mov. 2016; 29(1):37-44.

17 Formiga NFB, Ribeiro KSQS. Inserção do fisioterapeuta na atenção básica: uma analogia entre experiências acadêmicas e a proposta dos Núcleos de Apoio à Saúde da Família (NASF). Rev Bras Cienc Saude. 2012; 16(2):113-22.

18 Silva LWS, Souza M, Souza TO, Souza TF. Contexto do cuidado fisioterapêutico: reveses e vieses na inserção comunitária à atenção domiciliar. Rev Kairós Gerontol. 2013; 16(3):79-101.

19 Bin CR, Diamante C. Formação em Fisioterapia: como a saúde coletiva está inserida nas instituições públicas de ensino superior do Paraná. Cad Educ Saude Fisioter. 2020; 7(13):e071304.

20 Rangel Neto NC, Aguiar AC. A Atenção Primária à Saúde nos cursos de graduação em Fisioterapia no município do Rio de Janeiro. Trab Educ Saude. 2018; 16(3):1403-20.

21 Silva DJ, Da Ros MA. Inserção de profissionais de Fisioterapia na equipe de saúde da família e Sistema Único de Saúde: desafios na formação. Cienc Saude Colet. 2007; 12(6):1673-81.^-2222 Medeiros PA, Pivetta HMF, Mayer MS. Contribuições da visita domiciliar na formação em fisioterapia. Trab Educ Saude. 2012; 10(3):407-26.^,3131 Delai KD, Wisniewski MSW. Inserção do fisioterapeuta no Programa Saúde da Família. Cienc Saude Colet. 2011; 16 Supl 1:1515-23.

32 Seriano KN, Muniz VRC, Carvalho MEIM. Percepção de estudantes do curso de fisioterapia sobre sua formação profissional para atuação na atenção básica no Sistema Único de Saúde. Fisioter Pesqui. 2013; 20(3):250-5.^-3333 Nordi ABA, Aciole GG. Ampliando a família da saúde: ações de Fisioterapia na Atenção Primária na Saúde. Cad Educ Saude Fisioter. 2020; 7(13):e071310., which was confirmed in this study. Since the beginning of the course, the students identified, in the curriculum, teaching activities that mobilized contents approaching “SUS, PHC and observation experiences at Health Units with home visits” (E1, E4).

Although the activities were included in the curriculum, they were considered isolated activities that did not promote a continuous interaction with users and health teams, nor the observation of the physiotherapist’s work in PHC.

When the students started the internship, they reported feeling a “great expectation of entering into the patient’s reality” (E2), but also anxiety “[...] to know how people would receive the interns at their homes and how the team would react” (E4), “fear of doing it wrong” (E2), and the challenge of working in the reality of SUS, “because what we learn in the classroom is completely different” (E3).

Between the practice setting and learnings: meanings of an experience that mobilizes new knowledge, dialog, bonding and values the professional

In this study, the internship in PHC proved to be a moment of the students’ education that enabled them to interact with a community and to know “not only the users, but also their families and homes” (E3), discovering that “each home is unique, each family is unique” (E4), which can improve the care process.

To the students, the internship was a “gratifying” experience (E3) in their education, providing “professional and personal growth” (E2, E4), enabling contact/dialog with users, and allowing them to achieve positive results with the interventions they made grounded on knowledge from the Physiotherapy field. A “life-changing” experience (E2).

Due to the characteristic of the work in PHC, performed in the territory with users-families-community, the internship provided a live learning in which the student can problematize, together with the health team, social determinants of the health-disease process of users-families-communities⁵5 Koetz LCE, Périco E, Grave MQ. Distribuição geográfica da formação em fisioterapia no Brasil: crescimento desordenado e desigualdade regional. Trab Educ Saude. 2017; 15(3):917-30.^,2323 Ely LI, Toassi RFC. Integração entre currículos na educação de profissionais da saúde: a potência para educação interprofissional na graduação. Interface (Botucatu). 2018; 22 Supl 2:1563-75.

24 Toassi RFC, Olsson TO, Lewgoy AMB, Bueno D, Peduzzi M. Ensino da graduação em cenários da atenção primária: espaço para aprendizagem interprofissional. Trab Educ Saude. 2020; 18(2):e0026798.^-2525 Carvalho DFF, Siqueira-Batista R. Fisioterapia e Saúde da Família: inserção, processo de trabalho e conflitos. Vittalle Rev Cienc Saude. 2017; 29(2):135-45..

Coordinators and CHA perceived that the students’ presence in the team’s work process “is a plus” (C1), is “important, rich” (A6), “provides benefits” (A1) in a very “positive” way (A5), improving users’ health.

They also understood that the student is capable of “taking the team out of the comfort zone and speeding the work up” (A3), suggesting that the presence of the undergraduate student can stimulate, in the team, the need of permanent education to qualify healthcare.

The interaction with Physiotherapy students and the possibility of being “part of the educational process” (A3) allowed the CHA to engage in teaching, something that was not part of their lives and that added value to their work and professional role in the health team.

CHA are the professionals who strengthen the bond between community-families-users and the health service, contributing to improve the quality of healthcare³⁴34 Bezerra YRN, Feitosa MZS. A afetividade do agente comunitário de saúde no território: um estudo com os mapas afetivos. Cienc Saude Colet. 2018; 23(3):813-22.^,3535 Pinto AGA, Palacio MAV, Lobo AC, Jorge, MSB. Vínculos subjetivos do Agente Comunitário de Saúde no território da Estratégia Saúde da Família. Trab Educ Saude. 2017; 15(3):789-802.. As the CHA know what people need, they play a fundamental role in the expansion of the offer of Physiotherapy services in PHC³⁶36 Ribeiro KSQS, Araújo Neto MJ, Arangio MG, Nascimento PBS, Martins TNT. A participação de Agentes Comunitários de Saúde na atuação da Fisioterapia na Atenção Básica. Rev APS. 2007; 10(2):156-68^,3737 Sampaio RF. Promoção de saúde, prevenção de doenças e incapacidades: a experiência da fisioterapia/UFMG em uma unidade básica de saúde. Fisioter Mov. 2002; 15(1):12-23..

The students recognized the profession-related knowledge of the CHA and their role in the close contact they had with the families.

The experience in PHC provided new learning possibilities for the student, who “can see what life out there really looks like” (E1); in addition, it surprised the users who receive these students in their homes and did not expect “that a physiotherapist had the gift of intervening in the physical and psychological dimensions” (U1).

Students and users developed bonds, expressed by reports of “attachment” (E2), “discovery” (E3), “friendship” (U3), “conversation” (U1), “rapport” (U7), “incentive” (U1, U2), “participating and making a difference in the interns’ education” (U7).

In this relational construction, the care strategies were gradually modified, allowing the emergence of “other demands that perhaps the patient had never talked about before” (E2).

The development of bonds with users-families, allied with the construction of new knowledge in the field of Physiotherapy, were the most remarkable aspects to students during the experience of the PHC internship.

The bond is a relational care technology that consists in the construction of affection and trust relations between user and health worker³⁸38 Merhy EE, Franco TB. Por uma composição técnica do trabalho centrada nas tecnologias leves e no campo relacional. Saude Debate. 2003; 27(65):316-23.. It enhances the process of co-accountability for health and is associated with the concepts of humanization and comprehensive care, not to mention the fact that it has therapeutic potential³⁹39 Ilha S, Dias MV, Backes DS, Backes MTS. Vínculo profissional-usuário em uma equipe da Estratégia Saúde da família. Cienc Cuid Saude. 2014; 13(3):556-62.. By experiencing situations of closeness and partnership between professional and patient, the student becomes capable of embracing, hearing and guiding⁴⁰40 Souza ECF, Vilar RLA, Rocha NSPD, Uchoa AC, Rocha PM. Acesso e acolhimento na atenção básica: uma análise da percepção dos usuários e profissionais de saúde. Cad Saude Publica. 2008; 24 Supl 1:100-10., which can improve their knowledge about the population’s demands, transforming care into something that is shared, alive, symmetric, singular, and effective⁴¹41 Brunello MEF, Ponce MAS, Assis EG, Andrade RLP, Scatena LM, Palha PF, et al. O vínculo na atenção à saúde: revisão sistematizada na literatura, Brasil (1998-2007). Acta Paul Enferm. 2010; 23(1):131-5.^,4242 Seixas CT, Baduy RS, Cruz KT, Bortoletto MSS, Slomp Junior H, Merhy EE. O vínculo como potência para a produção do cuidado em saúde: o que usuários-guia nos ensinam. Interface (Botucatu). 2019; 23:e170627..

Advances and barriers related to the teaching of Physiotherapy in PHC

This study corroborated advances but also revealed barriers concerning the education of physiotherapists integrated into PHC teams and communities.

Among the advances, students understood that the curricular internship in PHC, in the context in which the health system was organized, allowed them to perform practices with individual and collective approaches that would not be possible inside the university. Such practices qualified their education and prepared them to work in SUS. The interventions aimed to break with the biomedical paradigm of disease, bringing the expanded logic of health to praxis and emphasizing collaborative and comprehensive care, a central category in the field of health⁴³43 Maia FES, Moura ELR, Madeiros EC, Carvalho RRP, Silva SAL, Santos GR. A importância da inclusão do profissional fisioterapeuta na atenção básica de saúde. Rev Fac Cienc Med Sorocaba. 2015; 17(3):110-5.^,4444 Portes LH, Caldas MAJ, Paula LT, Freitas MS. Atuação do fisioterapeuta na atenção básica à saúde: uma revisão da literatura brasileira. Rev APS. 2011; 14(1):111-9.. In addition to enabling students to practice the technical principles of the profession, the internship was an opportunity for reflection-action regarding ‘conflicts’ and ‘situations’ that, as professionals, they will face in teamwork⁷7 Bispo Junior JP. Fisioterapia e saúde coletiva: desafios e novas responsabilidades profissionais. Cienc Saude Colet. 2010; 15 Supl 1:1627-36.^,2525 Carvalho DFF, Siqueira-Batista R. Fisioterapia e Saúde da Família: inserção, processo de trabalho e conflitos. Vittalle Rev Cienc Saude. 2017; 29(2):135-45.^,4545 Simoni DE, Carvalho JB, Moreira AR, Caravaca Morera JA, Camargo Maia ARC, Boreinstein MS. The educational training in physiotherapy in Brazil: historical fragments and current perspectives. Hist Enferm Rev Eletronica. 2015; 6(1):10-20..

Furthermore, it was possible to observe that the PHC professionals and users valued the Physiotherapy students’ participation, which favors the inclusion of the profession in the team and makes the team and the community understand the role of Physiotherapy in the healthcare process¹⁵15 Batiston AP, Bonilha LAS, Pierette F, Medeiros AA, Duenha C, Grosseman S, et al. Implantação de uma nova proposta pedagógica para o estágio supervisionado em fisioterapia na atenção básica: relato de experiência. Cad Educ Saude Fisioter. 2017; 4(8):48-55..

Students considered the home care they provided during the internship as a tool to deliver comprehensive care to users and families. Through it, students could provide guidance respecting users’ health reality, understanding their environment, way of life and intra-family relationships, and approaching issues beyond the disease, like social and emotional problems²²22 Medeiros PA, Pivetta HMF, Mayer MS. Contribuições da visita domiciliar na formação em fisioterapia. Trab Educ Saude. 2012; 10(3):407-26.^,4646 Bezerra MIC, Lima MJMR, Lima YCP. A visita domiciliar como ferramenta de cuidado da fisioterapia na estratégia saúde da família. SANARE. 2015; 14(1):76-80.. The activity, however, was challenging to the students and required them to “understand the Health System” (E1) and search for different alternatives to perform their physiotherapy interventions, like “improvising with the shaft of a broom, with a chair, a towel” (E3). In the practices conducted at university, different materials and equipment are available to students; in home care, “there were no materials to take to the users’ homes and we had to find another way” (E3).

Working with groups was another challenge that emerged from the students’ narratives. As a health promotion strategy, groups are collective spaces that make it easier for people to understand the importance of guidance and healthcare, so that they can develop skills and autonomous care⁴⁷47 Pacheco AE, Antunes MJM. Revisão da literatura sobre motivação para o autocuidado na atenção primária em saúde. Rev Eletronica Gest Saude. 2015; 6(3):2907-18.^,4848 Maciel RV, Silva PTG, Sampaio RF, Drummond AF. Teoria, prática e realidade social: uma perspectiva integrada para o ensino de Fisioterapia. Fisioter Mov. 2005; 18(1):11-7.. To the students, it was a new curricular experience (“I’d never had this experience” (E3)), and conducting groups with an average of 50 elderly people in each was a great “challenge” (E3). It was an activity in which the student had to “interact with users” (E4) in an individual and collective way. A different opportunity that “we didn’t experience during the undergraduate course” (E4). When they participated in or organized groups, however, the students recognized the development of professional competencies that go beyond those they learn within the space of the clinic.

In their trajectory in the Physiotherapy course, the students perceived that there are few curricular opportunities for them to learn with different health professions about the role of each one and how they can work together in an interprofessional and collaborative way. Although students identified activities in PHC at the beginning of the course, they viewed the absence of contact with a physiotherapist in the basic team at the Health Unit and in NASF as a challenge to be overcome. The presence of the physiotherapist as a worker of SUS who acts in PHC promotes the recognition of the profession within the team and helps students understand the physiotherapist’s professional activity in public health³¹31 Delai KD, Wisniewski MSW. Inserção do fisioterapeuta no Programa Saúde da Família. Cienc Saude Colet. 2011; 16 Supl 1:1515-23..

The fact that the internship supervisor has no employment relationship neither with the service nor with the university was also mentioned as an aspect that hinders students’ integration into PHC. The supervisor is not a “professional of the Health Unit nor is he part of the faculty of the hiring Institution” (S1), which hindered the inclusion of this professional in the context of teamwork, affecting the action of the interns.

Students emphasized the importance of the internship in PHC so that they could experience interprofessional education (IPE) in the undergraduate course. The internship enabled them to understand the work, interact, and learn with different professions, having the explicit purpose of improving collaboration and the quality of care provided for users-families-communities⁴⁹49 Reeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, et al. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Med Teach. 2016; 38(7):656-68..

It is important to mention that, in this study, the students could interact and share activities specially with the CHA, nursing technicians, and with the coordinator of the Health Unit. This finding can be justified by the way in which the work process of these teams is organized. Healthcare practices organized by professions that work in isolation⁵⁰50 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376(9756):1923-58., including collective/group activities, are barriers to the development of competencies targeted at an interprofessional collaborative practice.

Teaching activities that stimulate learning within health teams with the intention of developing IPE must be incorporated into health curricula, replacing exclusively uniprofessional curricular structures that stimulate individualistic postures and the isolated practice of health professions⁵⁰50 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376(9756):1923-58.. Educational spaces promote collaboration among professions, qualifying the team to act in an effective and safe way in light of the complexity of health needs²³23 Ely LI, Toassi RFC. Integração entre currículos na educação de profissionais da saúde: a potência para educação interprofissional na graduação. Interface (Botucatu). 2018; 22 Supl 2:1563-75.^,2424 Toassi RFC, Olsson TO, Lewgoy AMB, Bueno D, Peduzzi M. Ensino da graduação em cenários da atenção primária: espaço para aprendizagem interprofissional. Trab Educ Saude. 2020; 18(2):e0026798.^,4949 Reeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, et al. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Med Teach. 2016; 38(7):656-68.^,5151 Tran C, Kaila P, Salminen H. Conditions for interprofessional education for students in primary healthcare: a qualitative study. BMC Med Educ. 2018; 18:1-8..

In the students’ perception, curricular activities in PHC should be present throughout the undergraduate course since the beginning - “we should have had more experiences of this kind” (E3) -, with clear learning objectives, so that students feel prepared to work in SUS³¹31 Delai KD, Wisniewski MSW. Inserção do fisioterapeuta no Programa Saúde da Família. Cienc Saude Colet. 2011; 16 Supl 1:1515-23.

32 Seriano KN, Muniz VRC, Carvalho MEIM. Percepção de estudantes do curso de fisioterapia sobre sua formação profissional para atuação na atenção básica no Sistema Único de Saúde. Fisioter Pesqui. 2013; 20(3):250-5.^-3333 Nordi ABA, Aciole GG. Ampliando a família da saúde: ações de Fisioterapia na Atenção Primária na Saúde. Cad Educ Saude Fisioter. 2020; 7(13):e071310..

They suggest the inclusion of teaching activities focusing on Public Health before the curricular internship, as well as experiences in practice settings in which they must do more than merely observe and that enable an effective interaction with teams-communities.

Placements in PHC not in alignment with the curriculum and lasting an insufficient number of hours may weaken the theoretical-practical debate that this learning experience can raise²²22 Medeiros PA, Pivetta HMF, Mayer MS. Contribuições da visita domiciliar na formação em fisioterapia. Trab Educ Saude. 2012; 10(3):407-26..

The expansion and strengthening of the physiotherapist’s action in PHC, not restricted to Primary Care Units or home visits, performed in interprofessional teams in the territories, and grounded on the perspective of comprehensive care and matrix support, have been discussed in the literature¹³13 Tavares LRC, Costa JLR, Oishi J, Driusso P. Inserção da fisioterapia na atenção primária à saúde: análise do cadastro nacional de estabelecimentos de saúde em 2010. Fisioter Pesqui. 2018; 25(1):9-19.^,1919 Bin CR, Diamante C. Formação em Fisioterapia: como a saúde coletiva está inserida nas instituições públicas de ensino superior do Paraná. Cad Educ Saude Fisioter. 2020; 7(13):e071304.^,3333 Nordi ABA, Aciole GG. Ampliando a família da saúde: ações de Fisioterapia na Atenção Primária na Saúde. Cad Educ Saude Fisioter. 2020; 7(13):e071310. and emerged, in this study, as a demand of education and work. These curricular movements of the physiotherapist education interact with the care practices in PHC, in different practice settings and contexts, bringing implications to both.

Final remarks

This research produced qualitative evidence that corroborates aspects that have been described in the literature about education in the health services. It adds to the existing body of knowledge because it presents the perception of different players who participated in the experience of physiotherapist education in PHC, including students, supervisor, health professionals and, especially, users. It extrapolates education and sheds light on how teaching-service integration can qualify the health system. Furthermore, it approaches the barriers that need to be overcome. The internship in PHC, in the context of this case study, was understood as an important curricular component of the undergraduate course in Physiotherapy. It enabled students to learn about and problematize the uniqueness of life in the territories, and also to develop bonds with users-families. Moreover, it strengthened the professional identity of the physiotherapist through the team’s and users’ recognition of the role of Physiotherapy in the context of PHC. Barriers were perceived due to the absence of the physiotherapist in the PHC team and to the fact that interaction with the team was restricted to certain professionals, limiting the analysis of the internship experience in its interprofessional perspective.

Research investigating students during their curricular trajectory and studies focusing on graduates are needed to shed light on PHC as a space for the physiotherapist’s education and work in Brazil.

Acknowledgements

To the Physiotherapy Course of Universidade do Vale do Taquari (UNIVATES), especially to professor Lydia Koetz Jaeger, and to the Postgraduate Program in Health Teaching (PPG EnSau) of Universidade Federal do Rio Grande do Sul.

References

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