ABSTRACT

This study aimed to analyze the changes in training induced by the Education through Work for Health Program (PET-Saúde), Interprofessionality edition, and to identify whether the assumptions of Interprofessional Education (IPE) and collaborative practices are being applied in the development of projects. This is a qualitative, descriptive, and exploratory case study, developed in the state of Rio de Janeiro. Open interviews were carried out with 32 actors working in the program, whose contents were analyzed in the light of the theoretical-methodological framework of IPE. Three categories were produced: PET-Saúde/Interprofessionality as a constructive dynamics of collaborative practices; Interprofessionality as a foundation for structuring curricula and pedagogical practices; The evaluation mechanisms of PETSaúde/Interprofessionality. The Interprofessionality edition triggered assertive experiences from the application of the assumptions of IPE and collaborative practices, such as induction of curricular reforms and the creation of interprofessional disciplines; however, it still does not represent a policy incorporated by teaching institutions. Special attention must be given to the evaluation processes, which are very incipient, and to the sustainability of the advances achieved, which require political and institutional support. PET-Saúde has progressively contributed to changes in teaching and to the dissemination of concepts and assumptions that guide IPE.

KEYWORDS
Universities; Teaching care integration services; Interprofessional education; Interdisciplinary placement.

Introduction

The changes in the epidemiological profile, with the increase of chronic non-communicable diseases and new environmental, infectious and behavioral risks, enhance the complexity of the health care sector and formalize the need to redesign the techno-assistance models and the formation processes, towards the integrality of care and the collaboration and professional performance^{11 Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010 [acesso em 2021 jan 15]; 376(9756):1923-1958. Disponível em: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61854-5/fulltext.
https://www.thelancet.com/journals/lance... ,22 World Health Organization. Framework for action on interprofessional education & collaborative practice. Geneva: WHO; 2010. [acesso em 2022 set 28]. Disponível em: http://apps.who.int/iris/bitstream/handle/10665/70185/WHO_HRH_HPN_10.3_eng.pdf;jsessionid=F3A135CF72ADCA28D077D6C57F2D1256?sequence=1.
http://apps.who.int/iris/bitstream/handl...} .

The proposal globally fomented in the sense of mobilizing those changes is the Interprofessional Education (EIP), the political-pedagogic strategy that promises to prepare the work force to offer more effective care and to respond to the necessities of health care^{22 World Health Organization. Framework for action on interprofessional education & collaborative practice. Geneva: WHO; 2010. [acesso em 2022 set 28]. Disponível em: http://apps.who.int/iris/bitstream/handle/10665/70185/WHO_HRH_HPN_10.3_eng.pdf;jsessionid=F3A135CF72ADCA28D077D6C57F2D1256?sequence=1.
http://apps.who.int/iris/bitstream/handl... ,33 Reeves S. Why we need interprofessional education to improve the delivery of safe and effective care. Interface. 2016 [acesso em 2021 mar 5]; 20(56):185-196. Disponível em: https://www.scielo.br/j/icse/a/VrvpZyszPQ6hrVp7SFhj6XF/?lang=en.
https://www.scielo.br/j/icse/a/VrvpZyszP...} . Conceptually, the EIP occurs when students of two or more professions learn about the other, with the other and with each other in order to improve the professional collaboration and, consequently, improve the results in health care^{22 World Health Organization. Framework for action on interprofessional education & collaborative practice. Geneva: WHO; 2010. [acesso em 2022 set 28]. Disponível em: http://apps.who.int/iris/bitstream/handle/10665/70185/WHO_HRH_HPN_10.3_eng.pdf;jsessionid=F3A135CF72ADCA28D077D6C57F2D1256?sequence=1.
http://apps.who.int/iris/bitstream/handl... ,44 Barr H, Low H. Introducing Interprofessional Education. Reino Unido: Centre for the Advancement of Interprofissional Education; 2013.}. It is supposed that, through the professional inter-relations, the students will learn how to work in a planned, integrated communicative and intentional manner, seeking for equate the health care problems that arise in the routine of the services. Thus, opportunities of shared learning in the real context of health care production are indispensable.

The Unified Health System (SUS), under the aegis of a techno-assistance model based on the strengthening of the primary care and on the shared action of the team, has been, historically, trying to establish a formation process coherent with its guidelines. The EIP assumes singular importance in this context, not only because it is admitted the premise that SUS is interprofessional, but also because formation and exercise proposals for the interprofessional practice already exist in the Brazilian reality^{55 Ceccim RB. Equipe de saúde: a perspectiva entre-disciplinar na produção dos atos terapêuticos. In: Pinheiro R, Mattos RA, organizadores. Cuidado: as fronteiras da integralidade. Rio de Janeiro: Hucitec; 2004. p. 259-278.,66 Peduzzi M. The SUS is interprofessional. Interface. 2016 [acesso em 2021 mar 5]; 20(56):199-201. Disponível em: https://www.scielo.br/j/icse/a/7MgQL4JM9dRYFDLYYzQVLHM/?lang=en.
https://www.scielo.br/j/icse/a/7MgQL4JM9...} .

Although the national systematized experiences of EIP are yet recent, there is a consistent repertoire of strategies in course and others predicted to the level of macropolitics that may induce the implementation of this approach in Brazil^{66 Peduzzi M. The SUS is interprofessional. Interface. 2016 [acesso em 2021 mar 5]; 20(56):199-201. Disponível em: https://www.scielo.br/j/icse/a/7MgQL4JM9dRYFDLYYzQVLHM/?lang=en.
https://www.scielo.br/j/icse/a/7MgQL4JM9...} . An outstanding milestone for the promotion of the EIP was the establishment of The National Politics of Permanent Education in Health, that consolidated essential aspects for the developing of formative actions for the health workers under the logic of the integration education-service-community, and that took over the services of SUS as privileged scenarios for the apprenticeship^{77 Peduzzi M, Norman IJ, Germani ACCG, et al. Interprofessional education: training for healthcare professionals for teamwork focusing on users. Rev. Esc. Enfermagem USP. 2013 [acesso em 2020 abr 10]; 47(4):977-983. Disponível em: https://www.scielo.br/j/reeusp/a/JwHsjBzBgrs9BCLXr856tzD/?lang=en.
https://www.scielo.br/j/reeusp/a/JwHsjBz...} .

Under the precepts of this policy, arise different initiatives focused on the reorientation of the formation processes in the undergraduate health courses, for example the Program of Education through Work for Health (PET-Saúde), constituted in 2008 from the accumulation constituted in anterior experience of integration education-services. As a public policy, it aims to consolidate the constitutional role of SUS of ordering the formation and of sensitizing and preparing professionals for the adequate confrontation of the different realities of life and necessities of health of the population^{99 Brasil. Ministério da Saúde; Ministério da Educação. Portaria Interministerial nº 1.802, de 26 de agosto de 2008. Institui o Programa de Educação pelo Trabalho para a Saúde - PET-Saúde. Diário Oficial da União. 27 Ago 2008.}.

PET-Saúde holds differentiated strategic components, such as the insertion of students in the reality of SUS services and the process education-apprenticeship enabled by tutorial interprofessional groups. It operates through direct intervention projects, based on situational diagnosis of the territory, that unfolds in actions of education, research and extension and that involves students, teachers, health care teams and the community user of SUS, aiming to assure an integral approach of the health-disease processes^{99 Brasil. Ministério da Saúde; Ministério da Educação. Portaria Interministerial nº 1.802, de 26 de agosto de 2008. Institui o Programa de Educação pelo Trabalho para a Saúde - PET-Saúde. Diário Oficial da União. 27 Ago 2008.}.

Since its institutionalization, the program went through a successive incorporation of guidelines for the developing of projects, adopting as focus priority areas of SUS, such as primary attention and health surveillance. Many were the advances observed, especially regarding the fomentation of the integration education-service, to the developing of new pedagogic practices and the deepening of the knowledges in public health by the students^{1010 Farias-Santos BCS, Noro LRA. PET-Saúde como indutor da formação profissional para o Sistema Único de Saúde. Ciênc. Saúde Colet. 2017 [acesso em 2021 nov 19]; 22(3):997-1004. Disponível em: https://www.scielo.br/j/csc/a/csQcsSpcfqtrBqQtWFZRsNz/?lang=pt.
https://www.scielo.br/j/csc/a/csQcsSpcfq... ,1111 Mira QLM, Barreto RMA, Vasconcelos MIO. Impacto do PET-Saúde na formação profissional: uma revisão integrativa. Rev. Baiana Saúde Pública. 2016 [acesso em 2021 dez 14]; 40(2):514-531. Disponível em: https://rbsp.sesab.ba.gov.br/index.php/rbsp/article/view/1682/1889.
https://rbsp.sesab.ba.gov.br/index.php/r...} . However, it could not alter the fragmented model of the curricula^{1212 França T, Magnago C, Santos MR, et al. PET-Saúde/GraduaSUS: retrospectiva, diferenciais e panorama de distribuição dos projetos. Saúde debate. 2018 [acesso em 2021 dez 14]; 42(esp2):286-301. Disponível em: https://www.scielo.br/j/sdeb/a/dTvgGzZNTxzm9BcVr6b9H4N/?lang=pt.
https://www.scielo.br/j/sdeb/a/dTvgGzZNT...} .

Considering this, in 2015, the program was redesigned, having its focus directed to the curricular change under the precepts of the interdisciplinarity and of the interprofessionality. Following this approach, two editions were launched. The first, PET-Saúde/GraduaSUS, was able to mobilize movements of discussion between different courses, aiming to incorporate the theoretical-methodological elements of EIP as foundations for structuring the curricula and of institutional pedagogical projects, and also lead to the creation of integrated disciplines. In spite of being punctual, those initiatives reaffirm the power of the program, subsidizing the elaboration of a new edition. PET-Saúde/Interprofessionality<sup>1212 França T, Magnago C, Santos MR, et al. PET-Saúde/GraduaSUS: retrospectiva, diferenciais e panorama de distribuição dos projetos. Saúde debate. 2018 [acesso em 2021 dez 14]; 42(esp2):286-301. Disponível em: https://www.scielo.br/j/sdeb/a/dTvgGzZNTxzm9BcVr6b9H4N/?lang=pt.
https://www.scielo.br/j/sdeb/a/dTvgGzZNT...

13 Magnago C, França C, Belisário AS, et al. PET-Saúde/GraduaSUS na visão de atores do serviço e do ensino: contribuições, limites e sugestões. Saúde debate. 2019 [acesso em 2021 dez 14]; 43(esp1):24-39. Disponível em: https://www.scielo.br/j/sdeb/a/ZnKPGMnksJcVQmJ79Wt38ny/?lang=pt#.
https://www.scielo.br/j/sdeb/a/ZnKPGMnks... -1414 Magnago C, França C, Belisário AS, et al. O PET-Saúde/GraduaSUS como mobilizador da integração inter, intra e extrainstitucional. In: Castro J, Vilar RLA, Dias MA, organizadoras. Educação e trabalho: interface com a gestão em saúde. Natal: Uma; 2020. p. 245-271.</sup>.

Launched in 2018, the Interprofessionality edition highlighted the promotion of the EIP and of the collaborative practices from the constitution of the tutorial groups minimally conformed by three different health courses. Given its uniqueness and constituted as the first macropolitics initiative of induction of the EIP, this edition was taken as an object of analysis of this study, aiming to answer the following questions: Which are the changes in the formation induced by the PET-Saúde/Interprofessionality? Is this edition collaborating with the developing of strategies aligned with the assumptions of the EIP and collaborative practices?

Considering the exposed, the research targeted to identify if the assumptions of the EIP and of the collaborative practices were applied in the development of the PET- Saúde/Interprofessionality projects and to analyze the changes in the formation induced by this edition.

Material and methods

It is a case study, exploratory and qualitative, developed in the state of Rio de Janeiro. The population of interest is composed by members of the PET-Saúde/Interprofessionality, whose projects were developed by education institutions that were also participants of the edition of the GraduaSUS. Met this criterion five projects, whose coordinators were invited to integrate the study and to indicate other members of the tutorial groups, being, at least, one preceptor, one tutor and two academics of different courses (Physical Education, Nursing, Pharmacy, Medicine, Nutrition, Obstetrics, Dentistry, Psychology, Collective Health and Social Work). Expressed interest in participating in the research and integrated the sample 32 subjects (tables 1 and 2).

The data was collected in 2020 through individual interview, carried out virtually in platform of web conference due to the social distancing measures imposed by the COVID-19. The interviews were oriented by a non-structured script, lasted an average of 60 minutes and were recorded with the consent of each participant.

The analysis of content for data treatment was used, applying for the stages of pre-analysis, exploring, inference and interpretation^{1515 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2016.}. The pre-analysis consisted in the transcription of the interviews, originating the analytical corpus, followed by the fluctuating reading of the material. In the exploring, were highlighted the scraps of semantic character of the corpus that could demonstrate correspondence with theoretical-methodological elements predicted in the guidelines for the construction and evaluation of the educational contexts in the perspective of the EIP^{1616 Barr H. Ensuring quality in interprofessional education. CAIPE Bulletin. 2003; (22):2-3.} Those scraps were reunited by similarity in three categories (box 1), whose findings were interpreted and confronted with the literature about the subject.

The study project was submitted and approved by the Committees of Ethics in Research of the Institute of Social Medicin/UERJ (Opinion nº 3.899.608), University Hospital Pedro Ernesto/UERJ (Opinion nº 3.977.438), University Hospital Antônio Pedro/UFF (Opinion nº 3.982.264), Municipal Department of Health of Rio de Janeiro (Opinion nº 3.993.894) and Municipal Hospital Dr. Munir Rafful (Opinion nº 4.039.647). The Inform Consent Form was sent to the interviewed by e-mail and returned signed by the same path. Aiming to preserve the anonymity, the subjects were identified by a letter (C - coordinator, T - tutor, P - preceptor, A - academic), followed by an arabic number.

Results and discussion

From the reports, were identified the central elements that subsidize the EIP and the collaborative practices in the ambit of PET-Saúde/Interprofessionality, being those represented in three categories.

The PET-Saúde/Interprofessionality as constructive dynamics of collaborative practices

It was highlighted that the main theoretical - methodological elements that base the objectives of settled initiatives in the EIP set out in the pedagogic processes developed in the ambit of the PET-Saúde/Interprofessionality. Among them, the multiprofessional composition of the learning groups, characterized by the presence of, at least, two different health professions. It is noteworthy that this composition, per se, does not imply the applicability of the precept of interprofessionality; it is necessary that the learning processes promote the adoption of new postures, relations and ways of perceiving the other professions^{1717 Barros NF, Spadacio C, Costa MV. Trabalho interprofissional e as práticas integrativas e complementares no contexto da Atenção Primária à Saúde: potenciais e desafios. Saúde debate. 2018 [acesso em 2021 dez 14]; 42(esp1):163-173. Disponível em: https://www.scielo.br/j/sdeb/a/WhJFzVYJtKrZs7zNjq5k49R/?lang=pt.
https://www.scielo.br/j/sdeb/a/WhJFzVYJt...} .

However, it is yet essential to assume the intention of promoting the development of the collaborative competencies, comprehended as those that enable the team work resolutive and aligned to the health care needs^{1818 Freire JR, Magnago C, Costa MV, et al. Interprofessional education and the formative actions of the emergency provision axis of the More Doctors Program. Saúde debate. 2019 [acesso em 2021 dez 10]; 43(esp1):50-63. Disponível em: https://www.scielo.br/j/sdeb/a/XksJxG6Q9NkBD4n5SNzL7Wq/?lang=en.
https://www.scielo.br/j/sdeb/a/XksJxG6Q9...} . Team work in the perspective of interprofessionality means to act with different professions/knowledge clusters, whose arrangements my transit collaboratively between specific areas, promoting the qualification of practices^{1919 Ceccim RB. Connections and boundaries of interprofessionality: form and formation. Interface. 2018 [acesso em 2021 jan 5]; 22(supl2):1739-1749. Disponível em: https://www.scielo.br/j/icse/a/XRJVNsRHcqfsRXLZ7RMxCks/?lang=en.
https://www.scielo.br/j/icse/a/XRJVNsRHc...} .

The competence can be understood as the capacity of to mobilize and to put into action a range of knowledge, abilities and attitudes, seeking resolution of problems and the confrontation of situations of unpredictability^{2020 Deluiz N. Qualificação, competências e certificação: visão do mundo do trabalho. In: Brasil. Ministério da Saúde. Humanizar cuidados de saúde: uma questão de competência. Brasília, DF; 2001. p. 7-17. (v. 2).}. It holds three dimensions: knowledge, that involves the formal knowledge that can be translated in facts; know-how, that belongs to the sphere of procedures and techniques; and to know-be/act, corresponding to the behaviors and to the social and affective relationships^{2121 Vieira A, Luz TR. Do saber aos saberes: comparando as noções de qualificação e de competência. Organ. Soc. 2005 [acesso em 2021 mar 25]; 12(33):93-108. Disponível em: https://www.scielo.br/j/osoc/a/9Scn7Ld6qf6g94qdNYqjDjK/?lang=pt#.
https://www.scielo.br/j/osoc/a/9Scn7Ld6q...} .

Applied to the work in health, the concept of competence entails integrating different knowledge that may allow the diagnosis and the problematization of the reality, the proposition and implementation of confrontation and complex decision-making strategies. To be competent is to be an agent of changes, and requires partnership, dialogue and power relations between different actors interwoven in the reality that is expected to be changed. In this direction, it is clear that EIP and permanent education share common objectives and benchmarks^{2222 Ogata MN, Silva JAM, Peduzzi M, et al. Interfaces between permanent education and interprofessional education in health. Rev. Esc. Enferm. USP. 2021 [acesso em 2021 dez 14]; 55:e03733. Disponível em: https://www.scielo.br/j/reeusp/a/K89qghvK3WgSN3pzcdKsZgR/?lang=en.
https://www.scielo.br/j/reeusp/a/K89qghv...} , as insinuates one of the interviewed:

Both pedagogic approaches are political bets committed with democratic manners of building knowledge, to articulate education and work and to transform the health care practices. Thus, they demand the mobilization of different actors, the overcoming of disputes and conflicts and the building of dialogues and mobilizing actions for changes^{2222 Ogata MN, Silva JAM, Peduzzi M, et al. Interfaces between permanent education and interprofessional education in health. Rev. Esc. Enferm. USP. 2021 [acesso em 2021 dez 14]; 55:e03733. Disponível em: https://www.scielo.br/j/reeusp/a/K89qghvK3WgSN3pzcdKsZgR/?lang=en.
https://www.scielo.br/j/reeusp/a/K89qghv...} . An important distinction between those approaches is that EIP has the explicit purpose of developing a range of competencies considered essential to the praxis of the interprofessional work.

Different international organizations have been working for the recognition and in the construction of a range of collaborative competencies, that may be adapted considering the context in which EIP is implemented. The best known productions are the matrixes of competence of the Canadian Interprofessional Health Collaborative (CIHC)^{2323 Canadian Interprofessional Health Collaborative. A National Interprofessional Competency Framework. Vancouver: CIHC; 2010.} and of the American organization Interprofessional Education Collaborative^{2424 Interprofessional Education Collaborative. Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: IPEC; 2016.}. Both consider collaboration as an interprofessional process of communication and decision making that allows that the knowledge and the individual and shared abilities of different health professionals may influence synergistically the patient care.

From this perspective, it is considered crucial the promotion of competencies that allow the members of the team to communicate and to solve their conflicts ethically, assuring equity in decision-making; have clarity about the roles, responsibilities and limitations of each professional category involved in care, that has to be centered in the patient/family/community, and formulate, implement and evaluate care practices in a joint manner, aiming to improve the results in health care^{2323 Canadian Interprofessional Health Collaborative. A National Interprofessional Competency Framework. Vancouver: CIHC; 2010.,2424 Interprofessional Education Collaborative. Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: IPEC; 2016.}.

On that matter, the testimonies of this study demonstrate that the Interprofissionality edition has been generating listening movements, of knowledge of different professional roles, and of discussion about which competencies can potentially add value to collaborative practices in Brazilian context.

The interviewed highlighted the importance of understanding first the role of each profession, to understand them clearly for, then. have the possibility to establish common goals. For them, EIP makes possible to overcome the disciplinary ‘silos’, which means to escape professional and communicative niches, in which each profession adopts a specific language.

Literature also brings up this discussion and reveals that, although the developing of a professional identity is a fundamental part of professional education, a disadvantage in this process, when it has single profession character, is that members of one group perceive the attributes of other groups less desirable, strengthening the phenomenon of ‘professional tribalism’. This construction of rigid identities can lead to tensions and has become a psychological barrier for the communication between different categories^{2525 Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgrad Med. J. 2014 [acesso em 2021 dez 14]; 90(1061):149-154. Disponível em: https://doi.org/10.1136/postgradmedj-2012-131168.
https://doi.org/10.1136/postgradmedj-201...} .

Under other perspective, the interprofessional formation collaborates to allow the professional to delimit more clearly her/his acting field, recognizing hers/his limits and the power of the sharing actions. We talk, here, about an interprofessional identity, that values the creation of dialogue spaces, apprenticeship and trust and the establishing of closer interpersonal relationships^{2626 Rossit RAS, Freitas MAO, Batista SHSS, et al. Constructing professional identity in Interprofessional Health Education as perceived by graduates. Interface. 2018 [acesso em 2021 dez 14]; 22(supl1):1399-1410. Disponível em: https://www.scielo.br/j/icse/a/wtqgWTz6VYZjqZW3Gp5yG4F/?lang=en.
https://www.scielo.br/j/icse/a/wtqgWTz6V...} .

PET-Saúde/Interprofessionality has been stimulating the developing of actions for interaction, communication and collective work between different undergraduate courses. Dialogue and the perception of being in an ambient that provides support allowing the expression of disagreements are sine qua non conditions for the recognition of common objectives, values, responsibilities and guiding compromises in team work^{2727 Agreli HF, Peduzzi M, Bailey C. Contributions of team climate in the study of interprofessional collaboration: a conceptual analysis. J. Interprof. Care. 2017 [acesso em 2021 fev 14]; 31(6):679-684. Disponível em: https://www.tandfonline.com/doi/abs/10.1080/13561820.2017.1351425?journalCode=ijic20.
https://www.tandfonline.com/doi/abs/10.1...} .

The unfoldings of this collaboration reflect in the modification of the practices, contributing for the central objective of the EIP: to improve the results in health care^{2828 Reeves S, Pelone F, Harrison R, et al. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst. Rev. 2017 [acesso em 2021 dez 14]; 22(6):CD000072. Disponível em: https://doi.org/10.1002/14651858.cd000072.pub3.
https://doi.org/10.1002/14651858.cd00007...} . To reach this objective implies in moving for the team work, yet this is formed by different actors that have their own conceptions build throughout their life and their academic-professional path. Together, these actors may adopt a resistant attitude, or leave it, becoming committed and willing to break and untie from a strictly individual attitude for, then, participate actively in the collaborative learning process.

The change in the attitude is the trigger that allows the collaborative practice to happen and to maintain an integrated and integral practice, that will benefit patients/families/communities, making it possible the best use of the resources available and the developing of more creative and effective care actions^{2929 Supper I, Catala O, Lustman M, et al. Interprofessional collaboration in primary health care: a review of facilitators and barriers perceived by involved actors. J. Public Health (Oxf). 2015 [acesso em 2021 dez 14]; 37(4):716-727. Disponível em: https://doi.org/10.1093/pubmed/fdu102.
https://doi.org/10.1093/pubmed/fdu102...} . Therefore, it is paramount to discuss and to apply the assumption of the EIP in the promotion of a reflexive and collaborative apprenticeship.

Interprofessionality as a basis for the structuring of curricula and pedagogic practices

The construction of educational contexts in the perspective of the EIP implies in assuming the intention of forming critical, ethical and capable professionals, to work collaboratively and with social responsibility. Such intentionality demands organizing curricula and content and using pedagogic methodologies that stimulate the promotion of knowledge and cooperative capabilities^{1818 Freire JR, Magnago C, Costa MV, et al. Interprofessional education and the formative actions of the emergency provision axis of the More Doctors Program. Saúde debate. 2019 [acesso em 2021 dez 10]; 43(esp1):50-63. Disponível em: https://www.scielo.br/j/sdeb/a/XksJxG6Q9NkBD4n5SNzL7Wq/?lang=en.
https://www.scielo.br/j/sdeb/a/XksJxG6Q9...} .

About this matter, the narratives reveal that there is an ongoing process of induction for the curricular reforms in different undergraduate courses involved in PET-Saúde, yet the curricular changes under the precepts of EIP do not represent a policy incorporated by the education institutions represented in this study.

Those findings are not substantially different from those already published about the GraduaSUS edition, which suggest that the construction of a project that contemplate the EIP as a structuring foundation of pedagogic projects and curricula is still a challenge for the education institutions^{1414 Magnago C, França C, Belisário AS, et al. O PET-Saúde/GraduaSUS como mobilizador da integração inter, intra e extrainstitucional. In: Castro J, Vilar RLA, Dias MA, organizadoras. Educação e trabalho: interface com a gestão em saúde. Natal: Uma; 2020. p. 245-271.}. Nevertheless, it is already possible to perceive changing attitudes and movements of discussion and collective construction that lead to the strengthening of EIP as an approach for choosing to transform pedagogical practices.

For Barr^{1616 Barr H. Ensuring quality in interprofessional education. CAIPE Bulletin. 2003; (22):2-3.}, the interprofessional apprenticeship, besides being predicted in the curricular structure, integrating the education modules, presupposes the combination of common and shared methods and of interactive contextualizing pedagogical resources. For being rooted in the apprenticeship in service, PET-Saúde is, per se, an educational proposal contextualized in reality.

In this direction, members of the program profit from the different health care devices, already used in the service´s routine, as pedagogical resources promoting the shared apprenticeship between different professions. They are, thus, besides being interactive, contextual resources that come from health care needs and apply to them. Are examples: interprofessional practice, home visit, singular therapeutic project, rounds, clinical cases discussions and projects in the communities.

For being contextual and for triggering actions that aim to respond to health care demands of the territory, PET-Saúde promotes apprenticeship based on inclusion and on the centrality of the user, as well as on the effective participation of the professionals of the service in the educational practices. The narratives demonstrate manners of learning and of teaching that put the user in the center of the actions, and that are based on the developing of closer relationships with the communities searching for mobilizations and inclusion of the social movements in the discussions and in the conduction of the services.

PET-Saúde, rooted in the proposal of the EIP, was referred as revolutionary, challenging, results generating, bold, contemporary and the possible path for formation; since, from it, it is possible to foresee another logic, and education route that makes more sense for being more integrated, active and

Enhanced as a change inducing policy, the interviewed alluded that the PET-Saúde helps to assure the ethical commitment of the public institution with the public policies; and that its aim of being a transformation trigger is fulfilled. Therefore, expressed the desire that the curricula shall be increasingly rethought beyond those who participate in PET-Saúde, so that, when it ends the proposal and changes achieved will be sustained inside the curricular projects in the institution.

It no longer makes sense to think the formation out of the world of work, since it is only from it that it is constructed a critical-reflexive reading of the reality that transforms the actors in active subjects. It is in this perspective that the integration education-service-community, urged by PET-Saúde, aims to transform the work process in a dynamic movement, the praxis; namely in a social activity consciously intentional, oriented to an objective^{3030 Silva RHA. Educação interprofissional na graduação em saúde: aspectos avaliativos da implantação na Faculdade de Medicina de Marília (Famema). Educ. rev. 2011 [acesso em 2021 dez 14]; (39):159-175. Disponível em: https://www.scielo.br/j/er/a/sgdWh5RzHCHhyrnxbmkXjSC/?lang=pt.
https://www.scielo.br/j/er/a/sgdWh5RzHCH...} . By incorporating an intentionality, placed by EIP as a qualification of the practices and of the results in health care, the subjects may interfere in the transformation of the socio-sanitary reality.

This power of the PET-Saúde was already demonstrated by previous studies referring to other editions of the program^{1111 Mira QLM, Barreto RMA, Vasconcelos MIO. Impacto do PET-Saúde na formação profissional: uma revisão integrativa. Rev. Baiana Saúde Pública. 2016 [acesso em 2021 dez 14]; 40(2):514-531. Disponível em: https://rbsp.sesab.ba.gov.br/index.php/rbsp/article/view/1682/1889.
https://rbsp.sesab.ba.gov.br/index.php/r... ,1313 Magnago C, França C, Belisário AS, et al. PET-Saúde/GraduaSUS na visão de atores do serviço e do ensino: contribuições, limites e sugestões. Saúde debate. 2019 [acesso em 2021 dez 14]; 43(esp1):24-39. Disponível em: https://www.scielo.br/j/sdeb/a/ZnKPGMnksJcVQmJ79Wt38ny/?lang=pt#.
https://www.scielo.br/j/sdeb/a/ZnKPGMnks... ,1414 Magnago C, França C, Belisário AS, et al. O PET-Saúde/GraduaSUS como mobilizador da integração inter, intra e extrainstitucional. In: Castro J, Vilar RLA, Dias MA, organizadoras. Educação e trabalho: interface com a gestão em saúde. Natal: Uma; 2020. p. 245-271.}. However, there is still the perception that the initiative cannot reach, in a more significant manner, a wider range of subjects. Thus, a common point observed in those studies refers to the necessity of expanding them, in order to enable the participation of a larger number of institutions, undergraduate courses, health care unities, students and workers at SUS. This expectation enhances the indispensability of the institutionalization of this proposal, that can and must be fomented by the university community and by the health care services.

The mechanisms of evaluation of PET-Saúde/Interprofessionality

The change in the formation paradigm also demands changes in the evaluation processes, that may be considered pillars for the recognition and the effectiveness of the EIP. Adequate evaluation contribute to the personal and professional growth of the actors involved in the educational intervention, and for the improvement of the educational pedagogic and institutional process, assuring that professionals endowed with the essential attributes for the collaborative work are being prepared. For Barr^{1616 Barr H. Ensuring quality in interprofessional education. CAIPE Bulletin. 2003; (22):2-3.}, the evaluation mechanisms have to assure continuous evaluation processes of the apprentices that may verify the development of competencies and attitudes, allow the planning of the pedagogic methods, and whose results have to be disclosed in order to assist the planning of new EIP experiences.

Moreover, considering that, in the ambit of PET-Saúde, the implementation of the EIP is being induced from the introduction of students and the developing of actions in the SUS scenario, the evaluation processes also shall consider the impact in the health care results. From this point of view, the evaluation is constituted in an act of apprenticeship capable of assuring the formation progress of all the actors involved in education, and an enabler instrument of experience exchange and of planning of actions that conduct to best care practices^{3030 Silva RHA. Educação interprofissional na graduação em saúde: aspectos avaliativos da implantação na Faculdade de Medicina de Marília (Famema). Educ. rev. 2011 [acesso em 2021 dez 14]; (39):159-175. Disponível em: https://www.scielo.br/j/er/a/sgdWh5RzHCHhyrnxbmkXjSC/?lang=pt.
https://www.scielo.br/j/er/a/sgdWh5RzHCH...} .

In this study, it was observed that the evaluation processes of EIP employed in the context of PET-Saúde were considered incipient or were not mentioned. Although it is recognized that the Interprofessionality edition provoked changes in education and in the service, the members do not have evaluation instruments, indicators and systematized results that may demonstrate the impacts of the program.

Some tutorial groups use intra-group evaluation strategies and of displaying the results reached with PET-Saúde, in general fomented by teachers and students that aim to narrate and to publish their experiences through scientific papers. Such movements are isolated, non-institutional and non-governmental, but represent an effort of accompanying the actions developed and the benefits perceived in the educational routine.

In the GraduaSUS edition, it was perceived an effort from the Ministry of Health in in undertaking, for the first time, a nationwide systematized evaluation process, about this formation model reorientation initiative, whose results subsidized the elaboration of the Interprofessional edition^{3131 Brasil. Ministério da Saúde, Secretaria de Gestão do Trabalho e da Educação na Saúde, Departamento de Gestão da Educação na Saúde. Programa de Educação pelo Trabalho para a Saúde: um panorama da edição PET-Saúde/GraduaSUS. Brasília, DF: Ministério da Saúde; 2018.}. Nevertheless, the results published indicate the lack of permanent evaluation mechanisms that identified the strengths and weaknesses of the program and, therefore, would subsidize the necessary adjustments for its improvement^{1212 França T, Magnago C, Santos MR, et al. PET-Saúde/GraduaSUS: retrospectiva, diferenciais e panorama de distribuição dos projetos. Saúde debate. 2018 [acesso em 2021 dez 14]; 42(esp2):286-301. Disponível em: https://www.scielo.br/j/sdeb/a/dTvgGzZNTxzm9BcVr6b9H4N/?lang=pt.
https://www.scielo.br/j/sdeb/a/dTvgGzZNT... ,1313 Magnago C, França C, Belisário AS, et al. PET-Saúde/GraduaSUS na visão de atores do serviço e do ensino: contribuições, limites e sugestões. Saúde debate. 2019 [acesso em 2021 dez 14]; 43(esp1):24-39. Disponível em: https://www.scielo.br/j/sdeb/a/ZnKPGMnksJcVQmJ79Wt38ny/?lang=pt#.
https://www.scielo.br/j/sdeb/a/ZnKPGMnks...} .

Were also predicted monitoring and evaluation mechanisms of the development of the projects of PET-Saúde/Interprofessionality, that would be monitored through reports and narratives of experiences emitted by the executing institutions, in loco visits carried out by ministerial advisors and monitoring and evaluation researches^{3232 Brasil. Ministério da Saúde, Secretaria de Gestão do Trabalho e da Educação na Saúde. Edital nº 10, de 23 de julho de 2018. Seleção para o Programa de Educação pelo Trabalho para a Saúde: PET-saúde/Interprofissionalidade. Diário Oficial da União. 24 Jul 2018.}. This aspect was mentioned by an interviewed, whereby the advisors’ visit was an opportunity for joint learning, although not enough for the production of data that that can contribute for the program’s sustainability and the EIP’s approach.

There are varied patterned instruments available to determine the satisfaction of the apprentice, the changing attitudes and the manners how the competences are being integrated to the everyday practice of the students. However, what can be observed is that the literature about the theme values more the attitudinal dimension (being) than the conceptual (knowing) and the procedural (know-how)^{3333 Frasson F, Laburú CE, Zompero AF. Aprendizagem significativa conceitual, procedimental e atitudinal: uma releitura da Teoria Ausubeliana. Cont. Educ. 2019 [acesso em 2021 mar 6]; 34(108):303-318. Disponível em: https://www.revistas.unijui.edu.br/index.php/contextoeducacao/article/view/8840.
https://www.revistas.unijui.edu.br/index...} Moreover, the national evidences about education and work experiences rooted in EIP do not have structured proposals on the collection and analysis of information that measure and judge their effects on practice and the results in health care.

For Carvalho et al.^{3434 Carvalho ALB, Souza MF, Shimizu HE, et al. A gestão do SUS e as práticas de monitoramento e avaliação: possibilidades e desafios para a construção de uma agenda estratégica. Ciênc. Saúde Colet. 2012 [acesso em 2020 dez 4]; 17(4):901-911. Disponível em: https://www.scielo.br/j/csc/a/zbbKf7BZXVhZZQCF4ZrLPdm/?lang=pt.
https://www.scielo.br/j/csc/a/zbbKf7BZXV...} , the evaluation procedures do not yet belong to the institutional culture, are scarcely incorporated to the practices and have, almost always, a prescriptive and bureaucratic character. When employed, may recover the commitment and the co-responsibility between the academy and the health care services, contributing to the developing of an organizational culture and for the process of institutionalization of the evaluation.

The public policies of the programs, projects and action that support them need to assure efficient and effective answers to the public character matters. In this sense, all the policies implemented shall be monitored and evaluated, in a transparent and democratic manner^{3535 Garcia RC. Subsídios para organizar avaliações da ação governamental. In: Cardoso Jr JC, Cunha AS, organizadores. Planejamento e avaliação de políticas públicas. Brasília, DF: Ipea; 2015. p. 233-96.}. Considering that EIP, through the PET-Saúde, constitutes a public strategy aiming to instigate transformations of the education and working professional practices to produce significant results for the qualification of the health assistance, the evaluation processes are also applicable and required.

Monitoring and evaluation can be perceived as part of a wider effort to improve the formulation of public policies, collaborating to improve the planning and the administration of the interventions in course, once they measure their effects and appreciate the influence of the ambient and of the context in which they are implemented^{3535 Garcia RC. Subsídios para organizar avaliações da ação governamental. In: Cardoso Jr JC, Cunha AS, organizadores. Planejamento e avaliação de políticas públicas. Brasília, DF: Ipea; 2015. p. 233-96.}. To evaluate the initiatives of introduction of the EIP in the undergraduate courses in health, to discover the effect of this intervention in education and in SUS, can assure to this approach in a space of recognition and to subsidize processes of decision-making based on evidences that aim to improve the strategies used for their implementation.

Final considerations

In spite of the different advances achieved by the previous versions of the PET-Saúde, fundamental for the structuring of the new arrangements that target the effective transformation of the education-apprenticeship; it is from the results of the Interprofessionality edition that are identified more robust integration processes, provoking an inclusive movement of the concepts of EIP and of collaborative practices, not only in the inner ambit of the universities and services of SUS, but only in the territories where health care is produced.

This study succeeded to demonstrate that, assuming as common thread the integration of education-service-community and as central focus the curricular change under the precepts of EIP, the PET-Saúde/Interprofessonality edition deflagrated assertive experiences of education-apprenticeship in SUS scenarios. Besides mobilizing curricular reforms and the creation of interprofessional disciplines, the program is managing to promote collaborative attitudes and competencies. In this sense, an attitude of openness for the alterity, opposing to the imprisonment in their own professional clusters, stands out. As impacts, are perceived behavior changes in front of the collective, recognition of its own functions and of the different professional roles, increasing of the implication in the exercise of co-production and co-responsibility for the care and its results.

Being anchored in the EIP premise of “learning together to work together”^{22 World Health Organization. Framework for action on interprofessional education & collaborative practice. Geneva: WHO; 2010. [acesso em 2022 set 28]. Disponível em: http://apps.who.int/iris/bitstream/handle/10665/70185/WHO_HRH_HPN_10.3_eng.pdf;jsessionid=F3A135CF72ADCA28D077D6C57F2D1256?sequence=1.
http://apps.who.int/iris/bitstream/handl...} , the actors of the PET-Saúde/Interprofessionality, in the SUS scenarios, draw upon management and production of care devices to promote the interactive, shared and collaborative apprenticeship among students and workers. They work, therefore, as inclusive pedagogic resources for the users and contextualized to their health care demands. From this point of view, the structured and performed collectively actions demonstrate that it is possible to teach and to learn from SUS’ daily routine.

The conquests achieved through interprofessional initiatives demonstrate availability of the actors of education and service to sever from the education processes and work based on the hierarchisation of the knowledge cores and of the power and authority relations^{2222 Ogata MN, Silva JAM, Peduzzi M, et al. Interfaces between permanent education and interprofessional education in health. Rev. Esc. Enferm. USP. 2021 [acesso em 2021 dez 14]; 55:e03733. Disponível em: https://www.scielo.br/j/reeusp/a/K89qghvK3WgSN3pzcdKsZgR/?lang=en.
https://www.scielo.br/j/reeusp/a/K89qghv...} . However, the dynamics of PET-Saúde and the approach of EIP did not yet manifest as structuring policies of the undergraduate courses, whose impediments for their institutionalization yet persist. Special attention must be given to the evaluation processes, yet quite incipient, that do not enable the systematization of the evidences about the impacts of the initiative in the formation, professional action and in the results in health care.

Another challenge is the sustainability of the advances achieved, what requires investment in resources, pedagogic methods, strategies for qualification of teachers and preceptors; just as greater political support to the education institutions to allow them to deepen and to assure the perenniality and legitimacy of EIP in the reorientation policies of the formation.

Even though this study has analyzed the PET-Saúde/Interprofessionality from the experiences circumscribed in a federative unit, it is proven that it has been contributing progressively for the transformations in the education and for the dissemination of the concepts and assumptions that orient EIP among students, teachers, professionals and managers.

References

Publication Dates

History