versión impresa ISSN 1414-3283
Interface (Botucatu) v.4 n.se Botucatu 2008
O cuidado no trabalho em saúde: implicações para a formação de enfermeiros
El cuidado en el trabajo en salud: implicaciones para la formación de enfermeros
Roseni Rosângela de SenaI,i; Kênia Lara SilvaII; Alda Martins GonçalvesIII; Elysângela Dittz DuarteIV; Suelene CoelhoV
INurse. School of Nursing, Universidade Federal de Minas Gerais/UFMG <email@example.com>
IINurse. School of Nursing, Universidade Federal de Minas Gerais/UFMG <firstname.lastname@example.org>
IIINurse. School of Nursing, Universidade Federal de Minas Gerais/UFMG <email@example.com>
IVNurse. School of Nursing, Universidade Federal de Minas Gerais/UFMG <firstname.lastname@example.org>
VNurse. School of Nursing, Universidade Federal de Minas Gerais/UFMG <email@example.com>
Translated by Carolina Silveira Muniz Ventura
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.12, n.24, p. 23-34, Jan./Mar. 2008.
With the aim of identifying the needs for changes in nurse training when taking care to be the domain at the specific center of nursing practice, a qualitative study was developed using interview data from focal groups involving lecturers and students from nursing schools in the state of Minas Gerais, Brazil. In these nursing schools, the concept of care that translates how to act incorporates an integral view of human beings and takes shape through relationships of intersubjectivity. However, the prevailing pedagogical and assistance-providing practice reiterates the biomedical model and weakens the notion of care expressed by participants. This indicates that the challenge for training is to be occupied with teaching that conserves the care practices of the specific professional center and their intersections within the healthcare field, in a movement that gives value to learning guided by reality, within which students experience and reflect on the care process.
Key words: Healthcare. Nursing care. Health education.
Com o objetivo de identificar necessidades de mudança na formação dos enfermeiros ao assumirem o cuidado como domínio do núcleo específico de sua prática, desenvolveu-se um estudo qualitativo utilizando-se dados de entrevistas em grupos focais com docentes e estudantes de escolas de enfermagem do estado de Minas Gerais, Brasil. Nessas escolas de enfermagem existe a concepção de cuidado traduzido como agir que incorpora uma visão integral do ser humano e que se concretiza em relações de intersubjetividade. Entretanto, prevalece uma prática pedagógica e assistencial que reitera o modelo biomédico e enfraquece a noção de cuidado expressa pelos participantes. Aponta-se, como desafio para a formação, a ocupação com um ensino que resgata as práticas cuidadoras do núcleo profissional específico e das intersecções no campo da saúde, num movimento que valoriza a aprendizagem pautada na realidade e no qual o estudante vivencia e reflete sobre o processo de cuidar.
Palavras-chave: Cuidado de Saúde. Cuidado de Enfermagem. Educação em Saúde.
Con el objetivo de identificar las necesidades de cambios en la formación de los enfermeros al asumir el cuidado como dominio del núcleo específico de su práctica, se desrrolló un estudio cualitativo usándose datos de entrevistas en grupos focales con docentes y estudiantes de escuelas de enfermería del estado de Minas Gerais, Brasil. En tales escuelas de enfermería el concepto de cuidado se traduce como actuación que incorpora una visión integral del ser humano y se materializa en relaciones de inter-subjetividad. No obstante prevalece una práctica pedagógica y asistencial que reitera el modelo biomédico y debilita la noción de cuidado expresada por los participantes. Se enfatiza como desafío para la formación la ocupación con una enseñanza que rescata las prácticas cuidadoras del núcleo profesional específico y de las intersecciones en el campo de la salud, en un movimiento que valora el aprendizaje pautado en la realidad en el cual el estudiante reflexiona y vive el proceso de cuidar.
Palabras clave: Cuidado de salud. Cuidado de enfermería. Educación en salud.
In the present paper, we provide the results of the research "Approach to healthcare in curricula of Schools of Nursing in the State of Minas Gerais"1, carried out by researchers of Núcleo de Estudo e Pesquisa sobre o Ensino e a Prática de Enfermagem (NUPEPE Nucleus for Study and Research on Nursing Teaching and Practice), of Universidade Federal de Minas Gerais (UFMG).
The paper aims to identify the needs of change in nurse training when nurses assume care as a domain of the specific nucleus of their practice in the intersections it makes within health work. The theoretical-methodological design of the study was guided by the Diretrizes Curriculares Nacionais (DCN National Curriculum Guidelines) of the Nursing Undergraduate Course. The DCN establishes the competences and abilities to be developed in the nurses' training process. These competences and abilities view care as the object of the professional action in health promotion, disease prevention and in the treatment and rehabilitation of illnesses (Brasil, 2001).
The premise of the study is that the nursing schools aim to provide training that takes the public health policies into account, and formulate and execute an ethical, political and pedagogical project, allied with the struggle for Sistema Único de Saúde (SUS - National Health System), in a field in which the object of the specific professional practice nursing care is expressed as a strategy to qualify healthcare and to intensify the struggle for healthcare integrality in Brazil.
We recognize that care assumes many connotations that cannot be translated exclusively as an activity conducted so as to treat a wound, relieve a discomfort and aid the healing of a disease. We understand that the meaning of human care is broader and is revealed as a form of expression, of relationship with another person and the world, that is, as a form of living life fully (Waldow, 2001). Thus, care is not reduced to an act; it is an attitude that "encompasses more than a moment of attention, dedication and devotion. It represents an attitude of occupation, preoccupation, responsibility for and affective involvement with the other person", as Boff argues (2004, p.33).
Conceptions of care are present in the debate about healthcare quality, a field in which Nursing articulates itself for the development of its social practice, having care as its specific nuclear object. It is necessary to recognize that there is a diversity of concepts that permeate healthcare and nursing care, and this, many times, hinders the construction of its meaning for workers and users. However, it must be considered that care is constituted by fundamental principles like: right, authenticity, life defense, receptiveness and alterity (Ayres, 2004, 2001). Therefore, even if it is difficult to delimit the conception of care that guides actions in healthcare and in nursing, the clarification of its constitutive elements becomes fundamental to the practice of the professions that assume it as guideline or are constituted by its engendering.
With these premises, it is hoped that schools offer an education that prepares a highly qualified professional, that is, with competences and abilities to provide healthcare in accordance with the principles of SUS, imprinting the logic of integrality and humanization of care on his/her actions.
This issue is central in facing the current demands in the field of health teaching and health assistance, which have been traditionally marked by the organization of reductionist practices, focusing on physiopathological problems and symptoms remission, which do not contribute to the understanding of care as construction of projects of life, health and disease coping. It implies a teaching-learning process marked by the sharing of experiences and reflections, in a search for the articulation between knowledge, powers and techniques, politically and socially contextualized towards an assistance practice guided by integrality and by the development of the other person's autonomy.
We have been watching a continuous growth in studies and discussions about "human care", and this is the best epistemological translation of nursing, the essential characteristic of nursing knowledge and practice which defines its scientific and professional body. In the area of nursing education, recent works have approached the teaching of care as caring practice, the application of educational models and pedagogical approaches that prioritize care, and innovative curricular experiences that search for centrality in care (Waldow, 2006).
In this understanding, we reaffirm the potential of training that is characterized by coherence between the institutional project and the health policies, articulating management, training and assistance spaces in order to amplify the territory of nursing care and consolidate the integral and humanized practices.
The research was carried out by means of the qualitative approach which, according to Minayo (2004), considers the possibility of incorporating the issues of meaning and intentionality as inherent in acts, relations and social structures, viewed, both in their advent and in their transformation, as significant human constructions.
The research's theoretical-methodological framework was based on the dialectical method to investigate the social practice of nursing in the context of the health practices. According to Gonçalves (2002), the dialectical method constitutes a theoretical-methodological reference that enables to analyze the object of study, departing from the worldview of the research participants, expressed in their forms of thinking about social reality. This method is based on the belief in the permanent movement that exists in nature and society, as well as the belief that this society, which is historically constructed, can be transformed by the elimination of contradictions by means of creative praxis.
The set of the study was constituted by schools of nursing of the State of Minas Gerais (in the Southeastern region of Brazil). After the project was approved by the School of Nursing and by the Research Ethics Committee of Universidade Federal de Minas Gerais, the mapping of the schools in the State was performed and 29 schools of nursing authorized by the Ministry of Education (MEC) were identified. Today, there are 104 nursing courses, including courses authorized by MEC, courses under accreditation process and courses authorized by the State Education Council. This information shows the quick expansion of the number of nursing courses in the country (Brasil, 2007).
For the inclusion of schools as scenery, the defined criteria were: the institution should have formed a class up to 2003 - the beginning of the project - and, in the set of the scenery schools, the different geopolitical regions of the State should be represented. In case there was more than one school with these characteristics, a public and a private school were included, and preference was given to those that started to operate first. In addition, we tried to guarantee the presence of the diversity of organizational, administrative and political aspects of each school. Thus, 12 schools met the inclusion criteria and were asked whether they were interested in participating in the research. As two schools did not want to participate, ten were dealt with as scenery.
Data collection was performed by means of collective interviews in the form of focal groups. Ten focal groups were conducted, one in each scenery, with the participation of 58 students and 58 professors. At the beginning of the focal group interview, we presented the purposes of the research, the objectives, the data collection procedures, and we assured secrecy and guaranteed that the data would be used exclusively for technical-scientific production. After the explanations, each participant signed a consent document.
The focal group discussion was triggered based on the guiding question "describe the approach to care used in the teaching of nursing at this school". The conduction of the discussion was supported by a script with auxiliary questions, which allowed to explore several aspects of the studied theme by using the participants' manifestations.
The focal groups lasted approximately two hours in each scenery, and were organized according to the group work moments presented by Dall'agnol & Trench (1999). The groups were conducted by a moderator and an observer. The former acted as a discussion guide, moderating everybody's participation around the research objective. To guarantee reliability in data reproduction, the participants' discourses in the focal groups were recorded and, subsequently, transcribed and submitted to discourse analysis, according to Minayo's (2004) orientation. The discourses of the participants in each group were coded by using the letters GF (in Portuguese, Grupo Focal Focal Group) and numbers from 1 to 10, corresponding to the sequence in which the groups were conducted. This enabled to relate the content of the participants' discourse to the research scenery without identifying the School.
The data were organized into spreadsheets, and the research corpus formed a database composed of the data set of the researched sceneries. These spreadsheets presented a panorama of the information collected in the ten sceneries, enabling parity analysis among them.
After the detailed reading and identification of the central ideas, the categories and subcategories emerged. The categories were organized in an attempt to identify some logic for the arrangement of the central themes that compose them. In the analysis, we tried to articulate the reality revealed by the focal group participants with the authors' knowledge and experience in the construction of the nursing DCN (Silva & Sena, 2006, 2003; Sena et al., 2002).
Care conceptions that emerge from nurse training
When the study's participants described the approach to care in nurse training, they revealed the concepts of care and caring practices that permeate the teaching-learning process and translate the conceptions about the object of the nursing practice in the several sets where they work. They also expressed the conceptions of nursing and health work, discussing the essence of the profession and the contradictions manifested in the thinking, doing and being dimensions of the nursing professionals.
The analysis of the discourses that were constructed in the focal groups revealed that there are different conceptions about care. It is important to highlight the possibility that the discourses point to a freedom of interpretation that seems to be fundamental to a political practice that is ethically coherent with the health needs and demands of the population and with the SUS principles.
The discourses of the study's participants showed a conception of care in which the caregiver and the being who receives care have a relationship and build a humanized therapeutic project. The participants expressed their conceptions of care stating that "providing care means listening to the other person, is being by his/her side" (GF3), "it means respecting the will of the other" (GF4), "it means giving shelter, being together" (GF6).
The analysis of the discourses allowed to state that the understanding of care as an element to strengthen the critical autonomy of the subjects involved in the care process must be constructed based on flexibility, intersubjectivity, recognition of the values of the human being and recognition of the other as a different being. This analysis leads to a conception of care, described by Waldow (2001), as based on its epistemological essence: presence, consideration, interest, dedication, preoccupation and affection.
To enrich this discussion, we used Ayres' (2004, 2001) theoretical framework. When the author discusses the reconstruction of the health practices, he highlights relevant aspects for the analysis of care in this scope. Ayres presents the elements movement, interaction, identity, alterity, plasticity, desire, project, temporality, non-causality and responsibility as inherent in and indispensable to the multiple relations in which care is constructed.
The participants expressed that nursing care is fulfilled in the possibility of "holistic attention": "provide care in all senses, see the person as a whole" (GF2), that is, an understanding of the being that is being cared for in all his/her dimensions, possibilities and interactions. Based on the discourses, it was possible to recognize, also, that the participants identified that nursing care should consider "co-responsibility" (GF4), "it should stimulate autonomy" (GF2) and "respect the subject in his/her decisions about his/her life" (GF2). We identified that the being who receives care and the caregiver are considered by the interviewees in the perspective of their singularities, in their ways of being, feeling and expressing, confirming the application of the humanization and integrality principles to the care provided.
The caring practice, revealed by the research subjects, is present in the touch, the discourse, the observations, the hearing, the receptiveness, in the establishment of bonds and in the capacity of acting in contexts marked by unpredictability. Thus, the different conceptions about care expressed by the study's participants revealed their intention to assume the perspective of user-centered care. This consideration points to the need to reconstruct the pedagogical and health practices, so as to make them become able to contribute to the configuration of a care model centered on users. It is important to rescue the nature of care as being sustained by interpersonal relations mediated by light technologies, understood as those that involve the relations between subjects, implying bonds, receptiveness and responsibility (Merhy, 2002a). It is important to highlight that user-centered care, according to Merhy's (2002a) perception, does not have an intimistic sense, but it is used in opposition to care centered on procedures, institutional routines, professional corporations or on any kind of private interest (centered on the use of products, equipment, services, installations).The interest of care is related to the user, including his/her ethical-esthetical-political experience.
However, the participants revealed that a practice centered on the professionals' action and on technologies still prevails in healthcare, with emphasis on individual and curative care. According to Afanador (1998), we verified that it is necessary to undertake a movement of care construction that values: the interlocutors' authenticity, respect to one's own and also to the other person's originality, the desire to share, the concern about being understood, as well as an attitude of permanent hearing and attention.
This recognition reinforces the importance of the use and valorization of light technologies as definers of nursing care. Such technologies should be present in all the interactions between nursing workers and the other health workers, and they should also govern the care provided for people, both individually and collectively, and the care given to families or population groups.
Nursing, due to its caring nature, has a tradition in the use of light technologies and needs to qualify them with the purpose of valuing its knowledge, practices, and its feeling of care provider. Therefore, nursing professionals' training must construct knowledge about the actions related to light technologies: moments of conversation, hearing and interpretation of meanings, moments of solidarity, in which responsibilities are shared concerning the problems to be faced, and moments of trustworthiness and hope, in which relations of bond and acceptance are generated, as Merhy (2002b) argues.
The analysis of the participants' discourses reveals that this degree of accumulation in the praxis of nursing teaching and care has not been reached yet. The interviewees mentioned their intention to rescue and re-signify the light technologies in nursing care as an ethical-political imperative for the defense of life with quality and centrality of care to individuals, groups and collectivities, in a citizenship exercise that requires changes in nurse training. They highlight the need to overcome, in the health practices, the biological focus centered on pathology and on curative and individual aspects, characteristics that are in opposition to the conceptions of care projected as image-objective by the study's participants.
Data analysis showed that curative care still predominates in nursing practices. Based on this observation, we noticed that there is a distance between conceptions of care formulated by the interviewees, what they express and what happens in the daily practice. The focal groups participants expressed that "the holistic discourse is beautiful, but training aims at the pathological dimension" (GF8), "there are conflicts between the school discourse and the real situation of the services" (GF8), "the care is targeted at the biological, pathological dimension" (GF3).
Consuegra (1998), referring to the care practice, also emphasizes that the true caregiver wants freedom, dialog and creativity, important principles to discuss the teachers' practice in the nursing professionals' training. Educating implies contextualizing the pupil about the social structures and, in nursing, the philosophy of education and that of care should be supported by the same paradigm (Consuegra, 1998).
The analysis of the discourses demonstrate that nursing care occurs in a fragmented way, not articulated with the integral care practices, which have potential to overcome the disease-oriented view; and also, the need to use the indispensable tools to the construction of the multiple relations in which care is built.
In this predominant mode, nursing knowledge and action bow to the hegemonic models of health knowledge and practice, supported by the biological, curative, and by individual assistance focused on disease. The focal groups participants expressed that "care is deep- rooted in the biological and this has been very emphasized throughout the course. So, a pathology is approached, even though superficially, and based on this, the teaching of care is inserted." (GF3).
It is possible to identify in the discourses the recognition of the need of change in nurse training, but few elements presented in the data analysis signaled a movement of change. We perceived a reiteration of the hegemonic conceptions guided by the positivistic paradigm, broadly practiced in health. Waldow (1998) analyzes knowledge construction in nursing, explaining that it is supported by the rational thought predominant in the "Scientific Age". The author states that this paradigm has influenced nursing since its emergence until the current times. By criticizing this influence, the author proposes new ideas centered on human care as philosophy of life and guideline to nursing.
Based on the analysis of the discourses, it is possible to infer that the process of change in nurse training and the construction of other possibilities of care in order to overcome the biomedical model are challenged by the lack of definition about the profession's instruments for the praxis of care. This finding is fundamental in view of the need of accumulation and mobilization of forces towards the construction of a new techno-assistance health reality, in which nursing is inserted in a more authorial way.
The focal groups participants indicated the need to construct systematization methodologies of nursing care and define a body of knowledge for the profession, both supported by concepts that enable to explain the caring practice. Based on the interviewees' ideas, we can infer that the ethical-political project of nursing should produce knowledge and a social practice that overcomes the reproduction of hegemonic and dominant practices in the health field.
It is important to recognize that, when we point to the challenges expressed in the analyzed discourses, we aim to contribute to the construction of a creative praxis. This aspect should be revisited by the interviewed professors and students so that, in a dialog with in-service nurses and users, new possibilities of care can be built, with emphasis on the caring practice that is centered on care. The discourses evidenced new practices that recognize the importance of subjectivity relations in care, both to professionals and users. In addition, the interviewees expressed the urgency of assuming human care as an attitude, as Boff (2004) proposes.
Care specificity in health work and implications for nurse training
The analysis of the discourses reveals that, in care provision, nursing operates in a field that is common to all the health workers. Its knowledge feeds and expresses a determined specificity that determines the technical directionality of its work, which articulates with the work of the other health professionals. The specificity of the profession is based on care as a specific domain of the professional nucleus, and it is presented, in the interviewees' discourses, as an element that feeds the tensions that constitute the caring praxis in the different intersections that the profession makes in the health field.
The study's participants revealed elements that constitute the nursing work process, focusing on the subject in the live act of providing care. The interviewees emphasized that the nurse, as caregiver, is supported by nursing knowledge and practices, aiming, in the act of providing care, to develop the autonomy of the being who receives care.
Nursing work is marked by the complexity and possibilities of the live work in action (Merhy, 2002a) and contains diversities of relations among the members of a health team. These relations are marked by cultural, socioeconomic, ethical and subjective aspects that define these and other relations and the construction of several different projects.
For his/her action, a professional mobilizes his/her knowledge and ways of acting, initially defined by the problem to be faced and using the specific knowledge of his/her professional action field, configuring a specific nucleus of knowledge. However, even with territorialized knowledge, there is the nucleus of care activities that covers the set of specific nuclei of each profession, including nursing, and it is common to all workers. This is the field where the relational processes that are care providers by nature occur, since they are activated by the desire of assisting in health (Merhy, 2002b).
The interviewees identified, in the specificity of the professions, that which could potentialize the competences of the specific nucleus of each professional and also the common competences. Among the identified discourses, some mentioned again the conflicts among professions, reaffirming the existence of power relations that need to be altered.
The understanding that care is constructed by the intersection of the specific nuclei of the different professions is stated by the participants when they reveal that "all the professions have a form of care" (GF1); in addition, they say that "nursing care is better received than medicine care" (GF1), and that the other professions do not have a view of care as nursing: "view the whole, and not the disease" (GF1). This opposition shows the conflicts that pervade the relations among nursing professionals and between them and health professionals, and which express a set of constitutive tensions in the health action. They also aroused expressions that reveal nursing as "a submissive and delegated profession" (GF4); the "nurse's subordination" (GF4); "the social division of work permeated by the definitions of competences, and not of care" (GF1); and the hierarchization of care.
On the other hand, other discourses indicate the intentionality of understanding team work: "it is necessary to learn how to work in a team" (GF5), "team work makes us grow" (GF4). This challenge of working in teams is mentioned by the interviewees as a factor that contributes to reduce care fragmentation, and increases the work's quality and problem-solving capacity.
When the construction of the non-private knowledge of the professions is accepted, even though the professional exercises constitute particular territories of in-depth production of knowledge and action, all the professions have, before themselves, the challenge of combining actions and knowledge from the specific nuclei and from the common fields of health workers in the construction of care. When we analyze the participants' expressions related to team work, we see that the analysis is permeated by conflicts, limits and difficulties. The participants state that team work does not exist, culminating in the partialization of care. They also state that health work is remarkably individualized and centered on acts carried out by professionals.
Although they refer to limitations present in the health services related to team work, the participants recognize the potential of this work, viewing it as a value that is added to the common nucleus of nursing and creates opportunities to the establishment of agreements that favor the multiprofessional exercise, focusing on interdisciplinarity.
We assume that the specificity of nursing is expressed by the relations with its own knowledge and actions that configure a field of knowledge that contributes to the quality of care. When we analyze the nucleus of specific competences of nursing care, we find a historical explanation for human care that became scientific, and we also discover the essentialness of care and its hegemonic performance by women, as part of gender division in labor. Another aspect that delimits the field of care in nursing is the centrality of the intersubjective relations that were gradually obscured by the preponderance of the incorporation of hard technologies into health assistance, characteristic marks of the 19th and 20th centuries (Silva & Sena, 2004).
The praxis of professional nursing is marked by a social, historical and cultural construction, in which institutionalization transits between "natural" care and professionalization, incorporating the disease-centered care model. This ambiguity was expressed by the interviewees as being present in nurse training. The analysis of the discourses identified expressions that show the historical legacy of women as caregivers and care viewed as a professionalization option for nursing workers. The interviewees' expressions have a rich content and allow to qualify nursing and care based on the contradictions revealed in the analysis of the ancient practice of nursing, marked by the presence of women in a form of expression of life defense.
We recognize that thinking of, providing and feeling care is complex, extensive and full of unpredictable events and conflicts, expressing different projects in dispute. Care takes place in a broad field of possibilities: management of the nursing team, forecast and provision of instrumental and institutional resources to the quality of health protection, and a broad view of the many actors involved in care (other professionals, family members and other people who are part of the affective bonds, members of the culture of insertion of individuals and collectivities, etc.) Nursing care has an individual, collective and institutional implication. We understand that, to provide such care, these possibilities should be coherent with the caring practice that is expressed in the daily routine of the health work.
The analysis of care and of its multiprofessional interfaces as a common object of the specific nuclei in health work provides subsidies for the orientation of nurse training without suppressing the specificity, and recognizing singular professional values in the science of nursing and in the caring practices.
In this sense, the study's participants revealed that teaching is being directed towards the assumption of care as a concept that pervades the entire training. They express that there are transversal contents that lead to care and are dealt with throughout the course. They also argue that, beyond the contents approached in the disciplines, care is materialized in training by means of the relations established between professors and students, and in the care that the student gradually builds during the course, in the diverse teaching-learning sets.
An important question that emerged in the discourses refers to the conception of care that the student builds based on reflections on the daily care practice that is guided by the professor. In this sense, one of the indications of the analysis of the discourses refers to the importance of the early insertion of students into real sceneries, so that care can be assumed in the daily routine of the health services. This analysis shows that teaching needs to be close to the daily questions of the health services, enabling the problematization of the nurse's caring practice.
It is possible to infer, from the analysis of the discourses, that care-centered teaching must be sustained by a pedagogical framework that values the student's active role in the construction of knowledge and of the conception of care. This construction is enabled by teaching that is based on concrete reality, in which the student experiences and reflects on the care process.
Henriques & Acioli (2004) analyze that professional training must be able to qualify the nurse to deal with the multiplicity of situations and technologies in favor of care. We consider that this analysis converges to user-centered care. This understanding strengthens the need to reflect on care in all its dimensions in nurse training, indicating that the challenges to approach care in teaching refer to the conceptions of education that permeate the nursing teaching practice and that are reflected on the way the curricular contents are organized and developed during the training.
The analysis of the discourses allows us to state that the organization of the care-centered teaching-learning process should overcome the traditional conceptions of nursing education, which are based on the dichotomy between theory and practice, so as to assume an education that contributes to the acquisition of competences and abilities for integral care. This construction finds support in innovative teaching methodologies that enable action/reflection/action regarding the caring process.
With this, we point to the need for transformations in the teaching-learning process, through the implementation of pedagogical conceptions that allow theory to be close to practice and vice-versa, and the problematization of the nurse's caring praxis as a possibility to develop care in an integrated and continuous way, individually or collectively, guided by an ethical-esthetical-political project of life defense. Thus, we argue that the approach to care in nurse training should allow the acquisition of competences in the service of a caring and integral project that performs an individual approach, without neglecting the collective dimension of the health problems, and that is user-centered, in the way Merhy (2002b) proposes.
The participants recognize that there is a process under transition and indicate signs of a new way of thinking in schools: "the school is under transition from a curative model to preventive health" (GF5), "constantly rethinking the concepts in order to provide care" (GF4). These considerations are presented as positive factors and some indications are identified so that the transformation processes can occur.
In addition, the participants recognize that a political-institutional decision for the process of change is needed, guaranteeing mechanisms such as: "the faculty should be more prepared" (GF5), "there is no ideology to support the changes" (GF8), "we need a system to evaluate the professors" (GF5), "the teaching of care is gradual" (GF3). Even recognizing the advances, the focal groups participants reflected on some fundamental aspects to the processes of change that need to be reviewed: "courage is needed in order to change" (GF4).
In the analysis of the discourses, it is possible to identify that there is an accumulation of new pedagogical and assistance practices in the study's scenery schools, which signals a change process in the nurse training. In spite of the challenges faced by the subjects to disrupt the traditional teaching models, the schools tend to adopt critical-reflective pedagogical conceptions that have guided the adoption of student-centered methodologies in the training process. The movement of change in teaching, with the incorporation of care as a guiding axis for training, emerges, in the data analysis, as an element that orients the required changes in the action scenarios of nursing, with advances in the technological organization of work, in knowledge production and in the rescue of the nurse's role in human care.
The analysis of the discourses reveals critical aspects and potentialities to the nursing schools for the necessary modifications in their teaching models, concerning the object of the nursing practice care. There are advances in the propositions regarding the articulation of care in the nursing curricula and in the public health policies. The study's participants signaled care conceptions that rescue the epistemological nature of care, supported by characteristics like bond, acceptance, receptiveness, responsibility, affection and intersubjectivity; but some contradictions were mentioned, revealing that the conceptions of care idealized by the participants are not based on pedagogical and assistance practices.
The discourses indicated that nursing needs to build its own amplified body of knowledge, based on technologies of the health knowledge field and of the specific nucleus of nursing. There is an intentionality of change expressed by professors and students, who see the need for a critical reflection of the part of the set of subjects responsible for the education/training process in nursing.
The daily routine of the health work is marked by conflicts and disputes between the common fields and the specific healthcare nuclei. It is possible to conclude that research, teaching and permanent education in nursing need to mobilize, not only to the fulfillment of the academic stages, but also to make care improvement be closer to the sector's reality, which is undergoing changes and in which several techno-assistance designs struggle for ways of performing healthcare.
An important difference in the care designated as specificity of nursing is that is refers to the entire organization of assistance, and that is why it seems so intangible. The object of nursing is the whole that organizes the system of care. Care, as the social practice of nursing, and nursing, as the science of care, are present in the discourses and challenges to the transformations in the health system and in the teaching of nursing. With the research results, we apprehended that the adoption of a critical-reflective conception will facilitate the implementation of a care that is in agreement and congruent with the disruption of the disease-centered hegemonic model, aiming to build a way of thinking, doing and being that is supported by care as the essence of the profession and of nurse training orientation.
The authors Roseni Rosângela de Sena and Kênia Lara Silva worked together in the paper's organization, discussion, writing and revision. Alda Martins Gonçalves, Elysângela Dittz Duarte and Suelene Coelho participated in the bibliographic review, discussions and in the text's revision.
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