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Educação em Revista

versão impressa ISSN 0102-4698versão On-line ISSN 1982-6621

Educ. rev. vol.37  Belo Horizonte  2021  Epub 06-Nov-2021

https://doi.org/10.1590/0102-469829077 

ARTICLE

PERSPECTIVE OF NURSES FROM THE FAMILY HEALTH STRATEGY ON THE POLITICAL-PEDAGOGICAL GUIDELINES FOR UNDERGRADUATE NURSING EDUCATION

ADRIANA MARIA ADRIÃO DOS SANTOS1 
http://orcid.org/0000-0002-1046-244X

DIEGO DE OLIVEIRA SOUZA2 
http://orcid.org/0000-0002-1103-5474

1 Teacher at the Centro de Ensino Profissionalizande de Alagoas (CEPROAL). Arapiraca, AL, Brasil. <adrea.maa@gmail.com>

2 Teacher at the Graduate Program in Social Work and the Undergraduate Program in Nursing, Federal University of Alagoas (UFAL). Arapiraca, AL, Brasil. < diego.souza@arapiraca.ufal.br >


ABSTRACT:

This study aims to analyze the perspective of nurses working in the SUS of the city of Arapiraca about the political-pedagogical orientations of the undergraduate Nursing program. This is qualitative research developed specifically with thirteen nurses of the Family Health Strategy. A semi-structured interview script elaborated by the authors of the research was used, composed of preliminary data of sociodemographic character and open questions about the formation process, its foundations, objectives and possible directions. The material from the interviews, transcribed verbatim, was submitted to a thematic analysis based on historical materialism. Nine categorical nuclei were identified, distributed in three thematic areas, namely: perceptions about the training process, specific and general; relationship between Nursing teaching and the health service; objectives of Nursing training. A cross-cutting element to the thematic areas is the orientation of the training to the labor market, although it is often present in a veiled way in the formal instruments that govern the training. Despite this, the process is dialectical, opening possibilities for criticism and transformation based on the eminent demands of reality and the experiences of the subjects involved.

Keywords: curriculum; nursing education; teaching; Unified Health System

RESUMO:

O presente estudo tem por objetivo analisar a perspectiva de enfermeiras(os) que atuam no SUS da cidade de Arapiraca sobre as orientações político-pedagógicas da graduação em Enfermagem. Trata-se de pesquisa qualitativa desenvolvida, especificamente, com treze enfermeiras(os) da Estratégia Saúde da Família. Foi utilizado um roteiro de entrevista semiestruturado elaborado pelos autores da pesquisa, composto por dados preliminares de caráter sociodemográfico e questões abertas sobre o processo de formação, seus fundamentos, objetivos e rumos possíveis. O material das entrevistas, transcrito literalmente, foi submetido a uma análise temática com base no materialismo histórico. Nove núcleos categoriais foram identificados, distribuídos em três áreas temáticas, a saber: percepções sobre o processo de formação, específico e geral; relação entre o ensino de Enfermagem e o serviço de saúde; objetivos da formação em Enfermagem. Um elemento transversal às áreas temáticas reside na orientação da formação para o mercado de trabalho, embora, muitas vezes, presente de forma velada nos instrumentos formais que regem a formação. Apesar disso, o processo é dialético, abrindo possibilidades de crítica e transformação a partir das demandas eminentes da realidade e vivências dos sujeitos nela implicados.

Palavras-chave: currículo; educação em enfermagem; ensino; Sistema Único de Saúde

RESÚMEN:

Este estudio tiene como objetivo comprender la perspectiva de las enfermeras que trabajan en el SUS en la ciudad de Arapiraca/Brasil sobre las orientaciones político-pedagógicas de la graduación de enfermería. Es una investigación cualitativa desarrollada específicamente con trece enfermeras de la estrategia de salud familiar. Se utilizó un guión de entrevista semiestructurada elaborado por los autores de la investigación, compuesto por datos sociodemográficos preliminares y preguntas abiertas sobre el proceso de formación, sus fundamentos, objetivos y posibles orientaciones. El material de la entrevista, transcrito literalmente, se sometió a un análisis temático basado en el materialismo histórico. Se identificaron nueve núcleos categóricos, distribuidos en tres áreas temáticas, a saber: percepciones sobre el proceso de formación, específicas y generales; relación entre la enseñanza de la Enfermería y el servicio de salud; objetivos de la formación de la Enfermería. Un elemento transversal a las áreas temáticas es la orientación de la formación al mercado laboral, aunque muchas veces está presente de manera velada en los instrumentos formales que rigen la formación. A pesar de ello, el proceso es dialéctico, abriendo posibilidades de crítica y transformación a partir de las exigencias eminentes de la realidad y las experiencias de los sujetos involucrados en él.

Palabras clave: currículo; educación en enfermería; enseñanza; Sistema Único de Salud

INTRODUCTION

Education consists in a broad social complex - which goes beyond the scope of teaching or school systems - in which decisive processes take place for the sphere of reproduction of the social being, namely: the ability to disseminate and learn knowledge capable of grounding conscious transformations, in the sense of human self-construction. However, in the capitalist production mode, its contingencies are limited and conditioned to the maintenance/reproduction of the system, its inequalities and degrading processes. The limitations and conditioning are established not by naivety or intellectual incapacity of the subjects involved in the processes, but by the ideological veils (produced by the objective conditions of history itself, in social relations) that make it difficult to apprehend and transcend these limits (MÉSZÁROS, 2005).

In Brazil, historically, education policies are the expression of a society that, from a process of unequal and combined development, has its state dimension extremely sensitive to the designs of the big capital, with simulacra of democracy, since the interests and ideas of the working class organized for the struggle are "suffocated", bureaucratized and regulated, under an important ideological role of education for this. In these molds, education has been constituted through services of restricted access, excluding a considerable part of the population or leading them to training in activities considered, by the capitalist viewpoint, of lower status (FERNANDES, 1982; RUMMERT; ALGEBAILE; VENTURA, 2013).

It is necessary to register, then, that from the analysis of the educational problematic, with historical materialism, it is possible to understand it as an expression of the correlations of forces undertaken within the structural antagonism between capital and labor, which eliminates any possibility of conceiving education as a neutral field. Among the various disputes in this field, we still cannot ignore the dismantling of public education at all levels, while the private sphere manages to expand, even in countries with deep economic inequalities, such as Brazil (RUMMERT; ALGEBAILE; VENTURA, 2013).

Moreover, during the last decade of the twentieth century, a great metamorphosis of all aspects (economic, social, political and cultural) occurred in Brazil; transformations, especially visible by the process of globalization/globalization of capital and the changes that unfolded from it (DIÓGENES; ANDRADE, 2015), which increases the size of the challenge to understand and demystify the intricacies of education in the service of capital. The new configurations of the globalized world and its accelerated process of scientific and technological "modernization" demand new forms of construction and dissemination of knowledge, pressing for changes in the process of training competent workers (in what the capital needs), including in the field of health, in line with the productive restructuring of the capital (SILVA; FERNANDES; TEIXEIRA; SILVA, 2010).

The flexibilization of productive relations came accompanied by crises of adaptation of workers driven to polyvalence and competitiveness, in addition to management by stress and the dismantling of health services, worsening the working conditions for those who work in the sector or hindering health care for other workers. That is, the changes established in the "world of work" from the productive restructuring have raised the degradation of human health to high levels, as denounced by the epidemiological indicators of the last four decades, especially with the increase in chronic degenerative diseases, external causes and occupational diseases/accidents (SOUZA, 2019).

In this scenario, strategies for health training are established in the midst of the conflict between the demands of new subjectivities in line with the dynamics of productive restructuring and the need to understand (and transform) this process in view of its repercussions on health. This problem is relevant to the field of nursing, considering its quantitative and qualitative participation in health services, such as the Unified Health System (SUS) in Brazil. It is the largest work force in health care in the country, with the Federal Council of Nursing (COFEN) currently accounting for 421,581 records of assistants, 1,330,447 of technicians, 569,189 of nurses and 292 of midwives (COFEN, 2020).

Obviously, the tensions arising from the productive reconfiguration processes have reached the education complex, with repercussions for the structuring of nursing education curricula, particularly discussed here at the university level. This is not a homogeneous context, since, if the process of capital globalization imposes with certain violence the need for new subjectivities, the process of Health Reform in Brazil, with the consequent rise of the Family Health Strategy (FHS), brought to the surface new horizons and new demands. As a result of this conflictive process, the Ministry of Education promulgated Resolution n. 03 of November 07, 2001, defining the National Curricular Guidelines for the Undergraduate Course in Nursing (DCN/ENF), when the need for commitment to the principles of the SUS was made explicit, with a view to training critical and reflective professionals (BRASIL, 2001), but this commitment, it must be emphasized, cannot be analyzed apart from the ideological strategies of the new capitalist configuration.

This context constitutes a challenge for the actors involved in the SUS and Institutions of Higher Education (HEI), in view of their training processes before the ability to apprehend the nuances of the real conflicts in their interface with health. Thinking specifically about HEIs, the process of constructing political-pedagogical projects in nursing should be based, in general, on the guidelines contained in the DCN/ENF, as well as on the principles and guidelines of the SUS (with a focus on primary/basic care), but which do not necessarily reveal such conflicts, because they are dynamic and crossed by diverse interests.

Considering these premises, the guiding question of the research was raised: what is the perception of FHS nurses about their training process? Analyzing the issue in focus from the perspective of the individuals involved in it is an important step to apprehend and understand the tensions and conflicts that constitute the training process, its limits and possibilities. Therefore, our objective was to understand the perspective of nurses working in the FHS, in the city of Arapiraca/AL, about the political-pedagogical orientations of undergraduate nursing education.

METHODOLOGICAL PROCEDURES

The present study has a qualitative approach, of the exploratory type, as it aims to focus on the perspective coming from the universe of the subjects that experience the process under analysis. The use of qualitative methodology in an attempt to apprehend subjective aspects that make up the dynamics of social processes allows one to make connections with the objective totality, always in reciprocal and dialectical determination (MINAYO, 2010).

The research was conducted in the area covered by the FHS of the municipality of Arapiraca, Alagoas. The municipality is geographically located in the center of the state, in the agreste region, being the second largest in Alagoas, a reference in the organization of primary health care and the headquarters of the 7th health region. It has 59 FHS teams and 10 Family Health Support Centers (NASF) teams, with an estimated coverage of 93.81% of the population (ALAGOAS, 2019).

The FHS is considered an instrument for changing the care model, acting as the articulating center of the integrated and regionalized health system. Thus, it has been considered the main space for the effectiveness of the relationship between health workers and residents. Nursing has played an important role in the trajectory of the FHS, since the mid-1990s, leading the formation of teams of community health agents and being a mandatory member of family health (COSTA; MIRANDA, 2008).

Thus, visits were made to each nurse in their respective Basic Health Units (BHU), after prior programming with the Municipal Health Secretariat (SMS) and scheduling the most convenient day and time with the interviewees. It is noteworthy that the quantity of interviews carried out, always individually, followed the saturation criterion, understanding it as the moment in which the knowledge formed by the researcher is able to understand the internal logic of the group or collectivity studied, showing itself to be repetitive (MINAYO, 2010).

With this, thirteen interviews were conducted, between December 2018 and May 2019, from a semi-structured script. This instrument was prepared by the researchers, containing space for the survey of sociodemographic data, in order to record their profile from the following variables: age, gender, marital status, number of children, religion, data on academic and professional training (training institution, year of training, time working in primary care, type of bond, other degrees and specializations). This profile worked as a starting point to get to know the interviewees better.

The interview script included questions about the interviewees' understanding of what the training process is; about the relationship between teaching and service, with emphasis on some issues about the SUS and about how this relationship appears in the DCN/ENF; about knowledge of the political-pedagogical project of the undergraduate course held; and, especially, if they can identify a political-pedagogical direction in the instruments that govern training, such as DCN/ENF and the political-pedagogical project.

The interviews were recorded and transcribed, respecting the way they were expressed, including the spelling mistakes, presented here, accompanied by the term "sic". The identity of the interviewees was preserved, being identified by codes ranging from E01 to E13. Later, we followed with the thematic analysis, with the apprehension of common areas between the statements of the different interviewees and, within them, categorical nuclei (MINAYO, 2010). We submitted this material to a historical materialist analysis, in which the subjective perspective expressed by the interviewees was the starting point, but not an absolute reflection of the process studied. With this, we can establish the connections between the predominant content in the particular group studied and the objectivity of the social totality that produces such context, in face of the historical elements already known.

We followed the ethical standards of Resolution n. 510/2016 of the National Health Council (CNS) (BRASIL, 2016). The study was previously submitted (in research project format) to the appreciation of the Research Ethics Council - CEP, via Plataforma Brasil, when it obtained approval for the realization in the consubstantiated opinion of n. 3.009.199. The interviews were only carried out after the nature of the research, its objectives, risks, and possible inconveniences to the participating subjects were explained. In addition, the Informed Consent Form (ICF) was presented for signature by the research participant, in two copies.

RESULTS AND DISCUSSION

Initially, it is worth pointing out the profile of the thirteen interviewees: nine were female and four were male. The age bracket varied between 27 and 54 years, the average age being 35.8 years. Eight interviewees were married, four were single and one was divorced; six had no children, while seven had between 1 and 3. As to religion, six were Catholic, one evangelical, one Buddhist, one spiritualist, two identified themselves in other Christian religions, and finally two were atheists or did not practice any religion, as shown in Chart 1.

Source: data collected by the authors during the research.

Chart 1 Profile of the interviewees 

Regarding education, we found that ten graduated from a public HEI. The year of graduation was between 1987 and 2017, which has repercussions on the time working in primary care, varying between 10 months and 21 years. The fact that they do not have another undergraduate degree was a unanimous issue, and 12 interviewees have a specialization, especially in the area of Family Health.

In relation to the semi-structured interview itself, we obtained nine categorical nuclei distributed in three thematic areas, as shown in Chart 2.

Source: data collected by the authors during the research.

Chart 2 Results by Thematic Area and Categorical Nucleus. 

Next, we present the analysis of each thematic area and its cores, based on excerpts from the interviews.

The formation process: from the academy to life

The first categorical nucleus in this thematic area concerns training as a point of insertion and/or qualification for professional practice. We found that there is an understanding of the training process as a moment of assimilation of knowledge directed to professional practice, with recognition of the historical process that raised Nursing to the status of a regulated profession based on norms and guidelines that govern, including, the training processes. This condition permeates the words of I13:

The training process in Nursing is something that came about practically, right? It was institutionalized to a set of knowledge necessary to perform the function, since before there was no nursing as such. [...] So the process of nursing education is a whole, a compendium that you assimilate. You assimilate and are developed by another professional, another staff, in this case a tutor so that you can adequately perform your Nursing action (I13).

It is worth remembering some aspects related to the origin of Nursing in Brazil. According to Germano (2011), this trajectory is consigned to the care practices that are being constituted without necessarily having a professional nature, a character achieved only later on. In general terms, especially in the nineteenth century, Brazilian Nursing emerges to treat the diseases of the poorest population within the Santas Casas de Misericórdia, with a religious character, embodied in principles such as obedience, respect for hierarchy, humility, abnegation, discipline, spirit of service, etc., somehow persisting until today, even with professionalization (GERMANO, 2011).

Only later, Brazil went through socio-economic transformations that led to some urban growth and the social problems that are peculiar to it. Thus, public health gains other contours in the twentieth century, when its relationship with issues such as sanitation, housing, hygiene, etc. becomes evident. From this demand, the National Department of Public Health (DNSP) emerged in 1920 and, with it, the first Nursing schools managed by nurses, when, finally, one can speak of modern Nursing in Brazil and, therefore, a professional training process (CAVALCANTI, 2017).

The curriculum of the Nursing course began to have a specific professional character, when it initially focused on disciplines of preventive nature, given its relationship with the DNSP. In this period, the influence of the Rockefeller Foundation stood out, with a clear interest in Brazilian industrial expansion, which presupposed minimum sanitary conditions, especially in commercial ports, in order to make the intended transactions viable (GERMANO, 2011).

The organization of nursing education began to assume new requirements, such as the completion of the Normal Course or equivalent, contrasting with the previous requirements, when they basically boiled down to knowing how to read and write. At the same time, it was assuming an elitist nature, reproducing the stigmas and prejudices of the Brazilian reality (GERMANO, 2011).

Thus, the training process reflects the historical-social totality, particularizing itself in ideological, political, technical and scientific foundations for the exercise of nursing, which are dynamic, but somehow extend to the current period. From then on, education has become a process capable of theoretically and methodologically molding the individual in the development of competencies and abilities specific to the profession, which are characterized as a basic requirement with an orientation toward the job market. Such orientation is reproduced in the statements of the nurses: "The training process is of fundamental importance because it gives us the direction we have, which mainly involves the theoretical issue of the profession. It is the north and the authorization for us to enter the job market" (I05).

Developing abilities based on a theoretical direction as a guide to authorizing the legal exercise of the profession, which in Brazil is done by means of what the DCN/ENF (BRASIL, 2001) defines, cannot simply be apprehended by naturalizing or neutralizing what the labor market is. One must consider the dynamics that constitute contemporary society, in general, from the contradictory relations of production before the development of productive forces, especially expressed in the exploitation of labor force submitted to the labor market.

According to Cavalvanti (2017), the profile proposed by the DCN/ENF addresses issues related to the development of a professional aligned to human needs, but this clothing ideologically masks the determinations of a system of production in crisis and that subjugates education to its purposes, thus ratifying its logic of unequal reproduction. Facing another form of sociability, the educational complex can and must go beyond the reproduction of values and knowledge that ratify mercantile relations. Reaching this horizon within capitalism comes up against the rigid limits of formal education, at its service. This does not mean that it is not possible to introduce, even in formal education, emancipating moments, which tension and question the foundations of the predominant formation process and, consequently, question the social dynamics itself, in its bases. This issue is expressed in the statements of nurses:

It is, it is, it is, in the, for example, maybe it will change with time, right? With the pedagogical plans that the course has. As I understand it, there is a preparation of the student to act in the broadest possible way, from the social context to the biological context, to the context of disease, health. I think that is it (I02).

This perspective gains more importance when we observe the condition of training as a link between academia and other dimensions of life, which is equivalent to our second categorical core of analysis in this thematic axis. This correlation presupposes the understanding of the human possibilities imbricated in the formation, in view of a wider scope of knowledge, as it could be evidenced: "I understand it as the construction, be it academic or political, of an individual who until then may or may not have had contact with a universe of opinions and knowledge about several aspects within an academic perspective" (I09).

The idealization that education has the objective of providing the link between the professional sphere and other instances of life emerges, through the development of a critical and reflective character on "opinions and knowledge about various aspects" that contribute to the construction of the individual. This includes, also, the possibilities of ratifying or questioning ideas, values, in short, the established way of organizing life.

There are concrete possibilities of at least directing the academic debate in its interface with other instances of life, but they presuppose a rupture with scientific fragmentation and the tendency towards specialization typical of labor market-oriented education. For Figueiredo and Orrillo (2020, p. 11),

[...] even if it does not act homogeneously, by and on the subjects, the university ends up working as a machine that reproduces the model of mass production. This hegemonic model mirrors the cultural values of the elites, forming specialists who are almost always incapable of perceiving the dichotomies of the world and uninterested in how politics acts in everyday life.

Therefore, health education, within the limits of capitalism, as a link between academia and the dimensions of life, must have a curriculum capable not only of integrating academic knowledge among themselves, but also with the other spheres of social reproduction, even to contest it, although it is part of it. It is worth pointing out that

[…] it is important to emphasize that there are mediations and actions at the level of educational institutions and curriculum that can work against the designs of power and control. Social life, like the curriculum, is not only about domination and control; there is room for opposition and resistance, for rebellion and subversion. The curriculum is, in short, a political territory (FIGUEIREDO; ORRILLO, 2020, p. 5-6).

Thus, tension mechanisms can be created that enable some space for emancipatory educational practices, which correlate health with the basis and dynamics of capitalist society, with a view to human formation in all its dimensions, beyond commodities. The connection between the academy and the health service is one of the mediations of this trajectory, as discussed below.

Relationship between nursing education and the health service

In this thematic area, four categorical nuclei were eminent: the dichotomy between theory and practice in the training process; the importance of the FHS in the training process; the relationship between the political and pedagogical spheres in the teaching and practice of the profession; and the differences between public and private HEIs.

Initially, we point out here the reflection of a curricular structure that reproduces the perception of the work process in Nursing in a fragmented way. This character is reproduced in some statements, when they give the impression that theory and practice are processes that occur at distinct moments:

Between teaching and service, right? Well, everything I learned in [higher education institution] I could apply in the service, but especially in the internship part, I think the internship reinforced everything I learned, for four years with theory during training, and the internship was when I could really apply it. So, all the theory, apply in practice and after training apply in life. Everything I learned at [higher education institution] we apply in our daily lives, even today (I01).

Theory appears with the status of a logical construct that must be learned a priori to be subsequently applied. In fact, this perspective of separation between teaching (theory) and practice is a major problem, since they maintain an organic relationship, in which one depends on the other, permanently. In the perspective of social praxis, there is no separation between theory and practice, since they are moments of the same process, reflecting each other (SOUZA; MELO; VASCONCELLOS, 2015). Only in the meager positivist scientific logic can make sense utilitarian theories, artificially produced (therefore, distant from social reality) and that violently try to fit (or invent) reality into their paradigms. In other words, in this logic, theory is constructed at the whim of the academy and practice must adjust to academic designs.

Foreseeing a greater integration of the training components, it is necessary to approach the local reality from the beginning of the course, with the final internship being only a moment of synthesis, when there is a greater continuity of the student's insertion in the health service routine. The movement between the theories that start from reality and the way back, with its reformulation according to the dynamics of reality, is decisive so that health needs do not continue to be subsumed by the elucubrations of the market and, therefore, so that the training has wider possibilities of criticism and transformation.

To this end, the approximation of nursing education with the reality of the SUS, more specifically in the FHS, can contribute to confront dichotomous perspectives. It is from the health system, with its possibilities and limits, that one can raise the training (in the logic of successive approximations) beyond academicism and its close relationship with the biomedical model. We found that this is recognized by the nursing workers, even because they work in the FHS, which brings them reflections, constituting an important categorical core of analysis:

Look, I've been thinking about this a lot lately, you know? I've been thinking about it a lot, sometimes, when I take a bath, when I go to sleep. I keep thinking. I think that teaching, with a health education in our country, cannot be at any moment disconnected from the single health service. [...] there is no way that SUS cannot be linked to professional training, there is no way, there is no way that we cannot link professional training to primary health care, because primary health care is a service coordinator. If you have an effective primary health care you will avoid many things, many [sic] pathologies and even social problems (I06).

The SUS emerges at a time of contestation of the health model in force in the country, with the Sanitary Reform, in an attempt to overcome its exclusionary and biomedical character. It was born with important participation of social movements and intellectuals of the political and academic left, including Marxist Collective Health and its defense of health as a social process and, therefore, of health practices in a perspective of transformative praxis, whose primary care has a structuring role (SOUZA; MELO; VASCONCELLOS, 2015).

To this end, the FHS plays a special role in the reorientation of the model, with a view to overcoming curativism and care focused only on the individual, extending it to the collectivity, contributing to the modification in the direction of health promotion and disease prevention (COSTA; MIRANDA, 2008) and revealing itself as a privileged locus for the training process that intends to incorporate these premises. Despite this, the proposal has run into the social metabolism of capital itself, especially in its contemporary neoliberal configuration and the intense and permanent attacks against public health, in favor of the medical-industrial/financial complex, such as the perennial underfunding of the system and the attacks against primary care, revising it towards a model that is far from the original proposal (CORREIA; SANTOS, 2017).

Within the SUS proposal, the issue of training workers oriented to its perspective is peremptory, but it comes up against the still conservative character of the curricular structures and the very hegemony of the biomedical model, including within the SUS. This is because the training model, hospital-centered and fragmented, based on a non-problematic teaching methodology is reproduced in the most varied spaces, fed by the very need for expansion and reproduction of capital, particularly in education and health. Thus, a syncretism of perspectives is constituted (in which the old paradigms still prevail), with the emergence of even pedagogical trends that appropriate the discourse of Health Care Reform, disguising themselves as defenders of public health, but oriented to the insertion of elements that contribute to the commercialization of the process of training and work (GERMANO, 2011; CAVALCANTI; 2017).

Under these conditions, the possibilities of the SUS as a genuine space for approaching the praxis perspective are restricted, against the fragmentation of training focused on the biomedical model, even because the SUS itself becomes mischaracterized and dismantled, including with serious reverberations for health workers, with poor working conditions, loss of social rights and precarious labor relationships. But, remembering Figueiredo and Orrillo (2020), the formation process is always dialectical, with the possibility of counter-tendencies. Even in a hostile scenario, of the dismantling of the SUS and the training perspective that underlies it, the process of struggle for its defense has a pedagogical character, with a decisive effect on the approximation between the reality of the classroom and the services, provided that the subjects that structure the possible political-pedagogical paths are able to grasp these elements, bringing them into the training process.

To think of the processes of struggles and resistance as pedagogical spaces, at the same time requires thinking of the process of formation as a political process. However, the meanings of "political" and "pedagogical" do not always seem clear, even in the relationship that they establish, according to the categorical nucleus that we will now analyze. In general, when asked about the predominant political-pedagogical direction/orientation in nursing education, there was difficulty in formulating answers, almost always returning to the previous question, in the theory-practice relationship:

I can. Yes, right. But related to what I think should happen? I think there should be more of a fit between what is proposed in the legislation and what is in reality. I think that during graduation we focus a lot on what is proposed, what is legal, what should be, but we forget a little bit to bring it to reality. I had a very big shock, right when I passed this contest, which was when I left the university, I got into a lot of trouble because I kept wanting things, the SUS, to be the way it was supposed to be, but with time I was coming back to reality (I05).

Thus, the political dimension is identified as a set of laws, components of a theoretical framework of the course, which is not effective in practice. In other words, the political dimension of the pedagogical processes would be restricted to addressing issues of professional regulation, but not in the sense that teaching-learning, by itself, is a political act. Moreover, it is emphasized that the political dimension is present in post-graduation, in the questionings and struggles for the SUS to be like the one taught in graduation, but, as it seems, soon abandoned in the face of reality. This is an eminently political process, because it is through the struggles and tensions created that the organized civil society and, in this specific case, the health workers, are able to generate demands for the deployment and implementation of public health policies, in the wake of what some authors call advocacy (NEVES-SILVA; HELLER, 2016) or, in certain conjunctures, articulating the struggles for health with the class struggles, against labor exploitation and the commodification of health (CORREIA; SANTOS, 2017).

There is a "quiproquo" of difficult equalization, as it reflects the character of distancing between teaching and reality, especially with regard to their conflicts. About this, the Freirean perspective has advanced with some contributions, going through three phases: in the first, represented by the work Educação e atualidade brasileira (Education and Brazilian actuality), Freire argues that educational praxis should be ballast for national development and the construction of a (bourgeois) democracy; in the second, when the work Educação como prática de liberdade (Education as a practice of freedom) is highlighted, Freire argues in favor of educational activities aimed at existential freedom, through psycho-pedagogical awareness; In the third one, which highlights the work Pedagogy of the Oppressed, Freire defends the construction of a revolutionary educational process, capable of contributing to the end of oppression, which presupposes the elimination of the oppressor's consciousness instilled in the oppressed (SCOCUGLIA, 2001, p. 327).

The theoretical evolution of Freirean criticism reveals a process that can only occur through a continuous approach to reality, apprehension of its contradictions and synthesis of its possibilities. In its final phase, with Pedagogy of the Oppressed, the inseparability between "political" and "pedagogical" is made explicit, because the need for a pedagogy for the "revolution of the oppressor's reality" only exists because another pedagogy has been established, that of the oppressor. Because of this, it is up to the latter to defend the neutrality of teaching, its exemption from social conflicts, as well as to ignore the possibility and need for social transformation. In doing so, it defends a technical pedagogy, devoid of political character, ignoring or hiding, on purpose, that such defense is, in itself, a political position.

In Nursing, this character permeates a set of particular issues, from the sexual division of labor to professional hierarchization in the health field; from the struggle against the biomedical model to political organization within the field itself. Thus, the issues linked to the exploitation of labor, pedagogically embodied in market-oriented training, are articulated to new elements, such as gender, territory, perspectives of science, health, care, and the world, among others that need to be discussed, always, from their expressions in reality, critically.

In this study, one of the categorical nuclei revealed different possibilities for the predominant political-pedagogical orientations, depending on the nature of the HEI, public or private. When asked about the possible differences, the question of labor market orientation seems to be the key point:

Well, a lot I don't know, but certainly we have a focus that is very much in private institutions. The public institutions, I mean, private institutions they had a fatter focus for technical practice and the development of technical skills [sic]. The public educational institution like federal and even state universities, they have an education focused on technical practice and will not leave it aside at any time, but they also have a very large incentive for research, development of knowledge [...] the other institution, in the labor market, their focus is this, because usually the people who are in it already have this mentality, so it starts from the economic principle of action (I13).

It is to be expected that the private sphere presents greater emphasis on the issues posed by the market, since it is genuinely inserted in the social reproduction with the purpose of obtaining profit, composing the dynamics of production-circulation-distribution-consumption of capital. Nevertheless, it is important to point out that the State (institutional sphere in which public education takes place) does not have a neutral character. On the contrary, the State acts in the face of class antagonism, being a space for the implementation of the political power of the dominant class (ENGELS, 2010), although it is not "immune" to the tensions and demands posed by the dominated classes. Without disregarding this limit, public education is the most fertile ground for the insertion of broader strategies already mentioned here, such as criticism of the biomedical model and the fragmentation between theory and practice, and the SUS is a space of mediation for such.

In fact, public institutions are more favorable to the symbiosis between public education and public health, which is explicit even among those who have some sympathy with market-oriented pedagogical perspectives, in a tone of criticism of the public HEI:

There is, there is a relationship. There is a relationship, but I think there are also gaps, depending on the institution where you graduated, your education is oriented to a different direction. Yes, I realize that we are trained in a very generalist way, mainly focused on SUS. This, in my humble opinion, suppresses a little bit the entrepreneurism in us. We don't look for personal advantages and profits, it is a training more focused on the system, in an altruistic vision that we don't see in private universities. [...] If you look at the people who make money with nursing, they don't have much of this training, they open a homecare or specialization to [sic] treat wounds, to get paid for it, it is not much of a university profile (I05).

The gaps cited by the interviewee reflect the hegemonic ideological composition, particularized in the individual need to be an entrepreneur, obtain profit, or make money with Nursing, even though this nurse studied in a public institution. Although it is legitimate for the category to want better income within the prevailing mode of production/reproduction, what is evident, as a backdrop to the analyzed speech, is the fact of uncritically inserting oneself into this dynamic (placing personal advantages and profits above training to work in the SUS and the construction of collective well-being), without realizing that the "making money with Nursing" derives from a process of mercantilization of health in which Nursing, as a workforce, is exploited directly or indirectly, even when it manages to increase its income in absolute terms.

Alves (2005) calls attention to the fallacy of entrepreneurship, a (pseudo)individual way out for a process socially constructed from the capital-labor antagonism and that, consequently, can only be equalized collectively (especially through class struggle). The discourse of entrepreneurship sells the idea of autonomy and possibilities of individual ascension, when in fact it is constituted by the determinations of the flexible accumulation regime, subordinating and exploiting the supposed individual entrepreneurs to the designs of capital, even if they are not employees/workers in the traditional format of the employer/employee relationship. This discourse is part of a set of ideological mechanisms that make the worker not see himself as such, but as a collaborator, associate, entrepreneur, self-manager of his work, etc. To leave this locus created by the flexible capital (the pursuit of individual interest above all else, feeding back into the mercantile logic) is often confused with a romanticized altruism. This confusion is based on a natural law worldview and, therefore, forges an idea of separation between the individual and society. On the contrary, we defend, based on historical materialism, that individual and society have the same ontological status and, because of this, there is no individual development without collective organization. In this sense, a critical education implies a critical professional performance, towards collective organization to face the contradictions that hinder the development of the category (and, in last instance, of the human kind) and the demystification of the exploitation mechanisms hidden in contemporary fallacies.

In summary, from this analysis of I05's speech, two aspects emerge: first, the fact that the public institution, more conducive to the defense of the SUS, is not, by itself, a guarantee of critical political formation in the face of mercantile relations, even because the ideological mechanisms of capital are molded in all spaces of social reproduction, reaching the process of human formation beyond the academy, but also within it; Second, from the first aspect unfolds the issue of the formation of class consciousness, expressing the increasingly powerful character of the capture of workers' subjectivity by the restructuring capital (ALVES, 2005), when workers begin to take the interests of the bourgeois class (in this case, personal advantages and profits) as if they were their own interests, without realizing it.

These differences converge, then, to the configuration of the training objectives that stand out in the perspective of the nurses, theme of the next section.

Objectives of nursing formation from the perspective of nurses

In light of the DCN/ENF, it is worth reflecting on the (political) pedagogical directions in the creation/reformulation of the curricula of undergraduate nursing courses, which brings here the questioning about the orientations they try to reproduce. It is worth pointing out that the DCN/ENF have the objective of humanistic training, carried out in a comprehensive way (BRASIL, 2001), which seems to be reproduced in the nurses' statements:

Yeah, I'll repeat what I've already said: it is to see the patient as a whole, treating his problems as I said, as I said, not only in his health problems, but interventions to his life that can help him to be an active. Ah, because it doesn't only depend on me, it depends on him too, sometimes it depends more on him than on me. We are here as helpers and supporters (I02).

This position is in line with the defense of the nurse profile intended by the DCN/ENF, with emphasis on humanistic training and comprehensive care to the individual, family and other groups, including giving them autonomy (BRASIL, 2001), which also reflects the tone of the dynamics embodied in the FHS, place of speech of the interviewees. However, the narratives do not present a problematization of the contradictions and conflicts at the core of the human training process, especially considering that Nursing is part of a society that, in general terms, produces dehumanizing processes as a reflection of these contradictions and conflicts. According to Tonet (2016), thinking about integral human formation presupposes apprehending, criticizing, and transforming the dehumanizing processes from their roots, since it is not possible to glimpse full humanization under unequal and inhuman social bases.

Human formation presupposes a process that is permanently able to connect the individual to the human race, without an obstacle to the full development of both poles of this relationship. However, based on social relations founded on the division of society (which unfolds in ever greater social inequalities), the formation process ends up acting, predominantly, as a mediation that distances the individual from the fullness of the human race, being a partial, fragmentary and, almost always, reifying process (TONET, 2016).

In fact, there is a contradiction or, at least, an omission, when the curricular guidelines, pedagogical projects of courses or any educational activities ignore the contradictions and conflicts of society that prevent the full connection between individuals and human kind, treating human formation by the romantic bias, devoid of tensions and contradictions. From then on, not only are the dehumanizing processes mystified, but the discourse of humanistic and integral formation assumes the status of a cliché, theoretically empty.

In this vein, the perspective of training for the market, of a biomedical nature and from a fragmented viewpoint is increasingly gaining strength, even though there is a narrative or intention of comprehensive training for the SUS. In the subjectivity of the nurses, this is reflected in a dialectic manner, since the human and integral formation is pointed out as the objective of graduation, but the paths for such are not glimpsed. Let's look at one of the statements:

First, to become able to develop the functions as a nurse, to care for the patient, to promote a care process, among others. And the functions of a nurse that involve more than just the patient. And second, to develop a capable human being, capable of developing an analysis regarding both his own, the context of the quality of life in which he is inserted (I13).

We noticed that the objectives such as those that appear in the DCN/ENF are present in the perspective of primary health care nurses, especially when they think beyond the sphere of the disease, aiming at the search for quality of life. However, there is not a deeper problematization of the directions to be taken; how this relates, paradoxically, to the demands of the job market; what are the limits of the latter for the full connection between individual and gender. The two categories that express the objectives of formation (integral formation vs. formation for the market) appear intertwined, coexisting in the subjects' narratives, often, it seems, without being noticed that they are antagonistic objectives.

Not even the political issues of the professional category itself, organized to fight for better salaries and working conditions, seem to have any relevance in this supposedly integral formation process. Nevertheless, the horizon of articulation with workers in general, as a class, seems to be distant from formality and academic bureaucracy, see DCN/ENF.

Nevertheless, as reality is dialectic, there is no way to suppress, in absolute terms, the critical perspective, as long as in the face of inequalities, the class in a disadvantaged position in this process can always take a stand and give some impetus to the transforming horizon. In our view, this condition is also present in Nursing, with greater chances of being strengthened in spaces such as the public university and the component services of the SUS. Although these instances have their limits, it is necessary that those who advocate a critical political-pedagogical perspective tension the possible directions within these institutions, always aiming for an emancipatory education; that is, in the form of educational activities that stand against the exploitation and alienation produced in the capitalist mode of production, with a view to transformative processes that contribute to the development of human potential, reconnecting individual and gender (TONET, 2016).

FINAL CONSIDERATIONS

The research allowed the analysis of subjective aspects only possible of apprehension through the qualitative methodological approach, allowing correlations with the historical-social process and, thus, bringing reflections and provocations that enrich the understanding of nursing education. We verified that there was a certain difficulty among the nurses of the municipality in describing the process of health training and, consecutively, its political-pedagogical orientations.

The nursing workers faced significant differences between what is taught in the classroom and the reality of the service, which translates into an understanding that separates theory from practice. Primary care is mentioned as a space with the potential to direct the training process towards integrality, but which has been suffering from mischaracterization processes that also reverberate in training and work.

The labor market issue is a determining element in the political-pedagogical directions taken in the face of the social metabolism of capital, even if it is sometimes subtly placed in the processes that take place in public institutions, a priori considered as a space with greater chances of questioning the market perspective.

The questioning or the clear positioning against the market perspective does not appear in the formal instruments that guide the process of Nursing education in Brazil, nor in the narratives of individuals and groups who have experienced it. However, they can be developed by subjects immersed in processes that are always dialectic and, because of that, capable of producing contingencies for criticism and transformation.

Studies should be carried out that enable the investigation of political-pedagogical processes that occur outside formal education, that are developed through the perspective of research that is, at the same time, intervention, and that have the potential of insertion in the academic field, generating new possibilities. The heterogeneity of this problem presupposes broad interventions, which address multiple determinations, but which are able to return to a common background of a critical and transforming education, in favor of human emancipation.

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* The translation of this article into English was funded by the Fundação de Amparo à Pesquisa do Estado de Minas Gerais - FAPEMIG- through the program of supporting the publication of institutional scientific journals.

Received: January 19, 2021; Accepted: August 30, 2021

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