INTRODUCTION

In the Unified Health System (SUS), integrality is one of the fundamental principles, which requires professionals to have a better knowledge of the user's health situation, considering their relationships and social history, thus ensuring adequate and quality care. One aspect of integrality refers to the "act of comprehensive care that has health practices as political-organizational axes, ways to build innovations and new technologies for user care in the SUS" (^{PINHEIRO, 2008} p. 260). The preamble of the Code of Ethics for Nursing Professionals affirms that respect for human rights, as a fundamental principle, is inherent to professional practice. Besides the rights to life, health, freedom and equality, people must be treated without distinction, including gender and sexual orientation. Article 41 also discusses the professional duty to "provide nursing care without discrimination of any kind" (^{COFEN, 2017}).

However, there is still fragility regarding this assistance with regard to some themes, especially human sexuality. The latter involves cultural and plural processes, conceptions and historical definitions that produce and transform nature and biology. Thus, "the possibilities of sexuality - of the ways of expressing desires and pleasures - are also always socially established and codified" (^{LOURO, 2018}, p.3). In this sense, the topic of sexuality is still impregnated with taboos and prejudices, which permeate both academic training and professional practice. Furthermore, keeping this subject under wraps can be a mechanism that generates mutual anxieties, uncertainties, and embarrassment. In the context of interpersonal relationships, topics related to sexuality generate, most of the time, discomfort on the part of the interlocutors, especially when the subject is sexual and gender diversity (^{VITIRITTI; ANDRADE; PERES, 2016}).

Considering the heteronormative culture of society, bringing heterosexuality as the norm, it is evident that prejudice against sexual diversity manifests itself through interactional factors that disqualify non-heterosexual sexualities, identities, behaviors and communities, demarcating social groups and valuing differently these groups and their members (^{COSTA; NARDI, 2015}). In view of this, the LGBTQIA+⁸ population, over the years, has had its rights constantly neglected in various areas of social context: health, education, leisure, housing, among others (SILVA et al., 2017). Thus, it is observed that men and women who do not follow the established model suffer prejudice and discrimination by society. Given this context, there is a need for health professionals, specifically nurses, to be trained to serve this population without discriminating against them, aiming at the quality of care.

The constructions that involve sexuality naturalize the normative heterosexuality, so that it seems inevitable. Lesbian and bisexual women show a sexuality that does not meet the standards of sexual behavior defined by heterosexuality (^{BUTLER, 2017}). Thus, this population becomes more vulnerable to prejudices and stigmas related to their sexual orientation and therefore requires adequate care in health services. However, it is verified that the assistance provided by health professionals, in its majority, is not adequate, with emphasis on the interaction between professionals and women, the approach of topics related to sexuality and the establishment of the professional-user bond (^{ARAÚJO et al., 2019}).

Female homosexuality is an emerging theme in the context of health care, imposing itself as an essential discussion in the training of professionals in the area, especially nurses in this study. Thus, it is expected to constitute the training of professionals able to provide effective and comprehensive care to these women. Therefore, nursing education institutions should include training that provides information about the LGBT population and, more specifically, about lesbians, in order to prevent prejudice against this group and also to address specific health care needs (^{PINTO; NOGUEIRA, 2016}).

A recent advance that includes the lesbian and bisexual women population in health issues occurred in 2010, when the Ministry of Health launched the National Policy of Integral Health of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals, of transversal character, contemplating the production of knowledge, social participation, promotion, attention and care. This policy has guidelines related to the inclusion of topics such as sexual orientation and gender identity in the continuing education processes developed by the SUS, as well as stimulating the production of scientific knowledge aimed at improving the health conditions of the LGBT population (^{BRASIL, 2013}). For this study, we will use the concepts of "homosexual" and "bisexual" provided in the LGBT Communication Manual of the Brazilian Lesbian, Gay, Bisexual, Transvestite and Transgender Association. The manual considers as homosexual "the person who is attracted sexually, emotionally, or affectively to people of the same sex/gender" (^{REIS, 2018}, p. 22), and bisexual "the person who relates affectively and sexually with people of both sexes/genders" (Ibidem, p. 21).

Considering that nurses must be able to provide care with equality, equity, and ethics, it was observed the need for the formative process in nursing to provide subsidies for the care of lesbian and bisexual women. Given the above, this study presents as a guiding question the following reflection: what is the perception of undergraduate nursing students about their training for the care of lesbian and bisexual women? Thus, this article aims to answer this question and identify the potentialities and weaknesses found in the academic practices of undergraduate nursing students.

METHOD

This is a qualitative descriptive and exploratory research (^{POLIT; BECK, 2019}). The study setting was the nursing course of a Federal University in the interior of the state of Rio Grande do Sul. The study included nursing course students enrolled in 2015.2 in the subject "Supervised Internship I", referring to the 7th semester of the course. It is noteworthy that in this period the students are already inserted in health services, performing the Supervised Curricular Internship, experiencing the practice of the professional nurse. The students enrolled in 8th semester courses were not considered due to the fact that the researcher was part of the students' class, thus avoiding conflicts of interest, embarrassment, and possible weaknesses of the study. Those who were away from the university due to exchange activities, certificates, and/or treatments were excluded. Also excluded were the participants of the study and research group to which the researcher belonged, since they were directly involved in its construction and execution. The population of this study included a total of 19 students, four of whom were excluded because they had access to the project through research groups. Thus, the final sample of the study totaled 15 participants, who were familiarized with the research objectives.

Data collection occurred from September to October 2015, using the semi structured interview technique (^{POLIT; BECK, 2019}), which included questions regarding the characterization of the participants, the approach, preparation and influence of the undergraduate nursing degree in the care of lesbian and bisexual women, as well as the experience/performance of care for lesbian and bisexual women throughout training and the positive and negative factors identified during graduation related to the theme. The interviews were scheduled, and the collection was carried out individually, at the institution of origin, in a place agreed with each participant, seeking to promote a scenario that provided comfort and privacy to the participants. Among the locations were: a classroom belonging to the institution's Nursing Department, previously reserved for the interviews; and a specific room made available by the institution's University Hospital, due to the fact that some students preferred to schedule the interviews at a time close to their internship. The interviews were recorded in a multimedia player, listened to carefully, transcribed in full, typed and formatted in a Microsoft Word document, version 2007, making up the study's database. The transcripts were identified alphanumerically by the letter D, referring to "student", and numbered according to the sequence in which the data was collected.

For the analysis of the findings, we followed the steps recommended by the thematic categorical analysis, which recommends breaking down a text into units and categories, according to analogical groupings. Among the different forms of categorization, the investigation through themes is considered effective and fast in the case of simple and direct speeches. The following steps were followed: pre-analysis, material exploration, treatment of results, inference and interpretation (^{BARDIN, 2016}).

In the pre-analysis, there was a floating reading of the findings and initial appropriation of the content, with subsequent selection of the most relevant parts to the research objective for the constitution of the corpus of the work, through the criteria of representativeness, homogeneity and relevance (^{BARDIN, 2016}). At the end of this stage, the selected data were edited for analysis. The second stage was permeated by decomposition operations, aiming at the definition of categories, through the cutting of the nuclei of meaning in the participants' speeches, which gave meaning to the aspects analyzed in the study. Thus, the transcriptions had underlines highlighting the relevant parts, later copied to another file. In the last step, the selected data were treated in order to be valid and meaningful. Thus, inferences and interpretations were made in order to highlight the main information found in the research and expose them clearly (^{BARDIN, 2016}).

After the final analysis, the application of this technique allowed the construction of three analytical categories, namely: influences of training in the care of lesbian and bisexual women; potentialities in the care of lesbian and bisexual women with respect to academic training; and weaknesses and alternatives about training in the care of lesbian and bisexual women.

The research complied with the devices and guidelines regarding the conduct of studies with human beings, according to the principles of bioethics of the Research Ethics Committee (REC) of the Federal University of Santa Maria (UFSM, from the Brazilian Portuguese Universidade Federal de Santa Maria), and was approved on August 14, 2015, under opinion number 1.181.419 and CAAE (Certificate of Ethical Appraisal Submission, from the Brazilian Portuguese Certificado de Apresentação de Apreciação Ética): 47531915.3.0000.5346.

RESULTS

As for the characterization of the participants, 12 were female and three were male. Their ages ranged from 20 to 33 years. As for the level of education, two had a technical course in nursing, working as professionals. One participant had a technical course in computer assembly and maintenance, one in accounting, and another had a degree in psychology, without completing the course.

DISCUSSION

According to the testimonies analyzed, it was observed that, from the contacts made by the nursing students with lesbian or bisexual women, there were no conflicting experiences, considering that they point to the acceptance of this population in society and the absence of prejudice. The students reported a generalist approach, placing the user as a priority, developing care under a perspective of integrality, in which sexual condition does not interfere in Nursing care. It was verified the absence of distinction between users, as well as the concern in treating them with respect. Similar data revealed that students from different health courses did not feel discomfort during the care of users of any sexual condition (^{GREENE et al., 2018}).

In counterpoint, some reported a lack of preparation for performing care for lesbian and bisexual women. They highlighted the difficulty in welcoming and the fear of not serving the users appropriately due to the uniqueness of their sexual status. In a survey with medical students, in order to identify their knowledge about LGBT users, there were reports of a lack of knowledge for providing care to this public (^{NAMA et al., 2017}). The authors further warned about the need for change in the level of knowledge of students for this topic. Faced with what was presented, this formative fragility can also be perceived in our local reality, in which students sometimes feel unprepared for the care to this public, revealing feelings such as fear and trepidation in the approach to lesbian or bisexual women (^{NAMA et al., 2017}).

According to the National Curriculum Guidelines (2001) for undergraduate nursing courses, the graduate profile should include the "ability to act, with a sense of social responsibility and commitment to citizenship, as a promoter of integral health of the human being" (^{BRASIL, 2001}). Thus, it is identified the need to raise awareness and strengthen training about sexuality and gender diversity, in its different forms of expression, contextualizing it in practice, in a natural way, without prejudices and difficulties and contemplating it, also, as another contribution to improve the quality of nursing care provided to the population - this is the major goal of this reflection (^{CARTEIRO; NENE, 2015}).

Working on sexuality goes beyond the knowledge obtained from the internet, from books, in the family context, from one's own life experience or from the attitude of centering the issue only on organic and pathological aspects: it is in this perspective that the need to advance in nursing arises, in discussions that address sexuality in its different stages of the life cycle. Knowledge about sexuality is fundamental to the quality of assistance and care to the patient/client. During training, it is important that the student acquires this knowledge in practical classes and internships, building a holistic view in its social aspects, rights and guidance on self-care, and working intervention in sexual health (^{FIGUEIROA et al., 2017}).

It was observed mastery of what is worked in the undergraduate course during the care performed with lesbian and/or bisexual women, relating the theoretical content to their practices. Thus, since the themes of homosexuality and female bisexuality are little discussed in the classroom, the care for these users can become weakened.

The nursing professional should be free of prejudices and concepts to provide equal care to these women and develop an assistance that enables the protection and promotion of their health (^{FREITAS; SOUZA; ARAÚJO, 2015}). An academic training that covers discussions focused on the LGBT group can have positive effects, since it corroborates the knowledge, skills and attitudes of professionals and students, promotes cultural competence and sensitivity, thus reducing difficulties in the approach to care (^{BELÉM et al., 2018}).

The participants identified, as a potentiality for care, the personal ease of acceptance of sexual and gender diversity, in order to assent and understand without personal judgments or prejudices. The fact of being in contact with these users was also mentioned as a facilitator for the care, because there is a greater knowledge and familiarity with this population. A study conducted with this same object concluded unanimously about the importance of bioethics in the training and moral and ethical development of the student (^{SOUSA et al., 2011}). In view of this, undergraduate nursing courses should take responsibility for ensuring a satisfactory ethical and bioethical training for students, so that they are able to discussions about citizenship, humanization, respect for diversities and the individuality of each being (^{GREENE et al., 2018}; ^{NAMA et al., 2017}).

Thus, it is perceived that, in the institution where this study was conducted, students identify the topic as a potentiality for care, emphasizing its importance, which is understood as a reflection of an adequate and quality teaching. In general, the undergraduate nursing degree aims to train generalist nursing professionals, with scientific and human preparation and sufficient training to assess, identify and implement the health and care needs of healthy or sick people, families and the community (^{ORTEGA et al., 2015}).

Due to the complexity of the subject, it is evident the difficult task encountered by teachers when teaching a subject of such relevance for the construction of critical thinking of students. It is noteworthy that the difficulties to work with the homosexuality issue occur by the limitation of approach in academic training and by particular issues to each individual or social group (^{FREITAS; SOUZA; ARAÚJO, 2015}). Considering that it is a theme permeated by historical, cultural and complex factors, there is a need for time and space within the training scenario for the students to learn and become familiar with this subject, in order to develop a care based on uniqueness and individuality.

In academic education, when addressing the topic of sexuality, the discussions that arise end up identifying prejudices and taboos, often perceived by silences, refusal of information and ignorance (^{SOUSA, 2015}).

The undergraduate course should offer this space for discussion and deepening about the theme, with theoretical and practical support; the importance of renewing concepts and values about lesbians is directly reflected in the care and comprehensive quality attention in the care process (^{CARTEIRO; NENE, 2015}).

The invisibility of the health of homosexual and bisexual women was also mentioned and, concomitant to this, the lack of preparation to work with these situations of care, permeated by doubts and insecurity. The care of lesbian women is often fragmented and decontextualized, because it does not address their sexual orientation, attending them indifferently as heterosexuals (^{FREITAS; SOUZA; ARAÚJO, 2015}).

In addition to the weaknesses in the academic field, the intrinsic prejudice in society and the cultural issue were mentioned as factors that influence the fragility of care, also being responsible for the scarcity of discussions on the topic in the classroom. Nurses inserted in a sociocultural context that tends to repress the topic of sexuality absorb the influence of existing beliefs, myths and taboos, conditioning their approach in a natural way (^{CARTEIRO; NÉNÉ, 2015}).

The persistence of prejudice and misinformation regarding issues involving sexuality also occurs, which generates consequences at different levels. An aggravating factor is perceived when prejudice and discrimination are present in areas responsible for promoting health, guaranteeing human rights and the well-being of the population - as is the case in the area of health and, more specifically, in nursing. Health promotion, prevention, and rehabilitation exist before any subject; however, their specificities must be taken into account, which necessarily makes it mandatory to act under the principles of integrality, equity, universality, and humanization (^{FIGUEIROA et al., 2017}).

Students feel the need for a more comprehensive discussion about homosexuality and female bisexuality during their academic training, emphasizing the little contact with the topic. Among the alternatives to minimize the weaknesses, it was mentioned the need to approach homosexuality as a whole, not only as a concept, but in its history of struggles and points of view. In this way, the possibility of bringing homosexual people into the classroom arises, with the purpose of reporting their daily lives and perceptions. The way nurses receive training on sexuality contributes to the construction/reconstruction of representations that will be present in professional practice, just as reflection about the practice can promote change (^{CARTEIRO; NÉNÉ, 2015}).

In contrast, some participants reported not feeling the need to cover these topics during graduation, since the user should be treated in its entirety. An alternative for those interested in reflecting about homo and female bisexuality would be the personal search for knowledge, based on their own initiative. The visualization and applicability of what is built in the classroom favors the understanding of the process of education/care, considering that knowledge needs to represent meaning for the student to perform theoretical-practical relationships, to the extent that he is co-responsible for the consolidation of knowledge (^{FIGUEIROA et al., 2017}).

Considering that the population of lesbian and bisexual women often has no visibility regarding their sexual orientation, being labeled as heterosexual, it is understood the need to address these issues during training, since much care should be adapted to the individual conditions of each user.

The study presents as limitations the fact that it has explored only the perspective of nursing students, not including the teachers who participate in the teaching-learning process, nor the lesbian and bisexual users who experience the care received from professionals and nursing students. Moreover, considering that the subject addresses a theme still surrounded by taboos and preconceptions, it is understood that there may have been embarrassment and inhibition to talk about the subject, with consequent limitation of speech regarding the perception of the participants on the subject.

This study aims to contribute to the identification of potentialities and weaknesses in the academic training of future nurses regarding the issue of homosexuality and female bisexuality, providing a reflection on the topic regarding the training of nurses and its impact on the quality of care provided to this population. Thus, in times of construction of new curricular guidelines for nursing, it is necessary to include discussions in this process, aiming to strengthen training in the area.

It is hoped that, based on the findings presented, new studies can be developed with a view to promoting teaching-learning strategies that foster critical and reflective thinking of students regarding the comprehensive care of lesbian and bisexual women. In times of expanding technological production, the development and validation of technologies can present itself as a potentially resolutive strategy for this demand. From this perspective, it is necessary to insert the participants in this construction process, in order to propose technological products or processes applicable and consumable by both training institutions and health services.

FINAL CONSIDERATIONS

The present study allowed us to identify that the care provided to lesbian and bisexual women presents social, cultural and particular influences of each student. The personal experience of the student, added to the opportunities at the university and their co-responsibility for the training, consolidate subsidies for the care of this population. It was also possible to identify that, even though the training shows some advances regarding the approach of this theme in the training, it still presents some weaknesses and challenges that can be minimized through a collective construction, which rethinks and reformulates the layout of the subjects through the insertion of this theme.

Thus, it is identified the need to expand the reflection on the subject in academia, in order to train generalist nurses prepared and confident to provide adequate care to lesbian and bisexual women, taking into account their specificities. Thus, a solidified understanding of diversities will be possible, promoting an egalitarian nursing care without discrimination.