resumo
Esse texto se consitui de relexões teóricas e vivenciais das autoras acerca da aricu
-lação entre pesquisa, ensino e serviços de saúde para a consolidação do Sistema Úni
-co de Saúde. As pesquisas de enfermagem na saúde coleiva possuem como desaio romper com as formas tradicionais em que se separa quem pesquisa, aprende, ensi
-na e cuida. É da produção invesigaiva e relexiva que se processa o movimento de transformação do processo de cuidar e de ensinar. Assim, as pesquisas para a consoli
-dação do Sistema Único de Saúde clamam por uma intensa ariculação entre o ensi
-no-serviço e a produção de conhecimento. Desaia-nos a consituir projetos de pes
-quisa junto com os trabalhadores e isso im
-plica em avançar da coleta de dados para a produção de dados, do levar estudantes para aividades e estágio para parceria e co-responsabilização pelas ações. Propo
-mos assunção do não saber para criar-mos práicas insituintes.
descritores
Enfermagem em saúde comunitária Educação em enfermagem Pesquisa em enfermagem Sistema Único de Saúde
The research and association between teaching
and care in the consolidation of the Brazilian
National Health System
*O
riginal
a
r
ticle
AbstrAct
This aricle comprises the authors’ relec
-ions about theory and experiences about the connecion between research, teach
-ing and health care services for the con
-solidaion of the Brazilian Naional Health System (SUS - Sistema Único de Saúde). The research in collecive health nursing face the challenge of breaking with the tra
-diional forms that separate those who re
-search, teach, learn and provide care. The movement for changing the process of car
-ing and teach-ing occurs through an invesi
-gaive and relexive producion. Therefore, the studies for the consolidaion of the SUS call for an intense connecion between teaching-service and knowledge produc
-ion. It challenges us to create research projects together with the workers, which implies advancing the data collecion to data producion, and taking students to the aciviies and internship for the alliance and co-responsibilizaion of acions. We propose assuming the lack of knowledge to create insituing pracices.
descriptors
Community health nursing Educaion, nursing Nursing research Uniied Health System
resumen
Este texto se consituye de relexiones teóricas y vivenciales de las autoras acer
-ca de la ariculación entre invesigación, enseñanza y servicios de salud para la consolidación del Sistema Único de Salud. Las invesigaciones de enfermería en salud coleciva ienen como desaío romper con las formas tradicionales de separar invesi
-gación, aprendizaje, enseñanza y cuidados. La transformación del proceso de cuidar y enseñar se procesa a parir de la produc
-ción invesigaiva y relexiva. Así, las inves
-igaciones para la consolidación del Siste
-ma Único de Salud cla-man por una intensa ariculación entre enseñanza-servicio y la producción cognosciiva. Nos desaía a ins
-ituir proyectos de invesigación conjunta
-mente con los trabajadores, lo que implica avanzar de la recolección de datos hacia su producción, del llevar estudiantes para acividades y pasanías a la asociación y co-responsabilización por las acciones. Pro
-ponemos asumir el desconocimiento para crear prácicas insituyentes.
descriptores
Enfermería en salud comunitária Educación en enfermería Invesigación en enfermería Sistema Único de Salud
cinira magali Fortuna1, silvana martins mishima2, silvia matumoto3, maria José bistafa pereira4,
marcia niituma ogata5
A pesquisA e A ArticulAção ensino-serviço nA consolidAção do sistemA Único de sAÚde
lA investigAción y lA ArticulAción enseñAnzA-servicio en lA consolidAción del sistemA Único de sAlud
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Rev Esc Enferm USP2011; 45(Esp. 2):1696-700 www.ee.usp.br/reeusp/
The research and association between teaching and care in the consolidation of the Brazilian National Health System
Fortuna CM, Mishima SM, Matumoto S, Pereira MJB, Ogata MN
introduction
We begin with a statement to situate our problem(1): the health crisis moves through pracices that no longer explain, cure, or solve.
the individual-biological paradigm and preventative care speak of life, disease, and death subsidized by knowledge. And this knowledge ignores the culture of the family, of the suburbs, of the slums, and its own interactions with the human beings who move through the health system. Knowledge no longer explains, welcomes, consoles, nor
encourages a ight for life.
Therefore, it is in the crisis of health services, educa -ional insituions, scieniic producion, the global soci -ety of control(2), and integrated world capitalism(3) that we ind the daily challenge of remaining invenive in a space where reproducion, the repeiion of the already-insituted, and exclusion predominate.
Day in and day out in the health system, workers cre -ate sparks of life, caring acions, and partnering connec -ions which are responsible for many avoided deaths(4). On the other hand, they can also produce
neglect, carelessness, and a lack of account -ability for their acions. This situaion points out the contradicion we experience in ev -ery aspect of the health care system and the training of its personnel.
In the insituions which train health workers, professors and students alike reach beyond technique alone and strive to teach and learn aspects such as caring, and
plac-ing oneself in another’s posiion.
Following suit, research iniiaives born from the desire to address human sufering
and misery are captured by the logic of capital gains, prof -it, individual authorship, and power, and produce some -thing diferent than originally desired. They create compe -iion for a robust lates curriculum, for lucraive patents, funding, and internaional citaions.
These are insituing movements(5-6), potent in their producion of powerful new ways of research-teaching-learning-caring, which are captured by the insituted logic. Out of this struggle between insituted and insitut -ing forces emerges the challenge of mak-ing other bets, invesing in other logics. We consider this to be the chal -lenge facing research in public health, of which Nursing consitutes an important labor force(7). And thus we ask: How can we conduct research that includes an efecive modiicaion of care seings? How can we produce part -nerships between actors and services that really ariculate training and research? More than this, how can we con -nect knowledge with pracices for the producion of life and inclusion of workers and users? These are some of the challenges ahead for the implementaion of Brazil’s Uni -ied Health System (SUS), which we support: this paper aims to relect on some aspects of this problem.
tHe emerGinG reseArcH on tHe serVice-LeArninG encounter
In general, research begins with needs selected by researchers who are linked to the study and/or by edu -cators who have their own areas of research and courses in graduate programs. Also apparent is the inluence of more generalized research that deines research prioriies and funding policies(8).
What we thus ind is that research and studies in the academy are shaped at a considerable distance from the pracice and reality of the SUS. Despite some iniiaives, such as the Research Program for the SUS (PPSUS)(8), a quesion has emerged in the ield of Public Health and the consolidaion of SUS, namely: How can we connect the knowledge, and the processes of building knowledge, pro -duced by the university and the health system with health pracices? It seems that a gap exists that must be bridged.
What stands out is that we do not quesion the sepa -raion of the diferent ields that consitute and construct society: what demarcates the social needs for the health of our populaion, the research objects de -ined by the researchers, and the body of knowledge taught in the training of health workers. Our scope is too limited to delve into these aspects, but they certainly are there for us to think about insituing logics of research, educaion, and care.
Today, much of our research builds proj -ects in which the health services and their workers, as well as their users, are invited to play the role of research subjects. From this statement, a quesion arises: aren’t these subjects being treated more like objects?
Armed with knowledge and posiions of power, we conduct interviews and apply quesionnaires, collect data, and analyze and publish it with the supposed idea that we are somehow returning knowledge to the community.
As we seek to listen more to what health care work -ers say, we ind dissaisfacion with this form of knowl -edge producion. We idenify feelings of strangeness and embarrassment on their part about being the object of research, which is not always explicitly present, but of -ten becomes present in imes not set for the interviews, in days when appointments are made and cancelled, in spaces which are of-limits for observaion, in records that are restricted to the health service. A type of relaionship becomes established, one of use, of polarizaion between those who understand and know and those who don’t, between the researcher and the subject to be analyzed.
If we take as a staring point the understanding that reality is muliple and shiting, which is produced, and produces itself, through encounters and separaions, and these are instituting
movements, potent in their production of
powerful new ways of research-teaching-learning-caring, which
that it is not external to us, we have already accepted the inadequacy/failure of this form of research that divides subject and object, research and reality(9).
It is through forming links with the insituions that train health workers, and which sill view themselves as the primary research centers, that health services may seek to improve and modify their pracices in teaching/ research and care. This precise connecion should emerge from a common labor, of being united in health and train -ing services: students, teachers, workers, and users(10-12).
This may already occur in some places, but in general researchers, teachers, and students atend health servic -es as visitors, viewers in need of some cases to illustrate
their theories, pracice their skills, or collect materials for research.
Despite several years of debate about the implemen -taion of the Naional Curriculum Guidelines for health courses, which require coordinaion between training and work experience(10), ime and again we are surprised by proposals to re-issue health educaion services. These are supposed to teach, research, and properly service (but usually with pre-selected users) teams with adequate diversity and quanity of workers, and unknown unmet demand; condiions very diferent from most SUS health care. How can we conduct research that includes the ef -fecive modiicaion of care seings and teaching?
It seems that a clue, an indicaion, lies in the vehement need to refuse the already established place of knowl -edge, since we do not know. Academic knowledge, techni -cal and scieniic, no longer explains; instead, couldn’t we reject the established roles, those of academia bringing soluions, workers seeking responses, passive users and students breeding pracices?
If we do not know—and in assuming this not knowing
we break with the supposed division between those who teach, those who learn, those who study, and those who care—wouldn’t these be acions of interface between all subjects at the liaison between teaching and service? This series of speciic acions that are performed by speciic individuals (teacher teaches, researcher researches, work -ers care, us-ers are cared for, student learns), does it not require the mainstreaming of insituions in a move to be triggered, invented, given agency?
It seems to us that research needs to be based upon a sensiive listening to what is occurring in health care ser -vices, of the students and users involved. Sensiive listen -ing, because it indicates the importance of the analysis of supply and demand.
If we ask a collecive of workers what they perceive as problems in their daily lives requiring research, an ava -lanche of diiculies will be ideniied, all sorts of prob -lems will be raised, including issues already addressed from invesigaive point of view.
This brings us the co-responsibility to think together
about the issues presented, which undoubtedly requires investments of all kinds: libidinal, structural, material, out -reach strategies, and disseminaion of research results, among others.
The demand for a given research topic must be ana -lyzed collecively, and in general it requires breaks, analy -ses in its broadest sense to see the emergence of another problem. Our lodestar for this discussion is the care and lives of workers and users.
Demand is modulated by supply(9); researchers by their presence and their quesions ofer something beyond the explicit, so they must to relect on what to ofer.
The research emerging from the collecive meeing will quesion authorship: whose idea is that one? Born at the meeing, born out of a combined relecion. Analysis and interpretaion are also tasks of the collecive that acively ponders the issue of research. This ends up deterritorial -izing the noion of data collecion, because they were not there to be picked a priori, but rather are produced in ex -changes at the ime of the research.
The invesigator, the reality, and the subjects are also in producion in this way of thinking of research, insofar as the research is intervenion(9), is not neutral, does not reproduce itself, and is creaion. Intervenion-research (9) is a mode of invesigaion ailiated with the insituion -alist movement(5), and which views the transformaion of reality as necessary to knowing it. In this process, the social experience is followed-up using and manufacturing conceptual and operaional tools for a collecive analysis aimed at transforming insituions and their insituted and insituing forces that are underway.
In our experience in the ield of public health we bet on the possibility of progress through research that is ef -fected by linking research with service-learning.
From 2001 to 2003 we conducted an intervenion re -search(13-14) with workers from a Basic Health Unit (UBS) that had a family health team. The team itself asked for assistance in understanding their diiculies with the con -necion between the new acion proposed for the family health team and the tradiional acion of the UBS.
We conducted weekly groups for two years, one in the morning and one in the aternoon, so that all staf could paricipate. During this period, the movements of the team in their connecions and disconnecions for the care of families were followed, and new meanings and work arrangements were produced for the workers.
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Rev Esc Enferm USP2011; 45(Esp. 2):1696-700 www.ee.usp.br/reeusp/
The research and association between teaching and care in the consolidation of the Brazilian National Health System
Fortuna CM, Mishima SM, Matumoto S, Pereira MJB, Ogata MN
The set of workers chose to work with educaional groups throughout one year, in 26 meeings of around two hours each, where the acions taken were analyzed; the workers served as a laboratory for instrumentaion on management with the groups. In this process, the unit management, technical and social division of labor, bio -power, and the relaionship between universiies and ser -vice were also under review.
Another type of experience has been the producion of workshops ofering relecion on the research carried out in the basic health network of the city, the basis of teaching performance. We conducted four workshops in 2011, holding discussions with nurses with the following structure: a presentaion by a guest on the topic of re -search, and a brief presentaion of the results of the sur -vey conducted, followed by discussion.
There was discussion about educaional aciviies, the clinical pracice of nurses, and the skills of nurses in prima -ry care. In these workshops, held in conjuncion with the Head of the Division of Nursing of the Municipal Health Secretariat, it was possible to produce meeings that drew out concerns about the themes.
concLusion
Forging links between research and service-learning on more creaive and innovaive bases is certainly chal -lenging and complex, but has greatly contributed toward the consolidaion of the SUS. How can we connect these
instances, given diferences such as work processes devel -oped for diferent purposes, but which may ofer connec -ions that empower tasks and responsibiliies?
We present a clue to the necessity of refusing the es -tablished forms with which we are familiar enough, which separate those who research, what or who is researched, and those who learn, teach, and care. We propose the as -sumpion of not-knowing.
To produce joint invesigaions and other modes of co -operaion we need to quesion how we produce and re -spond to the academic and insituional issues of science and technology in the country, which are aligned with the capitalist logic of producion. We face the riddle of the Sphinx: Decipher me or I’ll devour you.
It seemed to us that another clue that we could ofer as a possible staring point would be in the form of a chal -lenge: How can we provoke workers in the health services and educaion to exercise self-assessment of their work processes in acion, and from this perspecive follow the connecions that empower life with joy?
The ime for collecive and relecive producion is of a diferent order; it seems that we sill cannot decipher the riddle of the Sphinx in order to develop strategies through which we research the giving of care while caring about teaching and researching. With that we quesion the imeframes that do not coincide: those of the collecive producion, and the chronological and producivist pace of academia.
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