Interprofessionality in Brazilian national curricular guidelines for health coursesAbstract
This study aimed to analyze the inclusion of interprofessionality in Brazil's National Curricular Guidelines (NCG) for undergraduate health courses. This is a qualitative research based on documentary analysis of the guidelines, divided into two stages: exploratory reading and document analysis. The current NCG for undergraduate health courses make references to teamwork, however, there are few mentions of interprofessionality. Guidelines published after the World Health Organization (WHO) Framework for action on interprofessional education and collaborative practices contain more references to the inclusion of interprofessionality. It was observed that most guidelines for undergraduate health courses still include interprofessionality in a limited and sporadic manner.
Keywords:
interprofessional education; health human resource training; universities
Resumo
Este estudo teve como objetivo analisar a inserção da interprofissionalidade nas Diretrizes Curriculares Nacionais (DCN) do Brasil vigentes dos cursos de graduação da área da saúde. Trata-se de uma pesquisa qualitativa de análise documental das diretrizes, dividida em duas etapas: leitura exploratória e análise dos documentos. As DCN vigentes dos cursos de graduação em saúde fazem referência ao trabalho em equipe, porém, há poucas referências à interprofissionalidade. As diretrizes publicadas após o Marco para ação em educação interprofissional e práticas colaborativas da Organização Mundial da Saúde (OMS) apresentaram mais referências à inserção da interprofissionalidade. Observou-se que a maioria das diretrizes dos cursos de graduação em saúde ainda insere a interprofissionalidade de forma escassa e pontual.
Palavras-chave:
educação interprofissional; capacitação de recursos humanos em saúde; universidades
Resumen
Este estudio tuvo como objetivo analizar la inclusión de la interprofesionalidad en las directrices curriculares nacionales (DCN) de Brasil vigentes para carreras de pregrado del área de la salud. Se trata de una investigación cualitativa de análisis documental de las directrices dividida en dos etapas: lectura exploratoria y análisis de los documentos. Las Actuales Directrices para carreras de pregrado en salud hace referencia al trabajo en equipo, pero hay pocas referencias a la interprofesionalidad. Las Directrices publicadas tras el Marco de acción de la Organización Mundial de la Salud (OMS) sobre educación interprofesional y prácticas colaborativas presentaron más referencias a la inclusión de la interprofesionalidad. Se observó que la mayoría de las directrices de las carreras de pregrado en salud aún incluyen la interprofesionalidad de manera escasa y puntual.
Palavras clave:
educação interprofesional; formación de recursos humanos ensalud; universidades
1 Introduction
Defined by Law 10.172/2001, which establishes the National Education Plan, the National Curricular Guidelines (NCG) are documents that guide the development of pedagogical projects and curricula for undergraduate courses in higher education institutions (HEIs) in Brazil (Brasil, 1997, 2001). The NCG for the health area are developed through discussions by each professional category with its respective council. Once drafted, they are submitted for evaluation by the National Health Council (CNS) and subsequently sent to the National Education Council (CNE) for approval and publication (Brasil, 2016). The guidelines must cover the professional profile, competencies, skills, and emphases, as well as curricular content, course structure, internships, and complementary activities, in addition to defining strategies for monitoring and evaluating the training process (Brasil, 2003).
Opinion CNE/CES No. 334/2019 provides guidance for the development of the NCG and details each constituent component that should be included in the curricula of higher education courses (Brasil, 2019). One of the components that the guidelines must describe is competencies.
According to opinion CNE/CES No. 334/2019 (Brasil, 2019):
Competencies should be understood as attributes associated with learning itself (basic competencies), the ability to handle nonspecific situations (personal competencies), and those that ensure the performance of tasks and responsibility in professional practice (professional competencies).
Resolution No. 569, of 2017, issued by the CNS, which outlines the assumptions, principles, and common guidelines for the NCG of undergraduate health courses, reaffirms the Unified Health System (SUS) as the guiding principle for the training of healthcare workers and establishes that the principles and guidelines present in its legal framework should be included in the NCG. In line with these principles, this resolution emphasizes the inclusion of interprofessional work with the aim of training professionals capable of promoting comprehensive healthcare through collaborative work (Brasil, 2018a).
D'amour and Oandasan (2005) defined interprofessionality as the development of cohesive work among professionals from different fields and an education and practice orientation in which both collaborate synergistically. In 2010, the World Health Organization (WHO), through its Framework for Action on Interprofessional Education and Collaborative Practices, introduced the concepts of Interprofessional Education (IPE) and Collaborative Practice. IPE "occurs when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes," while Collaborative Practice "occurs when health workers from different professions provide care with a focus on comprehensive health, involving patients and their families, caregivers, and communities to deliver the highest quality healthcare at all levels of the service network" (WHO, 2010, p. 13). To achieve interprofessional work, changes in the logic of professional training and healthcare delivery are needed, adopting a new paradigm in education and practice.
Studies show that IPE yields positive results in improving knowledge, skills, and competencies for collaborative teamwork (Reeves, 2016). Competence is understood as "the result of the combination of knowledge, skills, and attitudes that enable professionals to perform their work," and skills as "the set of practices acquired mainly through demonstration, repetition, and critical reworking, which provide the professional with psychomotor mastery, expertise in a given task, and the ability to make decisions and solve problems in their field" (Saupe et al., 2006). However, the implementation of actions that promote IPE remains limited (Reeves et al., 2016; Guraya; Barr, 2018). Expanding IPE initiatives in undergraduate education is necessary to overcome the uniprofessional and biomedical reasoning that predominates in training (Peduzzi et al., 2013). The inclusion of interprofessional education and work in healthcare is a strategy aimed at strengthening and consolidating the SUS and its principles (Costa et al., 2018). Thus, the objective of this study is to analyze the inclusion of interprofessionality in Brazil's current National Curricular Guidelines (NCG) for undergraduate health courses.
2 Methods
The documentary research, which is qualitative and exploratory in nature, employed in this article aims to identify the incorporation of the concept of interprofessionality in the main documents of the National Guidelines for undergraduate health courses in Brazil. The NCG for all courses were accessed in June 2022, and the analysis was carried out between October 2022 and March 2023. For the selection of courses of interest for this analysis, Resolution CNS 287/1998 was used, which listed the following professional categories at the higher education level for the purpose of participating in the National Health Council: social workers, biologists, biomedical professionals, physical education professionals, nurses, pharmacists, physiotherapists, speech therapists, doctors, veterinarians, nutritionists, dentists, psychologists, and occupational therapists (Brasil, 1998).
All documents analyzed are public and normative texts from the field of education, authored by the Chamber of Higher Education of the National Education Council of Brazil. The search for documents was conducted on the website www.portal.mec.gov.br, where 14 guidelines in effect were identified, one for each aforementioned course.
The document analysis was carried out in two stages, conducted independently by two researchers trained in the adopted methodology and with experience in health services, specifically related to the theme of interprofessionality. Subsequently, the collected data were presented, and in cases of disagreement, a debate was held among the researchers until consensus was reached.
An exploratory reading was conducted to identify terms related to interprofessionality and to form thematic analytical categories, which would allow for an understanding of the documents in relation to the research objective (Bardin, 2012). The NCG were read three times during the exploratory phase. In this process, the following terms were sought in the documents: Interprofessional; Interprofessional Education; Teamwork; Collaborative Learning; Shared Learning; and Collaborative Practices, which are the terms listed in the WHO Framework for Action on IPE and Collaborative Practices, along with the concept of IPE. From this point on, thematic analytical categories were formed, with guiding questions being developed based on the study objective, as presented in Table 1.
3 Results
The NCG currently in effect for Biomedical Sciences, Biological Sciences, Nursing, Physiotherapy, Speech Therapy, Nutrition, Social Work, and Occupational Therapy courses were published during the period that saw the establishment of the first curricular guidelines for higher education health courses (2001 to 2003). As for the Physical Education, Pharmacy, Medicine, Veterinary Medicine, Dentistry, and Psychology courses, their NCG were published after the 2010 WHO Framework for Action on IPE and Collaborative Practices. The publication years for the definition of interprofessionality, the WHO Framework for Action on IPE, and each NCG are presented in Figure 1. The identification of terms related to interprofessionality is shown in Table 2.
Identification of terms associated with interprofessionality in the current NCG for undergraduate health courses
3.1 Inclusion of interprofessionality in the national curricular guidelines for health courses
All courses make reference to teamwork in their NCG, except for Biological Sciences and Social Work. However, only the guidelines for the Pharmacy, Medicine, Psychology, Dentistry, and Occupational Therapy courses contain specific references to interprofessional work. Furthermore, the guideline for the Pharmacy course recommends training for interprofessional practices to ensure the integration of teaching and healthcare services.
The guideline for the Medicine course mentions care in the family and community contexts, emphasizing interprofessional work and interprofessional learning. In the Dentistry curriculum, interprofessional, interdisciplinary, and transdisciplinary practices are encouraged, while the Occupational Therapy guideline includes participation in interprofessional teams.
3.2 Competencies for training
Except for the guidelines for the Biological Sciences, Veterinary Medicine, and Social Work courses, all other guidelines mention teamwork as part of the required competencies and skills. However, the NCG for Pharmacy, Medicine, Psychology, and Dentistry highlight interprofessional training as a required competency. The NCG for Biomedical Sciences, Nursing, Physiotherapy, Speech Therapy, Nutrition, Dentistry, Psychology, and Occupational Therapy all outline the same general competencies and skills necessary for training: Health Care; Decision-Making; Communication; Leadership; Management and Administration; and Continuing Education. Additionally, they emphasize leadership skills in multiprofessional teamwork.
The NCG for Medicine divides the required competencies into three categories: Health Care; Health Management; and Health Education. Leadership is also described as a competency in the Medicine NCG, but it differs from the other documents mentioned as it is associated with the exercise of horizontal interpersonal relationships. Moreover, it is the only guideline that directly includes interprofessional learning under the dimension of Health Education.
3.3 Training for SUS
The SUS is a reference point in the NCG for all courses except for the Biological Sciences, Veterinary Medicine, and Social Work. The Nursing and Nutrition NCG mention training to meet social needs, with an emphasis on the SUS, while the Physical Education training uses the SUS as a guiding axis. Furthermore, the Pharmacy course guideline highlights intersectoral and social actions guided by SUS principles and the integration of practical activities in the undergraduate curriculum within SUS spaces.
The NCG for Medicine and Dentistry emphasize training for SUS, basing general and specific competencies on its principles. These guidelines particularly emphasize several principles of SUS, such as universality, comprehensiveness, and equity. Additionally, the Medicine NCG prioritizes SUS as a field for practical training. The principle of comprehensiveness and the promotion of integral health are highlighted as structural axes for the competencies and skills in all the guidelines that reference SUS.
3.4 Curricular content
The guidelines present a curriculum focused on technical content, emphasizing scientific and biomedical knowledge specific to each professional training. However, the Social Work NCG does not include specific content for the health field.
All guidelines recommend the inclusion of interdisciplinary, multidisciplinary content, as well as practical training (internships and extension activities) in various fields of professional practice. The NCG for Medicine and Dentistry emphasize content related to public health that involves interprofessional work.
4 Discussion
Globally, healthcare systems face complex challenges due to environmental, behavioral, demographic, and epidemiological changes. Concurrently, in the education of health professionals, there is still a predominant focus on technicist, biomedical knowledge, with a prioritization of hospital-based practices at the expense of primary healthcare, as well as a lack of skills for collaborative work across professions (Peduzzi; Agreli, 2018). Interprofessionality thus emerges as a necessary strategy to change the practice and educational environments for healthcare professionals (Ceccim, 2018).
Since the publication of Brazil's National Education Plan, the NCG for health courses have been designed to train professionals focused on care and assistance based on the principles of SUS, which align with interprofessionality (Brasil, 2001). Among the SUS principles, comprehensiveness envisions healthcare as continuous, centered on the user's needs, addressing them in their entirety, while interprofessionality seeks to build collaboration in the workplace through the exchange of knowledge and shared learning, promoting user-centered care that recognizes individual differences (Viana; Hostins, 2022).
However, the results show that the guidelines contain few references to interprofessionality, as defined by the WHO Framework for Action on IPE and Collaborative Practices, despite some emphasizing teamwork. Costa et al. (2018) also found in their study that guidelines for the health area point to technicist content focused on specific disciplines, while some include guidance on training for comprehensive care and attention to health.
In the documents for Biological Sciences, Veterinary Medicine, and Social Work courses, no specific mention of professional training for SUS was observed, distancing these categories from interprofessionality. Although the guidelines for these courses do not highlight SUS, the specific work of biologists and veterinarians includes the fields of epidemiology, sanitary and environmental surveillance, with veterinarians being recognized as active participants in these areas, particularly in the Family Health Support Centers and Primary Care settings (NASF-AB), along with social workers who also operate in primary healthcare and can be part of these centers (Brasil, 2011; Federal Council of Biology, 2010; Souza et al., 2021; Vieira; Melo; Soares, 2023).
The guidelines for medical and dentistry training stand out from the others because they explicitly emphasize professional training focused on SUS principles and guidelines. In this sense, they demonstrate greater potential to drive changes in orientation, ensuring that interprofessionality is present in the pedagogical projects of these courses. The current NCG for Medicine was primarily shaped by the "More Doctors Program," which comprises a set of government actions aimed at strengthening primary healthcare and introduced modifications to the guideline concerning the professional profile, competencies, and curricular content, prioritizing training for SUS (Brasil, 2013; Oliveira; Santos; Shimizu, 2019).
From the WHO Framework of 2010 and the expanded debate on interprofessionality, it is observed that the NCG published after this framework included the terms interprofessional and interprofessionally in their discourse (WHO, 2010). The incorporation of the idea that graduates need to develop competencies and skills for joint learning and participation in cohesive and collaborative teams shows progress in reorienting health training. The NCG published before the WHO Framework (2010), such as those for Nursing, Speech Therapy, Nutrition, and Occupational Therapy, for example, are currently undergoing evaluation by the National Education Council and have already been approved by the National Health Council. These new versions incorporate interprofessionality as one of the necessary principles for the graduate profile (Brasil, 2018b, 2022a, 2022b).
Moreover, there are barriers within the work relationships among different healthcare professions, which are often hierarchical, divided by distinct behavioral patterns, even though they share a common goal. These divisions hinder dialogue about interprofessionality in practice environments and the formulation of guiding documents for professional healthcare practice that feature collective plans, such as the NCG (Braithwaite, 2016).
Thus, there is a strong need for IPE as the means to achieve interprofessional work. In other words, an educational guide must be implemented through which undergraduate, postgraduate, and healthcare professionals can learn to work collectively, with explicit interaction among participants, rather than dividing them into niches of specific activities (Reeves, 2016). Although the NCG lay the foundation for IPE, further investigation is needed to determine whether pedagogical course projects (PPC) indeed include strategies that allow for the paradigm shift required to promote interprofessional practice in SUS.
Regarding the competencies and skills found in the curricular guidelines, teamwork, communication, health care, and leadership are mentioned. However, these descriptions do not fully encompass interprofessionality. The Canadian Interprofessional Health Collaborative (CIHC) proposed, in a document published in 2010, interprofessional competencies to be developed in the training of healthcare professionals so that they can work in teams with a coordinated approach to shared decision-making around health and social issues. The six competencies listed are: interprofessional communication, patient-, family-, and community-centered care, recognition of professional roles, understanding team dynamics, collaborative leadership, and resolution of interprofessional conflicts (CIHC, 2010). The competencies mentioned align with those found in the NCG analyzed; however, the latter align more closely with the principles of SUS than with the adoption of IPE as an educational paradigm (O'Connor, 2018).
These NCG also encourage the integration of multiple disciplines and multiprofessional teamwork as essential skills. According to Braithwaite (2015), teamwork can be defined as "the combined activities of a group of people working effectively towards common goals". Therefore, the teamwork cited in the NCG differs from shared practice and learning, which are part of the interprofessional field. This field, beyond the combination of activities, involves the interaction, intersection, and collaboration between professions, seeking to reorient healthcare training (Ceccim, 2018).
Brazil, in its effort to reorient the training of healthcare professionals, has recently incorporated IPE into its policies, despite SUS and its legal framework having pointed to interprofessional teamwork since its inception (Freire et al., 2019). In this sense, the Brazilian Ministry of Education, in collaboration with the Ministry of Health, has been instituting programs aimed at reorienting health education in undergraduate programs since 2005 (Brasil, 2007; Brasil, 2010; Burille et al., 2013; Baptista et al., 2015).
The programs aim to "promote curricular changes aligned with the NCG for all undergraduate courses in the health field, considering strategies aligned with the principles of interprofessionality, interdisciplinarity, and intersectoriality". Thus, in 2018, the PET-Health/Interprofessionality call for proposals was launched (Brasil, 2018c; Freire et al., 2019). Furthermore, the programs urge the health and education sectors to work collaboratively in training the workforce to overcome the fragmentation of care and improve the ability to meet health needs (WHO, 2010).
Therefore, this analysis highlights the need and challenge of aligning with SUS principles from the perspective of interprofessionality, so that this topic can be more prominently addressed in professional training in Brazil (Toassi, 2017). Additionally, constructing NCG and, consequently, undergraduate curricula demands intersectoral collaboration between institutions and educational and healthcare bodies (Moreira; Dias, 2015).
5 Conclusion
The NCG are essential documents for fostering curricular changes. It was observed that most NCG for undergraduate health courses do not include interprofessionality and do not emphasize training focused on SUS. After the publication of the WHO Framework, the more recently published NCG included more references to the incorporation of interprofessionality.
This study presents the limitation of having opted for document analysis based on analytical categories, which may have imposed some interpretive rigidity. However, the analysis was carried out independently by two researchers, which broadened the perspectives. Moreover, based on the material analyzed, it was not possible to explore studies and experiences in which interprofessionality is already present in training.
Therefore, further research is needed to analyze interprofessionality in the context of healthcare professional training and the political and social processes involved in the curricular changes required to align with the principles and guidelines of SUS. Additionally, studies involving the actors responsible for drafting the curricular guidelines are suggested.
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Section Editor: André Pires | Layout Editor: Silmara Pereira da Silva Martins
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Translated by:
Lesy Editorial, E-mail: lesyeditorial@gmail.com
Source: Own elaboration