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Dreaming with the strengthening of Teaching-Service Integration Actions with Multi-professional Interns in Health: An Appreciative Inquiry

Amanda de Lemos Mello*, Marlene Gomes Terra, Cristiane Trivisiol Arnemann, Vânia Marli Schubert Backes, Elisabeta Albertina Nietsche, Silomar Ilha, Carmem Lúcia Colomé Beck, Sheila Kocourek, Maria Elisabeth Kleba da Silva

Department of Nursing, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil

*Corresponding Author:
Amanda de Lemos Mello
Department of Nursing
Universidade Federal de Santa Maria
Av. Roraima, 1000 - 97105-900 - Santa Maria, RS, Brazil.
Tel: +55 86 3215-5940/3305-0615
E-mail: [email protected]

Received Date: 24/09/2020; Accepted Date: 21/10/2020; Published Date: 28/10/2020

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Abstract

Objective: Dreaming about strategies that strengthen these actions of teaching-service integration in the context of multi-professional internships in health can be a way to stimulate creativity and start a journey to build collectively, based on dialog and interaction.

Material and Methods: This article describes the dreams that can strengthen actions of teaching-service integration from the perspective of interns linked to a Multi-professional Health Internship Program. For this purpose, an Appreciative Inquiry was carried out with seven interns linked to a lato sensu graduate program, of the Multi-professional Health Internship type, located in a Public University in the south of Brazil.

Results: Data collection was conducted in the 4D Cycle: Discovery, Dream, Design, and Destiny, from July 2017 to April 2018, by means of discussion groups and individual interviews. Data analysis was performed according to Green, with Edgar Morin's theoretical reference.

Conclusion: In order to strengthen teaching-service integration, it is necessary to agree with the health teams, managers, interns and others involved about the activities to be carried out; in addition, there are ways that the interns idealize to carry out these actions, as moments that favour interprofessional dialog among peers and promote democratic spaces for sharing knowledge.

Keywords

Public health, Education public health professional, Teaching care integration services, Internship non-medical.

Introduction

Preparing the public health professional of the future requires new content and different pedagogical proposals in the academic curriculum [1]. Linking theoretical education with practical reality in health services because the beginning of training is one of the potent bets to stimulate critical thinking and the diagnostic reasoning capacity of health professionals [2], especially to accompany the central characteristics present in public health, such as the multidimensionality of health care, interdisciplinary, inter-professionality, and the action that is established in this context [3].

Teaching-service integration can be understood as an agreed upon, articulated, and integrated strategy for collective work; as partnership relationships; between health schools and health work [4]. Several elements interfere in teaching-service integration, such as the importance of agreeing on the actions by the interns with those involved in educational teaching [5]; the interaction between people, made possible by teamwork and mutual cooperation [6]; the quality of the infrastructure and personnel of the health unit settings; and activity planning, among others [7,8].

Current evidence shows the potential of teaching-service integration in the context of the health area and the gains for training in public health, such as the production of changes in the professional practices and in the care model, based on the perspective of health care networks [9], constituting an important strategy for meaningful learning [10] with repercussions in the professional and personal sphere [11] and encouragement for inter-professionality [12]. However, there are also points to be strengthened, such as the importance of spaces for dialog and problematization in face of the presence of the hospital-centered model, which is still prevalent [4], as well as the fragmented curricula in discipline [9]. Strengthening these elements tends to put into effect and qualify PHE actions; health matrixing; creation of effective spaces for case discussions; team clinics (interconsultations); boost the development of team therapeutic plans; and, joint interventions [13].

In the context of postgraduate studies in the area of health, this requires fields of high quality practices in order to better train future specialists. For this, it is recommended that an educational policy be maintained to improve the integration of the university with the health and community services [14]. In the case of Multi-professional Internship Programs in Health (Programas de Residências Multiprofissionais em Saúde, PRMS), teaching-service integration occupies space as a central objective of the practices but, for this, it is necessary that the interns, teachers, and health teams participate in the training and recognize its importance for the qualification of public health care [5].

Therefore, the objective of this review is to identify, based on the scientific literature, the structural and procedural risk factors correlated to missed nursing care in hospitals.

With the establishment of the Unified Health System (Sistema Único de Saúde, SUS) in Brazil in 1988, several advances have been achieved through the construction and implementation of public policies, with regard to health as the right of all and the duty of the State. One of these rights aims to guarantee the population's access to the services, which must follow principles such as comprehensiveness, participation, and resolution in health care [15]. In this context, considering the complexity in the implementation of these principles, interministerial strategies were developed to guide the organization of care and, in an articulated way, the training of health professionals, seeking to integrate teaching institutions, health services, and the community [4,15].

Among these strategies is the National Policy for Permanent Education in Health (Política Nacional de Educação Permanente em Saúde, PNEPS) which, as educational proposal, advocates the consolidation of the permanent training of SUS professionals in the most different scenarios of health care, in order to articulate service needs and workers' capacity to resolve and manage health services [16]. Studies show that the Multi-professional Internship Programs in Health (PRMS) have presented themselves as an important ally of the PNEPS to overcome the hegemonic models of professional education, being an important strategy to strengthen the integration between teaching and health services [5]. In addition, it aims to favour the achievement of the SUS principles such as comprehensiveness, equity, universality, and the humanistic, technical, and ethical professional requirements for the qualification of the service provided to the users [17].

The PRMS were regulated in Brazil in 2005 and are lato sensu specialization programs in service in the Internship modality, which can be linked to universities, health departments, hospitals, and other health services. This modality requires from exclusive dedication from the interns, with a workload of 60 hours per week, including theoretical, practical, and theoretical-practical activities for two years, totaling 5,760 (five thousand seven hundred and sixty) hours. It also recommends the development of inter-professional practices in the areas of biomedicine, biological sciences, physical education, nursing, pharmacy, physiotherapy, speech therapy, veterinary medicine, nutrition, dentistry, psychology, social work, and occupational therapy. They are characterized by in-service training and aim to promote attributes that enable professional practice with excellence in areas of comprehensive health care, involving communities, management, and health education [18]. The interns' pedagogical guidance is carried out by tutors and preceptors, who are university professors and health service professionals, respectively designated for this assignment, with the activities in the PRMS being cumulative to the other activities they develop [17].

It is in this perspective that teaching-service integration emerges as a strategy to strengthen the relationships among teaching, health, and community. It is understood as an agreed upon and integrated work of students and teachers in the health area, with the teams and managers of the health services. It is a strategy that aims at the quality of individual and collective health care, by means of permanent training [4]. Teaching-service integration requires and, at the same time, enables movements of discomfort and reframing in the people involved, both in relation to the knowledge and practices developed and applied, as well as in relation to the roles played and ways of interacting built within the scope of organizations.

For Morin [19], it is necessary to build ways of thinking that allow us to connect things, instead of separating, enabling a more appropriate and timely understanding of the parts, in their relationship with the whole and with its context. Highlighting that we are beings of relationships, interactions, interdependent, and that we live in a multidimensional society, Morin [19] proposes foundations for the construction of a complex thought, which makes it possible to recognize essential links between autonomy and dependence, between order and chaos, between individual and society. In this perspective, this author reflects on the potentialities provoked in the productive interaction between university and society, such as openness to the problematization of central themes/issues (with the maintenance of open and plural research), primacy of the truth about the usefulness and ethics of knowledge committed to building the future.

Problematizing these aspects, among others, is a central challenge in the processes of permanent education in the health area. For Morin [20], we are products of society, which shapes us as individuals belonging to a time and a place, through its rules, laws, and interdictions. However, it is these individuals who produce society, in and through their interactions. If, on the one hand, there is a strong tendency for individuals to maintain and reproduce reality, there is a latent power to produce changes, as the encounter and dialog between subjects promotes exchanges and allows for a new meaning and intervention in this reality. It is in the dialogical order/chaos/organization that the new emerges, which implies visualizing, in the order of things, rupture powers (chaos) from which it is possible to generate new forms of (re)organization.

In view of the above, it is necessary to identify the experiences, perceptions, and dreams of the professionals directly involved in the process, that is, the multi-professional interns of the health area, with a view to strengthening actions of teaching-service integration, a fact that justifies the need and relevance of this research. It should be noted that the verb “dreaming” is used in this research, according to Cooperrider et al. [21] and to Arnemann et al. [22] referring to the opportunity to collectively explore hopes and desires for the future of their team or organization.

In this context, according to the appreciative research, the question is the following: What are the dreams that aim to strengthen actions of teaching-service integration from the perspective of interns linked to a Multi-professional Internship Program in Health of a Public University in southern Brazil? Thus, the objective was to describe dreams that can strengthen actions of teaching-service integration from the perspective of interns linked to a Multi-professional Internship Program in Health at a Public University in southern Brazil.

Materials and Methods

This is an Appreciative Inquiry (AI), which favours the identification of the best successful practices developed and employed by the people who work at an institution, in view of its strengthening and diffusion [21,22]. The scenario for conducting the research was a PRMS, affiliated with a Federal Public University, located in southern Brazil. This PRMS develops the practical and practicaltheoretical axis in the large public hospital, which is a reference for a region with 32 municipalities; in addition, it develops activities of different levels of complexity in the municipality's Health Care Network. During the study period, 130 interns were enrolled.

For the production of data, interns were selected who were representatives of the collegiate bodies of the PRMS, the Multiprofessional Internship Committee and in the Professional Health Area (Comissão de Residência Multiprofissional e em Área profissional da Saúde, COREMU) and Structural Assistance Teaching Nucleus (Núcleo Docente Assistencial Estruturante, NDAE), since these represented the other interns in collegiate and deliberative instances. This choice was made in order to seek as much participation as possible from the people involved in the context being studied. For this, it is necessary to cut the universe that includes the choice of different people who represent the plurality of this scenario [21].

The selection criterion for participation in the study was carried out by intentional invitations to representatives of Organs collegiate bodies of the PRMS - COREMU and NDAE. The selection criteria for participation in the study were the following: being an intern and having an active enrollment in the PRMS, and/or being a participant in COREMU and NDAE. The exclusion criterion selected was being on a health certificate or away from the PRMS during the data collection period. Thus, of the representatives of collegiate bodies of the PRMS, all responded to the inclusion criteria, totaling seven participants.

Data production was developed, as proposed by the AI, through the 4D Cycle, which is composed of four phases, namely: Discovery, Dream, Design, and Destiny [21]. These phases were developed from July 2017 to February 2018 through discussion groups and individual semi-structured interviews, as shown in the table below (Table 1):

Phase Objectives Technique applied
Discovery To identify the empowering actions of teaching-service integration developed in the PRMS Seven individual interviews and a discussion group (Mello et al., 2020)
Dream To explore the best ways to strengthen Teaching-Service Integration actions in the PRMS A discussion group
Design To plan the best possible strategies for implementing the proposals. Three discussion groups
Destiny To create strategies and support networks to implement the proposal designed in the previous phase. Two discussion groups

Table 1. Phase, objective and technique applied.

In this article, the data produced in the second phase of the research are presented. This phase was operationalized by a discussion group, held in October 2017, with a duration of two hours, coordinated by a moderator and an observer. It is worth highlighting that the discussion group took place with prior appointment of time and place and was recorded with an audio instrument, after the participants' permission. The meeting started with the synthesis of the previous phase, Discovery, which showed as successful actions of integration between teaching and service in the PRMS, the pedagogical activities carried out in the educational institution and in the health services: tutorials, preceptorship, sample of practices, assemblies, theoretical classes, team meetings, and activities with health users [10]. Subsequently, the following guiding question arose: What would be the best ways to strengthen the teaching-service integration actions in the PRMS? Other questions emerged during the meeting in order to encourage participants to think of attractive ways to contribute in the context studied, for example, asking them to imagine that these best ways of strengthening the teaching-service integration actions could become real: How would they happen? Which of their hopes became real?

Cooperider et al. [21] emphasize that this phase is a journey of mutual discovery, not an analytical journey; therefore, dreaming does not emphasize the identification of a better idea. Instead, the participants begin a journey of building together, in dialog and interaction, potential ideas to strengthen the study context, thus using the stories from the Discovery phase [10]. In this bias, this phase sought to identify strategies of agreement/participation to strengthen integration, as well as to idealize other actions of integration between teaching and service.

After the transcription and organization of the material produced, data analysis was developed according to the phases proposed by Green et al. [23]: immersion in the data, coding, categorization, and generalization of the data. The immersion of the data corresponded to the reading and re-reading of the material, enabling the researcher to establish the bases for connecting disconnected elements, providing a clearer description of the question investigated. The coding stage consisted of the process of examining and organizing the information and, subsequently, the entire data set. Subsequently, the codes were grouped, forming thematic categories and, finally, the identification of themes was carried out, being that a theme is more than a category, as it involves the description of the scope of the categories in relation to the interpretation, which was based in the complex thinking of Edgar Morin [19,20]. The choice of the complexity reference occurred because it allowed thinking about the concepts, without considering them concluded, as well as understanding the multidimensionality of the phenomena from the singularity of the possible interactions, relationships, and associations established [20].

The participants were identified with the letter R for Intern (“Residente” in Portuguese), followed by an Arabic number (R1, R2 ...). The study was conducted in compliance with the ethical aspects of Resolution 466/12 of the National Health Council and was approved under Ethical Opinion No. 2,169,380 on July 17th, 2017.

Results

Regarding the research participants, they were aged between 25 and 31 years old, being two nurses, two occupational therapists, one speech therapist, one physiotherapist, and one psychologist, four of whom graduated from public institutions and three from private/philanthropic institutions. Regarding their training experience, two had a master's degree and one had already completed an internship course in another municipality. Regarding their work experience, five had worked before joining the PRMS and two had the PRMS as their first contact with the world of work, after graduation.

The transcription and analysis of the data produced in the discussion group, related to the Dreams stage, resulted in a theme called “dreams of health interns about the teaching-service integration actions” and in two categories that are intertwined: “agreements for strengthening actions of teaching-service integration” and “idealized actions of teaching-service integration in the PRMS”.

Agreements to strengthen teaching-service integration actions

According to the participants, teaching-service integration can be strengthened with agreements mediated by employees, that is, tutors, preceptors, and managers of the PRMS, in order to assist in the construction of collaborative pedagogical practices. Among the listed dreams, they refer to the importance of knowing the health services that make up practical activities and, thus, being able to choose the field when entering the PRMS: they believe that this strategy could strengthen the teaching-service integration, since the personal/professional objectives and expectations would be aligned with those of the health teams that make up the services. This issue was evidenced because the interns went to the field through draws, without having the possibility to know the service.

I was very frustrated when I got here because I came from a Program in which I was the protagonist in choosing my field. In the other internship we had an experience that they called roaming, getting to know the services and being able to choose. (R1)

entered this field by lot! [...] When we arrived at the first day of school, they had already drawn without us seeing [...] I believe that there might have been dialog. (R6)

The studied PRMS allows interns to enter a health service and remain there during the two years of training. Due to this characteristic, the interns dream of the possibility of going through the other services that make up the Health Care Network (Rede de Atenção à Saúde, RAS) of the municipality during the training period.

Walking more through the Health System. For example, we spend about two years in a health service! So, there's no way to understand how the network works within the municipality where [the PRMS] is located. (R6)

Going through various services is good, [we] recognize what is happening at all levels of the network, manage to have a broader view of an entire context. (R7)

Research participants believe that teaching-service integration can be strengthened through dialog among peers, that is, PRMS managers and health teams, so that there is an agreement on the activities to be carried out by the interns. They also highlight the importance of the participation of interns in democratic spaces for the construction of agreements on their formative process.

So, I wonder: was it that the entrance to the internship in that service, was that team's interest? Yes or no? [...] So, dreaming about these discussions of how it happened wanting to have an internship. (R1)

We have to question the team about their interest. But, the ideal would be to have this conversation with everyone together: coordinators, teams, us (interns). All the involved thinking about mutual interest. (R3)

The participants questioned the care that must be taken with the health teams, in relation to their commitment and their responsibility with the work and training developed.

I believe that everything starts by being careful in dialog. If you're careful to show the field why to leave, if you have this relationship of responsibility for your actions and say: I'm leaving because of a training, then I give feedback or follow up a case when the person is at another level complexity of the system. I believe that is lacking. (R4)

The dreams reported in this category by the interns problematized pertinent issues to collaborate with the strengthening of the appreciative actions of teaching-service integration in the PRMS. The participants report the importance of knowing the other services that make up the health system during the two-year period of the PRMS, as well as the need for democratic dialog spaces for decisions and agreements on their tasks in the health services and care when negotiating different activities with the teams.

Idealized actions of teaching-service integration in the PRMS

In order to stimulate the imagination through dreams about strategies to strengthen the teaching-service integration actions, the interns point out possible actions that could be developed in the PRMS so as to collaborate with their educational teaching. The participants describe as essential the creation and strengthening of spaces that allow for the sharing of knowledge and for the discussion of cases related to users, especially those that provide dialog with other areas of training not covered in the Program, such as the medical. Still, even if the program is multi-professional, it is necessary to strengthen dialog between the PRMS colleagues.

There are core tutoring, for example, from nurses, basic care, but I don't talk to my colleagues in the core profession who are in the hospital. [...] Meeting spaces to dialog and listen. (R2)

A greater space for integration between the medical and the multiprofessional internships, both in classes and in case discussions. (R3)

I never met with all my colleagues, for example, all the psychologists in the Internship Program, at least once during the semester. (R4)

Also, they reflect on the theoretical classes held at the PRMS, especially on the choice of themes for discussion to strengthen the relationship between theory and practice, as well as on the methods used, in order to stimulate meaningful learning.

Vertical class doesn't work anymore, reading text doesn't work. [...] I think this is the focus of bringing what affects us in our daily lives to discuss, to make knowledge emerge, to produce knowledge, to produce other forms of care based on what really happens. (R1)

Theoretical classes have to be closer to the reality that we experience in the practice, there should be the participation of interns in the allocation of the themes of the theoretical classes. (R3)

The research participants dreamed of the possibility of revisiting the evaluation process, both from preceptors and tutors to the intern, and from the assessment of the preceptor and tutor by the intern. The interns assume the possibility of making it non-punitive, but constructive, with the active participation of those involved, with exchanges and feedback on their actions and activities.

When was there an evaluation space? When I speak evaluative, not in the sense of a score of 10, but in the evaluation that all actors sit and talk about what is being done as an internship and to question: What is sought and expected from this teachingservice integration? Democratically [...] I believe it needs to invest a lot in spaces of horizontality. (R1)

There is no effective dialog with most of the preceptors, about the evaluation we make of them. Space to favor the analysis of their practice, a discussion space. (R2)

The more participatory performance of the field preceptors, not only as inspection, but as actors in our training process. The face-to-face feedback of the final assessments by the preceptors, as a greater exchange of feedback to improve learning, not only as grades. (R3)

Still, they dreamed of the possibility of registering and sharing the actions performed by interns and other people involved in the PRMS, such as preceptors, tutors, teachers, and users; since the internship is a space rich in production and these experiences end up being lost over time, especially with the completion of specialization.

I think this memory would help to look at what has been built. Institutional support would be important to share good practices, to see what we've been doing. Think of a space for integration and publication. (R1)

That there is a way of recording these practices of the internship, to have a memory of the construction of internship in the country. You could start with the Program, even I think other programs have this, there are programs that even have an information system. (R4)

The participants dreamed of the need to create spaces for the care of interns and other actors involved in the PRMS. A welcoming environment, which enables listening and dialog, which provides a space for sharing, and which facilitates, to those involved, taking care of themselves and, consequently, taking care of the other, the collective. Still, they emphasize that there is a need to think about spaces that problematize and enable the emergence of new ways of producing care and empathy:

I bring up a question: What spaces are possible to implement so that these situations of our daily life are in the circle of dialog and that stimulate new and other ways of doing and producing care or being careful and empathetic? [...] To think of a care space. It is a care practice, an internship practice, not just for us. How can we think of integration if we are not integrated? (R1)

Regarding the preceptors and tutors, they should not only be more qualified in the pedagogical sense, but also engaged and human, especially human, to have these issues with empathy [...] to promote mental health spaces as a therapeutic group with a neutral mediator included in the workload. (R2)

All the spaces are important, I think some more than others. But, they are more theoretical questions, you know? To sit down and talk about the anxieties, this is not the case. And, I think that's why the intern gets sick. (R7)

The image below (Figure 1) presents the synthesis of the results and the interrelationship between the research findings, configuring the dreams that may strengthen the teaching-service integration actions from the perspective of interns linked to a PRMS from a Public University located in the southern region of Brazil.

nursing-health-sciences-synthesis-results

Figure 1: Synthesis of the results, Source: Elaborated by the authors, 2020.

Discussion

Edgar Morin's complex thinking allows us to envision education as a complex and multidimensional process [20]. This author warns about the countless causes of errors and illusions constantly renewed by knowledge throughout human history, which requires prudence, modesty, and method in the search for the truth. In this perspective, the practice of permanently questioning our possibility of knowing must be highlighted in any education. Protagonism, implication, and integration of those who know with their knowledge are permanent principles and needs of education. “In the search for the truth, self-observing activities must be inseparable from observing activities, self-criticism, inseparable from criticism, reflexive processes, inseparable from objectification processes” [20].

Under this perspective, teaching-service integration is instituted based on multiple aspects, as presented in the interns' speeches, who view pacts and actions in the perspective of strengthening this important strategy that aims to qualify the assistance provided to the health system user. Regarding the agreements to strengthen teaching-service integration actions, a number of authors highlight the importance of agreements in order to not only enhance the control of the outcomes, but also to provoke the people involved to discuss the intentions, the aims pursued in the process. Such agreements favor consequent and responsibly negotiated decision-making processes in favor of learning [24]. In addition, they highlight the importance of agreeing on spaces, schedules, and technologies to adapt service activities and educational practices [4]. Thus, it is necessary to pay attention so that the agreements are not based on private negotiations, that is, only between coordinators and managers [4,24]. It is to avoid “private” contracts, that participation beyond interns, health teams, service professionals, and users in discussions involving teaching-education is essential [4,25].

The dreams of the research participants involved the expansion of democratic and dialogical spaces, meeting what was evidenced in the studies cited. Thus, it is considered pertinent that the people involved in the PRMS have spaces to talk about the possible activities to be developed and to elaborate collective agreements, since everyone has the right to create, express, and share their own visions, especially because learning can be strengthened in the creation of shared meanings and dreams [26].

This same sense applies to the interns' autonomy of choices in relation to the health services, as well as the possibility of them having experiences in the different RAS services for the development of activities during their training process in the PRMS. In the Brazilian reality, other PRMSs are organized in different ways, for example, in the Internship Program linked to the Federal University of Pará, the performance of multi-professional interns occurs at the three levels of health care, interspersing them, namely: in promotion, prevention, and treatment and rehabilitation [27]. Regardless of the way that the programs find to organize and comply with the proposed objectives, there are different feelings that will produce a greater or lesser degree of well-being or discomfort in the face of that reality [28].

A pressing factor in this bias is to have clear strategies that can work as a support for interns, especially their path in the transit between the RAS networks, the main objective of the PRMS [17]. A number of authors report that a strategy that has helped in this process is the Training Itinerary, which discusses, among other aspects, the choice of the internship location, a process subsidized by field visits to learn about the services and by a group negotiation of these choices. In this PRMS, the interns stay one year in the same service and use this negotiation-choice project to foster reflections and strengthen them in the difficult moments of their experiences [28].

Regarding the idealized actions of teaching-service integration in the PRMS, the participants list a series of strategies that can assist in this relationship between the health teams, as well as the relationship between theory and practice and the collaborative and interprofessional work between colleagues and other members of the health team. Inter-professional collaboration can be explored in expanded spaces, as well as in sharing experiences from the PRMS practice with other colleagues at local, regional, national, and international levels. A number of studies point out the importance of interprofessional collaboration as a way to strengthen positive aspects such as autonomy, resilience, friendliness, and openness [29].

This aspect is problematized by Morin [20] when bringing the importance of mutual understanding, since it is a “means and an end” for human communication. To this end, the focus on education must concentrate on the quality of communication, in which dialog and a commitment to listen and understand are priorities. This element is considered fundamental when addressing the teaching-service integration, especially because it implies understanding among people from different organizations, such as universities, health services, community, and management bodies. For that, it is necessary to listen to the other from a mutual interest in the relationships to be established [27].

In addition, strengthening the theoretical classes can be a powerful way to promote dialog and to contextualize information and knowledge. For this, it is necessary that it enables pedagogical practices that understand alternative ways of connecting theoretical knowledge to reality, especially for considering the different learning styles [27]. It is in this sense that Morin [20] problematizes learning fragmented into disciplines, since education must encourage the general aptitude to explore, learn, and critically think about the multiple aspects and fundamental problems of reality, historically and socially contextualized. For Morin [20], “the separation of the disciplines makes it impossible to learn 'what is woven together', that is, [...] the complex”, as it causes loss of essential skills to contextualize knowledge and integrate them in their sets.

The weakening of the perception of the global leads to the weakening of responsibility (each person tends to be responsible only for their specialized task), as well as to the weakening of solidarity (each person no longer feels the bonds with their fellow citizens) [20].

Morin [20] highlights that, to understand human complexity, it is not enough to put different aspects of reality side by side, like pieces of a puzzle, but it is necessary to know how to unite them. In this sense, the performance of interdisciplinary research can contribute to the promotion of interest and openness to dialog by experts from different disciplines; however, it is not sufficient for the necessary integration of knowledge in the perspective of complex thinking. It is necessary to articulate different knowledge based on transdisciplinarity, which allows for the knowledge of the parties to be combined with the knowledge of the totalities, making the interaction between different ideas and individuals fertile and producing new possibilities of perceiving and intervening in the complex and multidimensional reality [20].

The PRMS can be a powerful way to collaborate with the contextualization of knowledge and to integrate it according to the reality of health and current public policies [5,18] . This also happens for evaluative processes. Evaluation can be a necessary moment for educational teaching, being a powerful space for reflection. There is evidence to show that this is a time when human beings can rethink their actions, not only with the context as a whole, but also with peers and with themselves. Thus, evaluations can assist in decision making, either through the identification of problems, as well as through the recognition of qualities and potential [19]. The pedagogical choices to be made in the evaluation process can be a way of strengthening the commitment to teaching-service integration, especially if they develop a more conscious, critical, and reflective approach to the choices, decisions, and actions carried out in the PRMS.

For this reason, there is an urgent need for evaluation to be a permanent and collective process that strengthens, above all, the ethics of understanding, since it is necessary to argue, not to accuse or condemn, since we are all susceptible to weaknesses and errors, that is, “if we know how to understand before condemning, we will be on the path of humanizing human relations” [20]. Through a process that seeks understanding, the other is not perceived only objectively, but as another individual with whom we identify and who we identify with us. Understanding - always intersubjective - implies processes of empathy, which requires openness, sympathy, and generosity [20].

Also included is the dream of the participants in the construction of spaces for the care of interns and others involved. It is in this context that it is necessary to reflect on the synergy maintained between the different life stories that circulate through the system, be them professional or personal, but which are not characterized only by signs and symptoms of a disease or by the planning and management of services. The subjective and sympathetic openness towards the other needs to be essential in all education [20], here considering the context of the PRMS. Spaces that strengthen mental health care or that will nurture love, sensitivity, and affection make those involved feel cared for and belonging to something special [27].

It is in this sense that a number of authors highlight the importance of articulating training and care processes, seeking to articulate teaching and service, and to encompass aspects that address subjective issues of training [30]. By continuing with this thought, the predominance in the health area of teaching centered on procedures is recognized, moving away from the expanded logic of health, which seeks not only the production of technical-scientific skills. Therefore, it is necessary that there are opportunities for teaching to raise issues that stimulate dealing with life, with emotions, that promote respect for human beings and the individuality of people [20], thus reflecting integral care for oneself and for the other.

Limitations

t is recognized that, as a limiting factor of this study, there is the delimitation of the context performed in a PRMS of a Public University, located in the south of Brazil, and for that this modality still being restricted to the Brazilian region, which hinders articulating the findings with experiences from other countries. Also, the small number of participants in a focus group that can influence the data collection process.

However, this study can contribute to the production of PRMS in other locations, as well as to the analysis of learning processes, with a view to discovering the potential in these spaces, reviewing the work done collectively and dreaming of possibilities that can strengthen inter-professional and collaborative practices, enhancing the teaching-service integration actions and taking into account the local and regional characteristics of each service; also as a way to influence other countries to offer programs aimed at professional training in public health, with a view to strengthening the teaching-service integration.

Conclusion

This article presents an innovative methodological process, based on the AI, with a view to strengthening a practice that already occurs in the PRMS, in order to enhance it. There are several dreams that can strengthen teaching-service integration from the perspective of interns linked to a PRMS, especially those related to agreements and actions that provide collective and democratic dialog, in order to build reflective, critical, and shared knowledge. From an appreciative perspective and based on complex thinking in relation to the teaching-service integration, the participants' dreams were considered essential to problematize the improvement of the educational teaching offered in the PRMS, especially aiming at the quality of the relationships among peers.

Acknowledgments

This study was financed in part by the Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil, CAPES) - Finance Code 001.

Declaration of Conflicting Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

References