Compreendendo o princípio de integralidade na visão de discentes da graduação em enfermagem

Este estudo objetivou investigar o conhecimento apreendido pelos discentes do 9o periodo da Graduacao em Enfermagem da Universidade Federal do Rio Grande do Norte sobre o conceito de integralidade do Sistema Unico de Saude. METODOS: Trata-se de uma pesquisa qualitativa, desenvolvida no Departamento de Enfermagem. O publico foi composto por 26 discentes do ultimo periodo do curso. Para coleta das informacoes, utilizou-se um questionario contendo perguntas abertas, preenchido apos consentimento dos participantes. A interpretacao das informacoes seguiu a analise tematica de conteudo segundo Bardin. RESULTADOS: Os alunos mostraram ter uma formacao adequada sobre o conceito de integralidade, descrevendo um bom aprendizado teorico, bem como as caracteristicas essenciais do principio. Entretanto, ainda ha lacunas no que se refere a uniao do fazer teorico e pratico. CONCLUSAO: Os docentes poderiam investir na metodologia de ensino que articula teoria e pratica, o que auxiliaria a aplicacao do conhecimento teorico nos servicos de saude.


INTRODUCTION
In contemporary times, the formation processes in undergraduate courses have facedconstant transformations, accompanying the social changes and changes in the epidemiological profile of health problems.These changes are mostly of a paradigmatic nature, covering both the practical and political aspects regarding the health and education systems 1 .
In the practical context of the healthcare systems and services, there is a change in the model of care, which transferred from the hegemonic, focused on the disease, to a model of social production of healthcare.According to law 8080/90, the principles of the Brazilian National Health Service (SUS) are universality, integrality and equality, which were strongly expressed in the Brazilian Health Reform ideals.Issues relevant to the health of society, ensuring citizenship and health as a right and duty of the Stateare explicit in these concepts 2 .
With the regulation of the SUS discussions were intensified about the formationof professionals in the healthcare context.The implementation of this system has brought many changes in the healthcare practice, which have resulted in significant alterationsin the process of formation and development of the professionals.In this case, care geared toward the principles of the SUS has been adopted as the teaching focus 3 .
Thus, in order to direct the formation processof professionals and make them able to act in this new system, the Curriculum Guidelines of Undergraduate Healthcare Courses was instituted, which focuses on the general and specific formation of graduates/professionals with emphasis on disease prevention, and the promotion, recovery and rehabilitation of health 3 .However, the graduation of nursing students, as well as the other areas of healthcare, is only slightly oriented toward an integration between education, work and citizenship.In such cases, the focus is on a theoretical-conceptual and methodological formation which does little to enable the interaction of theory and practice.Even with advances in the theory of thinking in healthcare,grounded in the principles and concepts of the SUS, there are still major challenges forthe formation and insertion of professionals with a viewgrounded in these concepts and, consequently, the implementation of education-service integration actions 4 .Due to this problem, the new healthcare model, and the new curriculum standards aimed at the union of constitutive and constituent knowledge through practices with the potential to overcome the education and services models that focus only on technical procedures.Thus, the adoption of a both biological and sociocultural approach is proposed, focusing on the care of the individuals, aiming for integral healthcare 2 .
With regard to the healthcare, this is represented as a challenge that directs the discussions that are being held regarding the transformation of the work process and also regarding the rearrangement of the professional formation methods in healthcare.Nursing is one of the healthcare professions in which the essence and specificity is the care for the human being, individually, or in the family or community, developing activities of disease prevention, health recovery and rehabilitation, working in teams 4,5 .In this sense, we can classify and qualify the care as a political device of integrality, this being one of the guiding principles of the SUS that treats the user as an indivisible whole inserted in the community.Furthermore, this definition encompasses the units providing services with all their levels of complexity, addressing the needs of individuals in a broad way 4,6 .Thus, the pursuit of a practice based on the principle of integrality, i.e., seeking integral health, should be included in everyday formation of these professionals.
For some nursing students, however, it becomes difficult to exercise critical thinking in their practices due to the persistence of the traditional model, which is focused on the professor.Furthermore, the fragility of integrality of the educational process, the gap between theory and practice, and the lack of articulation of the curriculum between teaching, research and extension projects influence the learning process of the students 7 .
Given the importance of the concepts regarding the nursing formation process emphasizing the concept of integrality of the SUS, this study aimed to investigate the knowledge acquired by undergraduate Nursing students of the Universidade Federal do Rio Grande do Norte concerning the concept of integrality of the Brazilian National Health System.Thus, it is hoped that this articlecan contribute to the improvement of the disciplines of the nursing course, seeking new ways of teaching, comprehending the current structure of the services.

LITERATURE REVIEW
To provide the theoretical basis for this study, a literature review of the narrative type was carried out.The databases of the Latin-American and Caribbean Center on Health Sciences Information (LILACS) and Scientific Eletronic Library Online (SciELO) were used, crossing the descriptors "Professional Practice" and "Health Care" registered in DECS and books by experts on the subject of care models and integrality.Data collection occurred from August to October 2011.One article and 4 books were identified, which were read in their entirety and analyzed descriptively.

Integrality from the view of students
The principle of integrality and the care models.
The care model is a way to organize and combine the healthcare actions in a given society, encompassing technological, care, and human aspects.In Brazil, various health models have been developed throughout history, however, with the implementation of the Brazilian National Health System (SUS), several strategies were introduced to change the hegemonic model focused on the disease 8 .
It is understood that this paradigm shift must be performed in a procedural and dialectic way, in view of the existing contradictions regarding the contextualization of the social, political, economic and cultural dimensions, on which the SUS is based.In this sense, to progress in the consolidation of this system suggests the demand for new mechanisms, which help in overcoming difficulties intrinsic to the social reality.One important aspect that guides the above context has been the construction of healthcare models that facilitate the solidification of the principles of the SUS 9 .
In this context, it is understood that, for the improvement of the care model according to the SUS recommendations, the articulation of the technical, care, and human resources is essential in order to implement the constructional principles and guidelines 10 .However, there are difficulties in adapting the care model to the principles of the SUS with greater integrality of the practice.
These guidelines consist of the right that society has to receive care according to the grouping of the needs and the duty of the State to develop healthcare services organized to meet the demands of society in an integral way.It is understood, therefore, that the SUS must meet the needs arising from the different levels of care through health promotion, recovery and rehabilitation, and disease prevention actions 6 .
In addition to directing actions that will satisfy the needs of health promotion and restoration, integrality raises the debate on how to shape the supply of services, establishing the multidisciplinary articulation and the different levels of care complexity.In a complementary way, integrality also directs the continuity of care provided, through monitoring by the referral and counter-referral system 11 .
Despite some care models remaining intact, a new care and management strategy is emerging in the SUS, as well as in the formation of healthcare professionals, particularly with regard to the healthcare praxis.This requires the adoption of dynamic and sensitive strategies to the social determinants and conditioners 9 .

METHODOLOGY
This was an exploratory and descriptive study with a qualitative approach, developed in the Nursing Department of the Universidade Federal do Rio Grande do Norte (UFRN).
A total of 26 undergraduate students participated in this study (with 38 students constituting the class) of the final semester of the nursing course of the institution.This number of participants was considered sufficient, due to the saturation of the content of their messages.The inclusion criteria established were: to be attending the final semester of the UFRN undergraduate nursing course and to agree to voluntarily participate in the study.
To collect the information, a questionnaire with open questions was used, allowing the informant to respond openly to questions using their own language.This instrument was guided by a script composed of open questions that focused on the understanding of the students concerning the concepts of integrality and how this is applied by them in the practice.
Before completing the questionnaire, the participants were informed about the purpose and aim of the study, as well as the voluntary nature of their participation and the anonymity of the information collected.On receipt of this information, and after agreeing to participate in the study they signed the Terms of Free Prior Informed Consent (TFPIC), in accordance with Resolution 196/96 of the National Health Council regarding research with human subjects.It should be noted that, prior to the data collection process the project was approved by the Research Ethics Committee of the Universidade Federal do Rio Grande do Norte, under protocol number 333/2011 and CAAE 0161.0.051.000-11.The completion of the questionnaires was carried out in the months from September to December 2011, in a private room in the UFRN Nursing Department.
The responses were read thoroughly and, after identification of units of meaning, coded according to content analysis, in the form of thematic analysis, according to Bardin 12 .The analysis and interpretation of the information were carried out based on the healthcare model.

RESULTS AND DISCUSSION
The method adopted allowed the results obtained to be listed in three thematic categories: perceptions of the students regarding integrality; convergences and divergences between theory and practice; and applications of integrality from the experiences of the students, which will be discussed below.

Perceptions of the students regarding the integrality
Integrality was expressed as a concept of conformity to the SUS, as explained below:

Integrality corresponds to being and all its complexity, considering the particularities of each person, i.e., each one according to their needs, including the different levels of complexity (Student 21).
Teixeira GB, Silva CA, Teixeira LB, Monteiro AI

Self-explanatory. As the individual is indivisible, promotion, prevention, rehabilitation, and curative actions should be integrally provided by the system (Student 16).
According to the Organic Health Law, integrality is understood as the articulation of preventive and curative, individual and collective actions and services considering each case and according to each level of complexity of the system 2 .This principle opposes the fragmentation and reductionism of the subject while observing the health risk factors, not restricted to curative actions 10 .
It should be noted that integrality is a principle that seeks to give support to the healthcare users, assuring them of actions that include promotion, prevention, treatment and rehabilitation, and guaranteeing access to all the levels of complexity of the Healthcare System 7 .
It is clear that the respondents comprehended the essential concept of integrality, seeking to contextualize the healthcare service as an indivisible whole in relation to the units that provide services at all the levels of complexity.Furthermore, they understood that the actions provided cannot be compartmentalized, representing a system capable of providing integral care focused not only on the disease but also on the health of the user 8 .
In this context, healthcare policies must support universal and equal access in their constitution, in the context of both preventive actions and care actions, taking into account that one of the meanings of integrality focuses on the relationship between these two types of actions, aiming for integral treatment with an emphasis on prevention without neglecting the care 8,11 .This new view of health is understood as a criticism of the traditional curative medical model, in which there is a fragmented practice in the treatment to the user.This care model did not have the association of public health with care practices and collective actions with individual care based on expertise within its scope, which reduced the suffering and the condition of the patient to merely the biological aspect 8,9 .
The traditional model of formation, the so called biomedical, was based on a Cartesian view of body and mind, thus eliminating the psychological, social and environmental aspects from the health-disease process.Thus, the person was seen as an object of study, a consumer of technology and manipulated by disciplines such as chemistry, physics or botany.The professionals were induced to the reductionism of the individual toa biological being and the physicians to simple providers of services 8 .
Given the context of reformulating the healthcare model, it should be noted that the concept of integrality can not be reduced only to the access of the population to the different levels of healthcare complexity, or to actions directed towards promotion, prevention, rehabilitation, and treatment, because integrality depends on other concepts for its realization 13 .
These include the concept of the re-signification of the role of the users, valorizing them within the system, from the moment in which the patient is established as an important part in the clinical diagnosis to the understanding of the health-disease process and to a possible intervention considering multiple determinants 9,13 .
Thus, it can be observed that, in addition to the medical-biological, the disease process has links with the life history of the individual, the family and society, with manifestations of the internal recollection caused by suffering and affliction from pain in every culture.In this study, this view was seen in the response of 24 students, who contextualized the concept of integrality as a holistic view of the individual, starting to see the person as a whole in their social, cultural, biological and environmental context: To me, integrality means considering the individual in their totality, in all the aspects that relate to their life (socioeconomic, biological, cultural) (Student 1).

Integrality consists of treating the individual holistically, considering the person to be inseparable, having their health closely linked to their biopsychosocial conditions (Student 5).
The word integrality in Greek hole ousia means to be healthy, i.e., being complete and healthy constitutes the reference for health.The disease and awareness of it, present conditions that are not restricted to the environmental aspects, but also extend to cultural and social relationships and also to the subjetivities 10 .
In this sense, integrality is a value to be sustained and defended in the practices of healthcare professionals, who, faced with the patient encounter, seek the dismissal of the reduction of the individual to the biological system of what is supposedly producing the suffering, i.e., to objectively see the patient as a whole 11 .
It should be noted that integral care aims for a service provision focused on the needs of individuals in a broad way, making it into an important axis for the construction of the SUS and likewise configuring it as a challenge in the construction of the system 6 .
With this, integrality aims to transformatively expand the availability of the care, centered on the individual, pursuing care focused on the idea of the totality of the subject.Thus, it tends to provide care for the organic, emotional, social, and spiritual aspects involved in the Teixeira GB, Silva CA, Teixeira LB, Monteiro AI Integrality from the view of students disease process of patients within a social context, giving less emphasis to the use of technology and more to restoring the vitality of the patient or the group 10 .This reflection is clearly addressed in the following discourses:

It is the view of the individual as a whole viewed in their biopsychosocial and environmental aspects (Student 6).
To see the person as a whole.To consider that they are embedded in a family context, that they occupy a certain position in society, that they have certain economic resources and so forth (Student 12).
The healthcare services must be prepared to carry out a broad search to establish the needs of the population that they attend, adopting the best possible ways to respond to the social needs 4 .
It is worth considering that the concept of integrality, as well as humanization and acceptance, are strongly interconnected to the quotidian of the healthcare services.Thus, it becomes impossible to perform integral practices without thinking about humanization in the care and acceptance directed towards the valorization of the subjectivity and citizenship of the user.This factor makes it possible to overcome the simple care and the access to medication, being situated mainly in the integrality of this care and respect for the rights of user 6,11 .
Given these contexts, it was observed that the students of the undergraduate course in nursing had an adequate formation in the concept of integrality, despite the different nuances presented.The responses expressed the theoretical teaching of the course curriculum, as well as the essential characteristics of the principle in question.

Convergences and divergences between theory and practice
Currently, a major governmental concern is with the professional formation courses, as the implementation of new care proposals in the healthcare sector necessarily impacts in the formation and training of professionals, not only preparing them technically, but also training them to meet the health needs of the person and the population 13 .
In this sense, the operationalization of the SUS has been much debated in the country with regard to the formation in healthcare, with the main issue being the gap between the formation of healthcare professionals and the practice expected in the services.Thus, for there to be qualified work, it is necessary that the principles and guidelines of the SUS are shared and exercised by the professionals working in the services in order to meet the healthcare needs of the population in the different levels of system 13,14 .
When asked about the opinions of the students regarding the interface that exists between theory and practice in the services regarding the concept of integrality, in order to know if there really is this exchange within the teaching-learning process, 23 students presented positive ideas regarding the subject, as evidenced in statements below: Throughout the undergraduate course we were encouraged to put into practice the concept of integrality, especially during the nursing consultations, either in the FHS, or in the hospital, the patients were always seen in their integrality, considering not only their main complaint, but their state of health as a whole (Student 24).
Several authors share the same idea, when they say that, in the context of healthcare transformation, the roles of the professionals have also been reinterpreted for primary healthcare.The new healthcare policy requires that a healthcare professional, as well as acting as a service provider with the actions of healing and rehabilitation, also actsto adequately achieve the SUS principles in the daily practice 13,15 .
The above factor enabled the emergence of a new curriculum model, which aims to train a professional with generalist, critical-reflective qualities 7,14 .Therefore, nurses should consider, in relation to their thinking and knowledge, the contents of biological and human sciences, gradually incorporating education, health promotion and disease prevention into their actions.These changes are backed by the new pragmatic vision under construction in the healthcare sector of the country, through the change in the concept of healthcare and in healthcare guidance combined with the social and environmental context 9 .
This new curriculum model also requires nursing students to act as agents of the teaching-learning process and participate in the effective construction of the Pedagogical Political Projects.Thus, the students would no longer be passive subjects and would collaborate with the transformation of the reality, valorizing them as holders of knowledge where they collaborate in the implementation and evaluation of the pedagogical proposal 15 .
Thus, it can be noted that the healthcare professionals, specifically those of nursing, must always work putting the theory and practice in harmony, not only regarding the concept of integrality, but with all the principles and guidelines of the SUS, so that they can exercise a quality care practice aimed at increasing the welfare of the population 4,7 .
From the moment that the students seek to act guided by these principles, it becomes necessary for the Teixeira GB, Silva CA, Teixeira LB, Monteiro AI Integrality from the view of students professors to interfere in this process leading their students to reflect on the subject addressed in the classroom and on the best way to apply the theory in the practice.Thus, attempting to promote the formation of professionals with the potential for the analysis of situations that may arise in their work environment, seeking to develop critical-reflective nurses 4 .
With regard to the professional formation, there is a fragmentation of the disciplines and of the curricula, which complicates the interdisciplinary in the education.There is compartmentalization between disciplines and the overall problems, simplifying issues that are complex and multidimensional.Thus, a substitution of disjunctive and reducing thought for complex thought should occur, that is, thought that distinguishes and unites 16 .
However, in this study negatives points were found related to integrality in the theory and practice interface.The students stated that professors do not always relate these two points, nor were they seen together in the practical training field, as seen in the following statement: It is not seen in the practice.Unfortunately, the way our curriculum is organized does not make the practice possible.Failure to use the referral and counter-referral in the healthcare services also causes this (Student 21).
The higher education nursing courses, even after going through major curricular changes, do not promote specific changes in the professional healthcare practices, since the teaching activity does not follow the philosophical and methodological assumptions of overcoming the traditional pedagogy, in which there is the biomedical-technical model in the nursing practice and in the healthcare services 17 .
Thus, this view of integrality as care provided to the individual as an indivisible whole, despite always being part of the nursing discourse, is not expressed in the practice due to the fragmentation and maintenance of the Cartesian model of knowledge prevalent in the healthcare field 17 .
Moreover, this failure occurs largely in the formation of the nursing students, who, as professional in the day-to-day, present difficulties to operationalize the concepts of integrality and the current focus of Collective Health as action in the services.This occurs due to the presence of the dichotomization between theory and practice within the teaching-learning process of the higher education courses in Brazil, as well as due to the lack of reorientation of the formation, based only on the technique, for a critical view 6,11 .
The current elementary problem is the lack of stimuli for the perception of the multidimensional factors (such as culture, economics and politics), for the links within a system.Therefore, it is necessary to redefine the rationality, promoting new thinking concerning the social and/or health-disease processes existing in the quotidian 18 .
Faced with this context, the need can be seen to reformulate the role of the professor and nursing students regarding the Pedagogical Project of the undergraduate course.This could create methods for articulation between the construction of practical skills of the students and the theoretical knowledge, especially as regards the field classes, preparing the undergraduates to deal with the reality of the social dynamics and production of the healthcare services 15,17 .
However, traditional teaching models adopt a technique which is dissociated from the social healthcare practice in which the technical-operational development is valued at the expense of critical reflections that cover the social, emotional, manual and ethical dimensions.This factor emerges as a challenge for the educational process, reiterating the need for the proximity of the academic world with the world of work 4,8 .It there fore appears that the knowledge acquired in the practical activities developed in the healthcare services constitutes the building blocks for knowledge and revaluation of already solidified understanding.The healthcare formation is being widely debated in view of the need to become closer and be more consistent with the healthcare needs of the population 4,7 .

Applications of integrality in the experience of the students
From the answers of the respondents, all had knowledge of the principle of integrality that, together with the other principles, governs the SUS.In this study, the students reported that the principle was applied in the quotidian of their practical training, as seen below: This was very well exercised, I specifically remember the first contact in primary care, where the professor insisted, during the consultations with the children, that we evaluate the social context of the children and what factors might affect their physical and mental health (Student 06).
Yes, in the practical training I sought to care for the pathological aspect, the clinical condition of the client, as well as for the subjectivity, the opinion about treatment, the fears and expectations of the user (07 Student).
We can observe that, despite some flaws in the development of the curricula and in the teaching-learning process, as cited by a minority of students in the previous category, they managed to provide qualified care to the user, focusing very well on the context in which the Teixeira GB, Silva CA, Teixeira LB, Monteiro AI Integrality from the view of students individual was inserted, as well as the biopsychosocial side.This perception shows that the students understood one of the true meanings of integrality, which puts the human being as an indivisible whole, and managed to insert the individual into a collective, social and family view.
The teaching of integrality can have its difficulties overcome or reduced if the traditional way of teaching, based on theory, practice and reproduction, is overcome.This is justified by the concept of integrality permitting different ways of articulating knowledge and healthcare actions to be identified in the concrete practical situations, forming a complex, opening opportunity to learn and to develop activities for the health of groups of humans or individuals 4 .
This view of integrality implies assisting the patient beyond the disease that motivates their suffering, meaning developing an action that takes a comprehensive look at the health needs of the subjects 11 .However, it is known that the integrality concept is much wider, seen in various nuances: in the levels of complexity of the SUS, primary, secondary and high complexity healthcare; and in the indivisible service, to provide the patient with resolutive care, focusing on care activities of health promotion, disease prevention, treatment and rehabilitation of the individual.With regard to the scope of these two meanings of integrality, only two students put forward responses to its applicability in the practical training fields: During the practical training I could implement Integrality in the nursing consultations, through the practice of care with a wide and integral approach, making referrals when necessary, as well as referring to other services (Student 14).

I advised the patients to carry out disease prevention, I told them about health promotion and when I needed to I referred them to the physicians and specialists, in order to perform more integral care (Student 11).
It was noticed that, in general, the students understood the meanings of integrality and knew how to apply it in practice.However, a deficit of these actions was observed when not all the meanings of integrality were found together in the knowledge of a single student.Thus, the knowledge was found to be fragmented in the responses, having to unite them to provide a broad meaning of the principle in question.
The field classes, which aim to teach the care, support the learning of integrality, they help the students to understand it, and collaborate in the understanding of knowledge and techniques that students can use in the care to the client.However, this principle is not adopted as routine in the quotidian healthcare practices, as the difficulty of teaching the concept of integrality does not derive from the difficulty of conceptualizing it, but from practicing it 4 .
The ability to demonstrate the articulation of the existing interactions with social problems depends on the teachers, whether in the situation of an individual consultation or from the perspective of bringing the students to the exploration of the dimensions and plans in other spaces of healthcare construction 4,15 .
Given the above, a person who has the ability to unite and solidify the separate fragments of knowledge, to conceive the set and does not focus on the particular, would be able to provide a sense of responsibility and citizenship, therefore favoring existential, ethical and civic consequences 16 .
It therefore becomes necessary to further contextualize the SUS principles in the teaching-learning process.This can be achieved through interventions in the form of teaching, in which professors focus the learning on practical application without undervaluing the theory presented in the classroom.In addition, students can be encouraged to seek extracurricular knowledge, whether in books/articles or with the people involved in the work context in which they are included, undertaking practical training to be able to contribute to the services more effectively.
Only one of the respondents said that integral care was not fully inserted in their fields of practical training, due to not visualizing the opportunity to apply this concept as a student, since most of the time, the individual felt constrained by deadlines and practical performance at that moment, having no view of the continuity.
Integral care involves changes in the power relationships between health care professionals in pursuit of the establishment of a multidisciplinary team, as well as changes in the relationship between the professional and the service users aiming to effectively increase their autonomy 15 .Without the existence of a critical and expanded formation, the healthcare worker cannot truly comprehend health as a social production, nor the complexity of their acting from qualified listening, through the needs of the population 17 .

FINAL CONSIDERATIONS
Integrality, regarding its benefits and meanings, has still not yet gained the generalization or visibility necessary for this principle to be included in the formation and practices of all healthcare professionals.Thus, it becomes imperative that the healthcare services and professional formation institutions incorporate complete and contextualized care, in order to achieve integrality in its amplitude.
It is believed that it is not good enough to only carry out the reform of the curricula of the nursing courses Teixeira GB, Silva CA, Teixeira LB, Monteiro AI Integrality from the view of students without changing the way of thinking and acting of the teachers and students, contributing to a quality praxis.In this way, all teachers could invest in teaching methodology that combines theory and practice, using pedagogical dynamics in their classes that bring students together and recognize them as active subjects in the learning process.Furthermore, integration between the healthcare services and universities is necessary, in order to bring the students closer to reality and to establish learning strategies which promote dialogue and the exchange of experiences between the formal and informal fields of knowledge.This may contribute to the implementation of this concept in the professional practice, impacting in the acquisition of skills to meet individual and collective needs.
It is worth highlighting that this study was hampered by the lack of studies related to the application of the principle of integrality in the formation of the nurse.This factor indicates the need for further studies to be developed on the subject.It is considered that, for the production of care in the undergraduate course, the faculty, students and user of the SUS triad is important.Given the above, it can be seenthat the adoption of changes in the formation process of the nurse can contribute to having professionals qualified to meet the requirements and subjectivities of the population.