Critical Review

The use of active methodology in

nursing care and teaching in national
productions: an integrative review*

The use of active methodology in nursing care and teaching in

national productions: an integrative review

Utilización de metodología activa en la enseñanza y atención de

enfermería en la producción nacional: revisión integradora
Fernanda Ribeiro Sobral1, Claudinei José Gomes Campos2

Abstract Resumo Resumen

The objective of this integrative review Esta é uma revisão integrativa de literatura Esta es una revisión integradora de litera-
was to identify and analyze the scientific cujo objetivo foi identificar e analisar pu- tura, cuyo objetivo fue identificar y analizar
publications regarding the use of active blicações científicas sobre o uso das me- publicaciones científicas sobre el uso de
methodologies in nursing care and tea- todologias ativas no ensino e assistência las metodologías activas en la enseñanza y
ching in Brazil. The survey included natio- de enfermagem no Brasil. O levantamento atención de enfermería en Brasil. El releva-
nal publications, from 1999 to 2009, using bibliográfico incluiu publicações nacionais, miento bibliográfico incluyó publicaciones
the following databases: LILACS, BDENF, no período de 1999 a 2009. Foram verifica- nacionales, en el período de 1999 a 2009.
MEDLINE and SciELO. A total of 28 articles das as bases de dados LILACS, BDENF, ME- Fueron verificadas las bases de datos LI-
were selected. The results and analysis DLINE e a biblioteca eletrônica SciELO. Fo- LACS, BDENF, MEDLINE y la biblioteca elec-
pointed to problematization as the primary ram selecionados 28 artigos. Os resultados trónica SciELO. Fueron seleccionados 28
active methodology used, the lack of theo- e a análise mostraram a problematização artículos. Los resultados y análisis mostra-
retical frameworks to plan the pedagogical como a principal metodologia ativa utili- ron a la problematización como la principal
action, and the excessive use of teaching zada, a falta de referenciais teóricos para metodología activa utilizada, la falta de re-
techniques that do not always characterize planejar a ação pedagógica e o uso exces- ferenciales teóricos para planear la acción
innovation. In conclusion, the implementa- sivo de técnicas de ensino que nem sem- pedagógica y el uso excesivo de técnicas
tion of innovative methodologies requires pre caracterizam a inovação do método. de enseñanza que no siempre caracterizan
further studies and more investment in Conclui-se que a implementação das meto- la innovación del método. Se concluyó en
research and dissemination on the subject. dologias inovadoras ainda carece de mais que la implementación de las metodologí-
estudos e necessita de maior investimento as innovadoras aún carece de más estudio
em pesquisa e divulgação sobre o assunto. y son necesarias mayores inversiones en
investigación y divulgación sobre el asunto.

descriptors descritores descriptores

Education, nursing Educação em enfermagem Educación en enfermería
Learning Aprendizagem Aprendizaje
Problem-based learning Aprendizagem baseada em problemas Aprendizaje basado en problemas
Nursing care Cuidados de enfermagem Atención de enfermería

* Extracted from the End-of-Course Monograph “Utilização de metodologia ativa no ensino e assistência de enfermagem na produção nacional: revisão
integrativa”, Nursing Department, Faculty of Medical Sciences, University of Campinas, 2009. 1 Nurse, graduated from the Nursing Department, Faculty
of Medical Sciences, University of Campinas. Campinas, SP, Brazil. [email protected] 2 Ph.D. Professor, Nursing Department, Medical Sciences
Faculty, University of Campinas. Campinas, SP, Brazil. [email protected]

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in nursing care and
/ Inglês
2012; 46(1):202-11 Approved: 05/12/2011 teaching in national productions: an integrative review
www.scielo.br/reeusp
www.ee.usp.br/reeusp/ Sobral FR, Campos CJG
 Introduction form their context. To do this, it is important to adopt ped-
agogical concepts that bring theory and practice closer
Historically, the education of health professionals and pose problems of daily nursing work situations(1-2,6).
is based on the Flexner model of medical courses, that Therefore, it is noticed that political attempts have
emphasizes on biological aspects, fragments knowledge, been made towards adopting innovative teaching strate-
enhances the theory-practice dichotomy, and disregards gies – also referred to as active methodologies (AM)(8-9),
the needs of the Brazilian national health system (Sistema thus confirming the idea that the search for knowledge
Único de Saúde – SUS)(1-2). in nursing should bring healthcare practice and education
Similarly, there is still a broad use of traditional teach- closer, considering that nurses use the teaching-learning
ing-learning methodologies in the education of health process in every healthcare action they perform. This
professionals. The highlights of these education models, requires professionals to constantly review their actions
which Paulo Freire referred to as banking, are the teacher- and perform any planning always based on reality, which
student knowledge transfer, an excessive valorization of means it is necessary to encourage and adjust educational
technical education, and the dissociation between the practices(10-12). It should be stressed that, in this active pro-
theoretical knowledge that is received passively by the cess, the work of the educator is not the only determinant
students and their social context(3-5). factor for those methodologies to be successful: students
must also become autonomous and responsible for their
In the 1980s, it was already noticed that professionals own learning(13).
lacked preparation to work in the health area because of
the discrepancy between their education and The active methodology (AM) is an educational con-
the reality of their profession . There was a
(6) cept that encourages critical-reflexive
growing mobilization of educators seeking a teaching-learning processes, in which stu-
...it is noticed that
critical-thinking education with a view to so- political attempts have dents participate and are committed to their
cial transformations. Among those analytical learning. The method proposes the elabo-
theories, the liberation pedagogy or problem-
been made towards ration of teaching situations that promote
posing was developed, with emphasis on the adopting innovative the students’ critical-thinking regarding the
educational model proposed by Paulo Freire, teaching strategies reality’; a reflection about problems that
which made important contributions in the – also referred to as generate curiosity and pose challenges; the
health area(3,7). The method emphasized on active methodologies provision of resources to research problems
and solutions; the identification and organi-
the dialogic relationship between students (AM), thus confirming
zation of the most appropriate hypothetical
as well as between students and teachers,
the idea that the solutions to the given situation, and the ap-
in the academic environment, as well as be-
tween the population and the professionals, search for knowledge plication of those solutions(7,14).
in educational health practices(5). in nursing should bring Therefore, AM are based on problems
healthcare practice and, currently, there are two major types:
Therefore, to integrate theory and prac- and education closer...
the Problem-Based Learning (PBL) and the
tice, healthcare service and teaching, a re-
Problem-Posing Methodology (PM).
view should be done of the methodological
proposals used in the education of health In PBL, a tutorial group is formed, in
professionals. However, the change in the teaching-learn- which the teacher presents a problem that has been creat-
ing process is arduous, because it breaks with the tradi- ed by a commission of experts. The problems contain the
tional teaching models and the education of profession- essential themes for students to complete the curriculum
als concerned with humanized care(8). Recognizing these and be prepared for professional practice. In this method,
needs, today many discussions point to the use of new contents or disciplines are integrated. The students study
pedagogical practices, and higher educational institutions the problem as a group and individually. Next, the group
have been encouraged to redefine their social role and gets together again to re-discuss the problem. This is a
value the quality of healthcare in health practice, adopt- proposal that directs the whole curriculum organization
ing the referred innovations (1-2,8). and demands complex structural changes, because it is
the choice of the institution(8,15). The inconvenient aspect
The National Education Bases and Guidelines Law (Lei of the PBL is the existence of a virtual study setting, where
de Diretrizes e Bases da Educação Nacional – LDB) and attempts are made to associated pre-defined contents,
the curricular guidelines of nursing undergraduate course which usually do not represent a trustworthy reality(8).
contemplate these paradigmatic changes as they establish
that universities must encourage the association between On the other hand, the problem-posing pedagogy has
teaching, research, and care, requiring innovation and its theoretical-philosophical foundations supported on
quality in the political-pedagogical project. These guide- Paulo Freire’s framework. It is a teaching model commit-
lines suggest investments in educational strategies that ted to the liberating education, which values dialogue,
encourage students to reflect about society, and trans- demystifies reality and encourages social transformation

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through a critical and awareness-building practice. In The objective of this study is to identify and analyze
this case, the studied problems require a real setting, so the Brazilian scientific publications in nursing about the
that knowledge development occurs based on meaning- use of active methodologies in teaching and care.
ful experiences(5,8-9).
METHOD
The PM has five stages. The first is to observe the real-
ity: based on the study theme appointed by the teacher, In this study, an integrative literature review was per-
students identify the problems of the social reality. The formed, which permits to summarize articles and draw
second stage is to identify the key-points: students use general conclusions to analyze the scientific knowledge
previous information to reflect about the causes and de- about the issue under investigation. This research was
termine the essential points of the problem. In the third conducted following a few basic stages: 1) elaborate the
stage, the students seek scientific knowledge and funda- study theme; 2) conduct the literature review; 3) organize
mental information to understand the empirical manifes- the collected data; 4) interpret and evaluate the study
tations and the theoretical principles of the problems. The outcomes; 5) present and disseminate the review (16-17).
fourth stage is to formulate solution hypotheses: students
analyze the feasibility of applying the studied solutions to In the 1st stage — elaborate the study theme — the
the identified problems. The final stage is to apply the so- following guiding question was used: how are active
lution to the reality, which consists of students putting the methodologies used today in nursing education and care,
most feasible solutions into practice. This is an essential according to what has been published on this theme in
characteristic of problem-posing and does not depend on national scientific journals?
the level of impact that the solutions have on society(3,14-15).
In the 2nd stage, the literature review was performed
Problem-posing can increase actual actions, because using BIREME (Virtual Health Library), and the electronic
it uses a real setting, and it is an alternative that does databases: LILACS (Latin American and Caribbean Health
not require many physical changes in the institution. The Sciences Literature), BDENF (Nursing Database), MEDLINE
changes are related to the class program, the attitude of (international Health Sciences Literature), and the SciELO
the teacher and student, and to the diversity of the study (Scientific Electronic Library Online) open access electron-
locations. However, in this case, learning outcomes are ic library. The keywords used in the searches were cho-
not completely controlled and predictable(8,15). sen from the Health Sciences Descriptors (DeCS/Bireme):
aprendizagem, aprendizagem baseada em problemas,
With the purpose to promote reflections and discus- educação em enfermagem, enfermagem (learning, prob-
sions about the reality of nursing education in Brazil, we lem-based learning, nursing education, nursing).
intend, through this review, to identify the use of AM in
nursing education and care based on the Brazilian scien- The advanced search used two or three descriptors si-
tific production. multaneously. Therefore, in the BDENF, LILACS and MEDLINE
databases, besides the SciELO electronic library, the follow-
The relevance of this theme for the field of nursing ing terms were grouped at the same time problem-based
education is due to the new national health policy and learning/ nursing education; problem-based learning / nurs-
the development of human resources, which required ing and problem-based learning / nursing education / nurs-
reviewing the direction given to nursing education and ing. On the other hand, on SciELO, the descriptor problem-
practice(1-2,6). Furthermore, because education is one of based learning was used alone, and the descriptors learning/
nurses’ major roles, particularly in care and education, it is nursing/ nursing education were used simultaneously.
also worth knowing the teaching-learning methods used
in health education activities with the purpose to identify Also on SciELO, the keywords problematização (prob-
the transformations of the teaching strategies used in the lem-posing) and enfermagem (nursing), were crossed
healthcare area(11-12). simultaneously in an attempt to contemplate important
studies that had not yet been included. We highlight that
This study does not have the purpose to specify what is although these are not official descriptors, the search pro-
being used and how it used, because the experiences and vided significant outcomes.
reports presented in the literature about innovative meth-
odologies does not provide sufficient elements to identify The inclusion criteria used to select the sample were:
details, or, at least, some characteristics of the methods be- articles published on national journals, from 1999 to
ing used. We do, however, intend to obtain an idea of that 2009, addressing the theme active methodologies, con-
use or the attempts made to apply AM and the possible sidering all the areas of interest in nursing, and providing
variations of this approach. Furthermore, the study does free online access to the full-text. This period was chosen
not have the objective to show if those methodologies im- considering that the number of publications on this issue
prove learning nor focus on the use of methodologies only are growing in the national setting, and because the use
in the integrated curriculum, because, in fact, compared to of new pedagogical practices is a new phenomenon in the
other countries, this use is incipient in Brazil. country, and has been growing over the last years(1-2).

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2012; 46(1):202-11 teaching in national productions: an integrative review
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 The literature review conducted in March 2009 pro- essential that the dissemination about the use of innova-
vided an initial sample. During the following months, an tive methodologies is not limited to higher education, but
exploratory reading was performed of the articles’ titles made available to all other education levels.
and abstracts, followed by a first reading to determine
if the articles were appropriate for the proposed theme. RESULTS
Next, a selective reading was performed, that is, a deeper
reading of the whole articles. Based on this reading, all
On BDENF and LILACS databases, 29 (7%) and 64 (17%)
studies considered irrelevant for the study theme were
articles were found, respectively. On MEDLINE, the search
excluded. Next, having established the final sample, an
resulted in 176 (44%) articles. The search on the SciELO elec-
analytical reading of the articles was performed, with the
tronic library provided 129 (32%) articles. The search on the
purpose to organize and summarize the information from
databases, considering that all the descriptors and keywords
the selected articles to answer the study objectives(18-19).
used, found 398 articles. After reading the title, abstract and
In September 2009, following the same aforementioned
full texts, 370 (93%) articles were excluded because they did
steps, another search was conducted, and new articles,
not contemplate the study theme (Table 1). Therefore, the
which had not yet been available on the databases, were
final sample consisted of 28 (7%) articles (Chart 1).
added to the sample.
Table 1 - Distribution of the articles that were found, excluded and
In the 3rd stage, organizing the collected data, a specif-
selected according to the electronic databases - Brazil - 1999 to 2009
ic form was used for the data collection with the purpose
to take note of information considered the most relevant Databases Found Excluded Final sample*
to meet the study objectives. Therefore, the final sample BDENF 29 26 3 (1%)
was organized according to the date of publication from LILACS 64 56 8 (2%)
the latest to the oldest, and alphabetically according to Medline 176 173 3 (1%)
the authors’ last names. The form contained data such SciELO 129 115 14 (3%)
as year, author, title, journal, type of active methodology, Total 398 370 28 (7%)
country region that used the method, forms of application
*Numerical data in rounded percentages
(education or care) and thematic content.
The results revealed that the innovative methodolo-
In the 4th stage — interpreting and evaluating the out- gies predominated in southeast Brazil with 17 (61%) stud-
comes — the categorization was based on the incidence ies, followed by the South with six (21%) articles, the
of the content and on the characteristics present in the northeast with three (11%), and two (7%) in the mid-west.
selected studies. This way, we divided the content into The search did not find any articles from the north of Bra-
three main recurrent themes: a) the teaching-learning zil that contemplated this methodology.
process / teaching strategies; b) health education activity;
c) professional development / permanent education. Regarding the methodologies used in nursing educa-
tion and care, 13 (46%) articles adopted problem-posing
In the 5 stage — presenting the outcomes — the in-
th
(PM), 11 (39%) applied AM. Three (11%) manuscripts ad-
formation from each study, which were considered the dressed participative methodologies, and only one (4%)
most relevant in the review, were described. The data used PBL.
were summarized and presented individually to facilitate
the critical analysis of the sample. It is highlighted that 24 (86%) articles reported that
the innovative methodologies were applied to class disci-
However, in this stage, it is necessary to point out plines, and 13 (46%) evaluated the implementation of the
some considerations about the review process that was adopted methodologies.
conducted. This study has some limitations regarding the
incompatibility between the descriptors and keywords The most reported theoretical frameworks were Paulo
used by the researchers of the surveyed articles. On the Freire’s, with six (21%) articles, Maguerez and Bordenave
one hand, this can limit the final sample of the study, with five (18%). The other studies used different frame-
while, on the other hand, it can provide many articles, works or did not state which one.
but with several themes, making it difficult to find manu-
scripts that would interest the research theme. Twenty (71%) articles focused on education, 16 (57%)
of which addressed undergraduate education, graduate
Furthermore, the fact that the articles should be avail- and technical education levels were addressed on two
able online, but only through free access, may also have (7%) texts each. Two (7%) articles were dedicated to the
contributed for other national studies not being included. permanent education of nursing professionals, and one
However, the present study authors consider it important (4%) for community health agents (CHA). Regarding the
to select articles that have free access to any person, rath- manuscripts focusing on care, there were five (18%) ar-
er than those available only to a limited privileged part ticles that addressed the use of active methodologies in
of the population, such as academic communities. It is health education projects for the population.

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Chart 1 – Selected studies per area, year of publication, title, and journals - 1999 to 2009

Area # Year Title Journals

Uso de metodologia ativa na disciplina gerenciamento de enfermagem em saúde coletiva
1 2009 Rev. Eletr. Enferm.
da FEO/UFPEL.
Texto & contexto
2 2008 Curso técnico de enfermagem do PROFAE-Ceará: a voz dos supervisores.
Enferm.
3 2008 Processo de ensinar e aprender em UTI: um estudo fenomenológico. Rev Brás. Enferm.
Aprendizagem baseada em problemas em ressuscitação cardiopulmonar: suporte básico
4 2008 Ver. Esc. Enferm. USP
de vida.
5 2008 A experiência de realizar um Estágio Docência aplicando metodologias ativas. Acta. Paul. Enferm.
6 2007 Construindo um programa de educação com agentes comunitários de saúde. Interf. com Saúde Educ.
Metodologia da problematização no ensino em enfermagem: uma reflexão do vivido no
7 2007 Esc. Anna Nery
Profae-RS.
Reflexão e interação: uma nova perspectiva para o ensino da enfermagem por meio da
8 2007 Online braz j Nurs.
aprendizagem vivencial.
Implementando as unidades educacionais do curso de Enfermagem da Famema: relato de
9 2006 Interf. com saúde Educ.
experiência.
10 2006 Educação permanente: uma ferramenta para pensar e agir no trabalho de enfermagem. Rev. latino am Enferm.
Utilização da pedagogia problematizadora na graduação de Enfermagem para o
EDUCATION

11 2006 Rev gaúcha de Enferm.

atendimento do paciente agressivo.
O ensino de enfermagem em saúde mental e psiquiátrica: visão do professor e do aluno
12 2005 Rev latino am Enferm
na perspectiva da fenomenologia social.
13 2005 O planejamento estratégico situacional no ensino do gerenciamento em enfermagem. Acta. Paul. Enferm.
Utilizando técnicas de ensino participativas como instrumento de aprendizagem
14 2005 e sensibilização do manejo da lactação para profissionais de enfermagem de uma Acta. Paul. Enferm.
maternidade.
Concepções pedagógicas no processo ensino-aprendizagem: uma visão reflexiva dos Ciência, Cuidado e
15 2004
alunos de graduação em Enfermagem. Saúde
Professor e aluno compartilhando da experiência de ensino-aprendizagem: a disciplina de
16 2003 Rev. latino am Enferm.
Enfermagem pediátrica da Universidade Federal de Mato Grosso do Sul.
Assistência de enfermagem ao portador de alterações na integridade cutânea: um relato
17 2002 Rev. Esc. Enferm. USP
de experiência de ensino-aprendizagem.
18 2002 Ensino de administração em enfermagem: relato de experiência. Acta. Paul. Enferm.
19 2002 Posicionamento de enfermeiras sobre ensino problematizador. Rev latino am Enferm.
20 2001 Capacitação pedagógica: uma construção significativa para o aluno de graduação. Rev. latino am Enferm.
21 2000 O ensino do exame físico pulmonar através do método da problematização. Rev. latino am Enferm.
22 1999 A problematização da violência como experiência de ensinar em Saúde. Interf. com saúde educ.
Reflexões sobre o ensino de dinâmica de grupo para alunos de graduação em
23 1999 Rev. Esc. Enferm. USP
Enfermagem.
24 2009 Percepções de mães de prematuros acerca da vivência em um programa educativo. Acta. Paul. Enferm.
Competência dos enfermeiros em problematizar a realidade do serviço de saúde no Texto & Contexto
25 2007
contexto do Sistema Único de Saúde. Enferm.
CARE

26 2004 Cartilha educativa para orientação materna sobre cuidados com bebê prematuro. Rev. latino am Enferm.
27 2003 A experiência de jogos em grupos operativos na educação em saúde para diabéticos. Cad. saúde pública
28 2000 Atividade educativa no alojamento conjunto: relato de experiência. Rev. latino am Enferm.

One (4%) scientific production was performed by pri- the influence of conservative methods that generate, in
mary care nurses. Three (11%) articles counted with the some professionals, a resistance to accept other pedagog-
participation of nurses from the service and faculty. The ical concepts; the students’ difficulty to become respon-
other 24 (85%) articles were published by nurse-professors. sible for self-learning; the inflexibility of institutions and
In the present study, the contents of the articles were health services; some professionals’ equivocated percep-
grouped into three central themes: learning process and tion of losing power and their lack of knowledge regarding
teaching-learning strategies, covered in 19 (68%) articles; the pedagogical theories(13,20).
health education activities, with five (18%) manuscripts; and To better understand the following discussion, Chart 2
permanent education of nursing professionals with four (14%). presents the synthesis of the critical evaluation of the se-
In both education and care, it was found that there are lected articles according to the numerical order presented
some common setbacks to apply the new methodologies: on Chart 1.

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2012; 46(1):202-11 teaching in national productions: an integrative review
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Chart 2 – synthesis of the critical evaluation of the selected articles – 1999 to 2009

# Synthesis
A brief report on how the activities are performed, it is understood that it refers to AM, similar to problem-posing. Partnerships are established
1
between municipal health departments and the university to implement changing actions.
Uses PM with a pre-elaborated educational material (traditional resource). Strength: easier to work as a team; weaknesses: restricted
2
internship fields, little support from the municipal administration.
Faculty tries to individually apply a differentiated education practice, it is an AM: students experience the real problems and have a more
3 dialogical relationship with the professors. An effort is made to make changes that would improve education. Difficulty: faculty lack
preparation about pedagogical concepts.
In the discipline, a massive amount of content is presented, with a previous distribution of theoretical material. Emphasis is on technical
4 and theoretical training. There is no contact with the reality, only with a simulated situation in the final phase of the PBL. The students’
evaluation is mostly traditional. Difficulty: students rooted to traditional processes.
Faculty internship in the graduate course applying AM in an undergraduate class discipline. There are traces of the problem-posing method.
5
Different strategies were used in teaching and evaluations, blending traditional and innovative methods.
The PM was partially used to support the preparation of community health agents. The educational actions involved dynamics, participative
6
strategies, which later were extended to the community.
Presents the PM, based on the arch method by Maguerez. Attempts to employ the integrated curriculum model in the technical course, but
7 does not provide details regarding that integration. Is concerned about developing the action-reflection-action process. Difficulties: limited
to specific contents; interdisciplinarity; interconnected with places for practice.
Discipline applied with the objective to problematize; uses AM to solve daily problems. Strategies focus on group dynamics to encourage
8
knowledge development. Few data are presented about the activities that were adopted.
Emphasis on the changes of the PM and the curricular model of an institution. Difficulties in the implementation: different understandings
9 about the method, unclear pedagogical cycle, interdisciplinarity, insecurity and a redefinition of faculty roles. Strengths: the education-
service partnership is strengthened and a connection is established between the courses.
An elusive and vague report about the application of PM in professional development. The teaching practices adopted approximate the
10 theory of everyday life, but the educational activities are not associated to the working process; the practices were occasional and isolated.
Difficulty: lack of investment by the institutions in training and a lack of commitment from the professionals.
Discipline based on problem-posing a hypothetical situation. An attempt is made to innovate the teaching strategy, promoting interventions
11 and reflections. The contact with the simulated practice improved learning, but there is no information about the activities that were
performed, it only describes the PM steps. Emphasis is on the educator’s attitude change and their will to establish interdisciplinarity.
Reports experiences in the discipline, which emphasizes on the direct contact with the social reality, favoring learning. No reference is
12 made to the methodology used, but it follows the AM characteristics, tending to problem-posing. Highlights: a more dialogical relationship
between teacher and student, constant changes in attitude and reflections about the practice.
The discipline uses the Situational Strategic Planning as a pedagogical resource rather than as a methodology. It is an AM, focused on the
13
problem-posing of reality. It attempts to include other active learning strategies. Difficulties: vulnerable human and material resources.
Uses participative methodology (actually, pedagogical techniques) that promotes participation and exchanging experiences. The activities
14 problematize real situations, but aim merely at the participation of the people involved, prioritize on technical-biological aspects, restrict the
students’ and professionals’ view. Traditional evaluation methods are used to verify the assimilation of the content.
The discipline prepares students to develop pedagogical practices that favor the construction of knowledge and critical-reflexive behaviors to
15
the benefit of the individual/society. Its discourse is consistent with AM, but the activities are still based on the traditional education model.
The approach is characteristic of AM, and includes elements of traditional and liberating education; it permits students to express feelings
16 and improve their autonomy. It appears to be a transition method: it seeks new paths for pedagogical practice, while maintaining conservative
characteristics of the institution (formative evaluation of students measured by grades).
PM experience reports. Activities performed with guided studies. Difficulties: excessive content, interdisciplinarity, faculty educated by
17
traditional models. To solve these problems, the following were performed: systematic discussions, advising with experts, faculty training.
Uses problem-posing, including the phase of the arch method in the theoretical-practical intern fields. Students evaluated the teaching
18 method as positive, but there were difficulties regarding its implementation: students’ adaption to the method, relationship with the health
team members, the exact identification of the problem and its implementation, the faculty’s lack of skills to work with the method.
Statistical demonstration of the advantages of using problem-posing. It does not emphasize on the application on the method, but shows the
19 outcomes of the teaching process before and after it is used. The participation in the discipline makes a positive change in the participants’
view about the importance to plan health education activities that value sharing practical and cognitive knowledge.
The discipline reviews faculty practice, seeking strategies that permit active knowledge development and the integration of theory and
practice. The information about the teaching method is vague and general, therefore it is not possible to specify the methodology, but
20
its structure resembles the awareness-building pedagogy. The study seeks alternatives to make learning more dynamic and introduces
techniques that emphasize on student participation.

Continues...

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...Continuation

# Synthesis
The discipline uses dialogued exposition strategies, practical demonstrations, and activities in the classroom. It follows the arch method of
Maguerez, which starts with the observation of a virtual reality, which is valid, but perhaps not very efficient, because in the final PM stage,
21
in the real practice field, many students still had doubts, and “extra reinforcement” classes were necessary. A new method is used, but with
traditional evaluation.

The discipline intends to prepare socially contextualized professionals. It recognizes and incorporates the students’ daily experiences in
the activities. The pedagogical activities involve more than simply applying techniques and/or knowledge provided in advance, it seeks to
22
develop skills and attitudes that provide students with the necessary tools to understand and face the reality, integrating with the professional
at the service, who have different interests.
Discipline with a reflexive theoretical-experiential proposal of the educational strategies that are used, aiming at their reconstruction. It uses
23 several educational and evaluation strategies. Students face an initial difficulty to understand the dynamics used for teaching and overcome
this though their personal interest to become responsible for their learning.
Implementation of a group of activities to promote knowledge development among users of a service, aiming at hospital discharge.
24 Problematizing education was used. However, the method appears to consist merely of forming groups that share experiences and read the
educational material. Practice is not associated with theory.
The use of AM in a specialization course. Nurses problematize the reality of the health service where they work. Despite being at a distance,
25 the course associates theory to the participants’ practice, who develop the ability to look to their reality, rise problems and find changing
actions. Difficulty: problematizing a single theme of the reality.
Health education activity that uses PM. The instrument developed in the study (handbook) is an educational resource produced by
professionals and users of the service, using problem-posing during the educational practices. It is not a permanent and pre-molded
26
instrument. It is, actually, one of the objectives of the referred active process and emerged from the group members’ attitude of sharing
knowledge, and was adjusted to their needs.
Uses educational techniques in the form of games that follow general ideas of active methodology. The educational resources contributed
27 with the training of the multiprofessional technical team, encouraging them to search new teaching alternatives to change health behaviors.
Limitation of the process: poor technical-scientific improvement of the professionals; difficulties in the professionals-participants interaction.
Educational activity that uses the participative, but not the awareness-building method. Group dynamics and a practical demonstration
of care are performed. The study proposes new forms of work, but the didactic techniques appear to be traditional, besides disregarding
28
the experience of the target population. The evaluation of the process was performed using an educational game, which resembles the
application of an exam, with aspects of punishment and reward.

DISCUSSION The study also identified some educational tendencies

adopted by the Brazilian nursing area, namely PM. It was
Considering the yielded results, it is observed that the observed that the articles that used active methodologies
innovative methodology predominates in the most de- presented mainly problematizing characteristics or ap-
veloped regions of Brazil. These data expose the power proaches with a main idea, conceived on the manuscript
relationships exiting in the construction of new educa- itself, very similar to the active method; therefore, in the
tional actions, which are (re)produced based on the so- present study, we classify those approaches as AM.
cial, political, and economical interests of certain his- Moreover, in the context of the analyzed articles, it
torical moments(21-22). The dominant sectors of society is understood that the participative methodologies con-
have no interest to invest in educational programs that tained problematizing elements in their applications.
develop students’ critical thinking, because knowledge However, it cannot be stated that they refer to PM and,
development promotes a greater ability of understand- in some cases, there are doubts regarding the fact of con-
ing and analysis. When knowledge reaches the majority sidering them as active teaching methods, because they
of the population, it generates a potential for change and focus merely on student participation, and not on the re-
the new methodologies can help overcome conservative flections, actions, and transformations that they promote.
models and promote social revolutions(7).
It should also be stressed that the studied articles that
Furthermore, changes in education cover the physical referred to participative and active methodologies, but
and material structures of institutions and the disposi- did not have a clear theoretical-methodological frame-
tion – personal, institutional, and governmental – to face work, were those that presented the highest variety of
radical changes in the education processes(9). In order to pedagogical resources: group dynamics, dramatization,
make these changes effective, there is a need for techni- educational games, group discussions and other techno-
cal and financial investments from the power authorities, logical materials and tools.
combining this cooperation to the group actions between
municipalities, educational institutions and organizations New teaching methods are understood as challenging,
representing the community(23). because they demand the teachers to choose pedagogi-

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2012; 46(1):202-11 teaching in national productions: an integrative review
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cal strategies that allow students to participate actively(24). requires a new pedagogical activity based on firm objec-
Therefore, it is important for the faculty to be familiar tives, and with the following main features: subjects have
with a variety of pedagogical activities, or always cre- an active participation in the teaching-learning process;
ate new teaching situations, because there no method is they seek knowledge and take possession of knowledge,
better than the other to address all contents. The most think critically about what they have learned to then act
important skill is knowing how to combine the many dif- and transform the reality in which they live(7,14-15).
ferent methods to keep students interested, increase the
possibilities of learning and achieve the goals of the edu- Knowing the methodology being used offers the
cation proposal(14). educator more flexibility to work. Therefore, using new
methods is not sufficient if the teacher does not have a
It is, therefore, essential for the faculty to make a criti- well-structured pedagogical concept to plan his/her work,
cal and sensible plan of their actions, because choosing and, particularly if the methods serve the single purpose
techniques and tools is not enough, it is necessary to to follow a fad when in fact the banking method is the
know the pedagogical concept adopted in order to apply one being used. To think about teaching methods and in-
the procedures that are appropriate for learning(7). struments implies a consistent and constant theoretical
reflection about learning(26).
It was found that the teaching techniques used follow
the main idea of the AM: problematize reality. However, We do, however, admit that is it not always possible
some of the activities reported in the articles may not to use new methods in the best and most desirable way,
provide the desired critical thinking that is valued by the even for those who master their foundations. The lack
active method. It is noticed that maintaining a biomedi- of infrastructure at healthcare services and educational
cal view of care is not only a hindrance to overcoming the institutions may risk the educational practice, making it
dichotomy between theory and practice, and between discouraging. However, this does not justify the profes-
teaching and care, it is also an influence on the faculty sional not seeking new teaching strategies, because other
practice, which has a tendency to use techniques that re- instruments or alternatives may be used, which could
inforce the students’ passivity(13). promote health education and professional development
In some articles, it was observed that there was little activities(14,26).
information about the application of the chosen method- Some articles from the sample criticize the use of tra-
ologies and the theoretical framework; it is possible that ditional teaching methods in nursing education. However,
the use of these pedagogical practices occurred empiri- keeping a conservative educational structure does not
cally, with a poor theoretical foundation (25). mean a disregard of the institutions with the education
The articles reported some activities that suggest us- process. We highlight that the strengths of each method-
ing AM; however, the pedagogical instruments that were ology lies in how they are used. The chosen techniques
used do not, necessarily, characterize the activity as inno- can adopt different pedagogical concepts, which at times
vative. Using technological resources or forming groups are centered on the teacher and at others on the student
does not mean the AM is being effectively put into prac- or on socialization(20).
tice. Innovation is more than simply using new technologi- Many of the studied innovative methodologies are
cal elements; it consists of using resources that represent strategies applied only to class disciplines. Most political-
new forms of thinking the teaching-learning process (8). pedagogical projects do not follow these isolated chang-
The techniques used by the educators are the means es. However, the use of new approaches may be useful for
to accomplish the education proposal, and, inevitably, all the nursing contents, which justifies the need to adjust
depend on a theoretical-philosophical perspective(7). It is the methods(21).
important to recall that every pedagogical concept has
In fact, in PM, students identify the problems observ-
specific sociopolitical intentions and the techniques used
ing the social reality and this methodology can be used
can characterize the teaching action as manipulating or
to teach specific themes of a discipline, but is not always
emancipating(20).
appropriate for every content, considering that some are
Hence the importance of having the educational prac- better learned with one or more different method choic-
tice grounded on knowledge theories, because not all the es(15). There is, however, the possibility to apply problem-
techniques reported in the articles are in fact innovative, posing in planning a discipline or some of its themes, as
though being referred to as such. Some experiences are well as in planning the whole curricula(8).
centered on a conservative education, but adopt different
teaching strategies only to be included in the “fad” of new Some of the studied articles mentioned evaluation
pedagogical methods. processes of the AM implementation. Only one study
evaluated the methodology with former students of a
Therefore, an alert must be made that AM are not a technical course, and obtained positive results about the
mere set of tools aimed at professional education or edu- differentiated performance they have at work. This is a
cational actions at healthcare services. This methodology key point in the action of developing new teaching meth-

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teaching in national productions: an integrative review 2012; 46(1):202-11
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ods, because any innovative methodology implies process fessional education of nurses and in care, it is important
and formative evaluations to generate a critical reflection to establish and strengthen partnerships between educa-
about the practice and identify improvements and diffi- tional institutions, municipal departments and the health
culties in the teaching process(1,24). system. They must share responsibilities and combine col-
laborative actions between the groups capable of making
There were studies that evaluated both the student changes, with the purpose of finding new options of plan-
and the adopted methodology, whether in the education- ning and managing the education and working process
al institution or the healthcare service. In these cases, sev- in the healthcare system, increasing and diversifying the
eral evaluation means were used and adjusted. In other learning settings(23).
articles, however, the evaluation was not consistent with
the innovative methodology, as it was applied in the tra-
ditional fashion. CONCLUSION

Furthermore, two basic nursing areas for the appli- The present study identifies the attempts made in
cation of innovative methodologies were investigated nursing to adopt innovative pedagogical concepts in the
the articles: teaching and care. Examples of the former teaching and care practices. Despite the difficulties to
are undergraduate, graduate and technical courses, in break with the traditional teaching methods, some educa-
addition to permanent education programs for nursing tion and nursing care institutions are aware of the need to
technicians, aides, and professionals such as community change education and professional practice.
health agents – all of which counted with the direct work
of nurses. The latter included methods used to develop However, studies mostly present experiences of active
educational health practices with patients and their fami- methodology applied alone in class disciplines or teach-
lies, with a view to promoting critical thinking, skills and ing and care activities. These experiences are motivated
attitudes to improve community and individual health(3). by personal rather than institutional interests, which is
rare. The nurse-faculty makes the strongest effort to ap-
Education is a continuous process of personal and ply innovative pedagogical methods. Difficulties such as
professional development. It is not limited to the school the lack of support from the government or educational
environment, and also extends towards the workplace. institutions impede making radical changes in education,
Nurses, working in teaching or healthcare, influence the demanding the teachers to adapt the active methodology
education and work of healthcare professionals. Nurses to the resources available in their reality of work.
are in the position of changing the healthcare service of
a place to make it suitable for learning, because, most of The surveyed studies provided little information about
times, they are the ones responsible for the health educa- the use of the adopted methodology, but it was observed
tion actions(27-28). there was a predominance of the problem-posing method.
Some emphasized on the idea of problematizing the real-
Nevertheless, the study outcomes show that there are ity, with variation of the active methodology, while others
few studies by nurses working in the primary healthcare were unclear regarding the theoretical frameworks used.
network. The published studies are mostly associated Some proposed new types of evaluation to the students
with undergraduate courses or the personal interests of consistent with active methods, while others insisted in
nurse-faculty. This is not a negative fact; however, im- using traditional evaluation methods. Most performed
portant examples may be lost because of the lack of dis- some type of evaluation about the method used, stressing
semination of studies that do not have the partnership on their positive outcomes and exposing the difficulties.
between teaching, research and care.
Several teaching instruments and strategies were
In fact, some of the studies found chose to use virtual used, but not always did they refer to an active method,
realities or situations that simulate the reality because because the resources used could sometimes maintain
there was no available place to perform the practice, student dependence and the manipulation of knowledge,
which means they had to make adaptions to the AM they thus characterizing that the continuation of the traditional
used. Still, it is possible to become close to the social re- teaching method.
ality both through direct observation (in person, in loco)
and by other means (audiovisual), but, in this case, there It should be highlighted that the pedagogical tech-
may be loss of information inherent to the representation niques used could serve as an active as well as a conserva-
of the reality. The important aspect is for the different tive methodology, and that all methods contribute to de-
strategies to create situations and address contents that velopment of the professional. However, there should not
contribute to the students’ learning and allow for some be an overvaluation of practical over theoretical learning.
personal and social transformation(3,14). One must always seek alternatives that favor both skills,
thus promoting the individual abilities of students.
In this sense, some of the analyzed articles highlight
a factor that hinders the ideal implementation of AM: Nevertheless, the study also revealed that the imple-
the lack of partnership. To promote changes in the pro- mentation of innovative methodologies still requires fur-

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2012; 46(1):202-11 teaching in national productions: an integrative review
www.ee.usp.br/reeusp/ Sobral FR, Campos CJG
ther studies regarding Brazilian nursing, which confirms method has already been implemented, to show its real in-
that despite the current concerns with the education pro- fluences in learning and the consequences on society. Fur-
cess of the professionals, more investment is needed in thermore, studies should include an evaluation of how new
research and dissemination in this theme. It is also impor- nurse processionals – graduates who have experienced the
tant to perform studies that evaluate the outcomes of ac- active pedagogical methods – have used this new pedagog-
tive methodologies in educational institutions where the ical paradigm in their teaching and care practices.

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