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Structuring a philosophical and theoretical framework in the pedagogical project to teach nursing care.

OBJECTIVES
to analyze the philosophical, theoretical and methodological conceptions of the Theory of Praxic Intervention in Nursing in Collective Health by professors at a federal university, aiming at structuring a reference proposal for teaching nursing care.


METHODS
Convergent Assistance Research, with 17 teachers, gathered in convergence groups for instrumentalization and production about the referential.


RESULTS
the focus was primarily on issues considered preliminary to the theoretical and philosophical deepening of theory; and then a theoretical-methodological essay on historicity and dialectics was developed for teaching in nursing care.


FINAL CONSIDERATIONS
when electing Theory of Praxic Intervention in Nursing in Collective Health, the potential of the referential to make operational, in the teaching of assistance, the assumptions of historicity and dialectics operational, founding new conceptions for care. This decision represents a paradigmatic challenge exposing weaknesses in the formation related to its Cartesian origin and its limitations regarding intrinsic philosophical complexity.


INTRODUCTION
Choosing a theoretical framework to guide nursing care as the basis for the Pedagogical Course Projects (PCP) of a higher education institution (HEI) is a founding criterion of undergraduate nursing courses. This structure implies that nurse teachers combine knowledge and understanding of the guidelines of the PCPs, as well as commitment to them, in order to legitimize the application of the framework used to support their practices in the teaching routine, always aiming to improve health education in Brazil (1) .
The creation and development of a pedagogical project is a complex process, which requires integration and commitment from the faculty and students and alignment with the National Curriculum Guidelines (NCG), which a priori point out practices responsive to the expectations of real health needs of populations. Thus, this development must be mediated by the Structuring Teaching Nucleus (STN) of the respective courses, in order to guarantee the protagonism of teachers and students, the promotion of discussion forums on professional training and field research that best elucidate the "written and the achievement "presented in the PCPs (2) .
It was in the midst of a scenario of recognition of the Nursing course and reformulation of PCPs that nurse professors at a federal university in southern Brazil were mobilized to choose a philosophical framework, theoretical and methodological to support the teaching of nursing care and converge with the principles of Collective Health and the Unified Health System (UHS), precisely to tune with the NCGs, thus opting for the Theory of Praxic Intervention in Nursing in Collective Health (TIPESC), by Emiko Yoshikawa Egry (3) .
By deepening the collective understanding (nurse professors) about this desired reference, the present convergent care research (CCR) was developed and, through convergence groups, the participants went through TIPESC concepts and concepts, whose philosophical bases conform to with the worldview of historical materialism and dialectical materialism. The theoretical bases of TIPESC result from these conceptions, which are the conceptual and dimensional categories; and, based on this philosophical and theoretical framework, the theory is operated methodologically through five stages, all expressing the objective reality, from the capture of that reality, through the interpretation, interventionist proposition, intervention and reinterpretation of such reality (3) . Thus, TIPESC as a theoretical conception seeks to understand the contradictions in the face of health phenomena, that is, the dialectic present in the objective reality of Public Health Nursing in the historical moment of people's lives (4) .
The work that compiled the creation of the theoretical framework was published in 1996, and today there are countless works whose object of study involves TIPESC, carried out in the Postgraduate Program in Nursing at the School of Nursing at the University of São Paulo. In this sense, it is considered that the theory has helped the processes of reinterpretation of objective realities; and, although the necessary transformations, arising from these reinterpretations, have not yet been overcome in their essentiality, the framework demonstrates potential with regard to the development of critical awareness of all those involved in the processes, as well as the notion of the relevance of collective work, elements essential to future transformations (4) . Therefore, based on the above and seeking to align with the initiatives of scholars who aspire to effective changes in the paradigm that guides nursing care, as well as realizing whether the intrinsic strength of a research proposal that combines PPC review with the structuring of a reference for this purpose, is configured as a guiding question for the study: As nurse professors of an undergraduate nursing course, they develop knowledge and understanding of TIPESC, aiming at structuring in the PCP a proposal for a theoretical and methodological framework for teaching nursing care?

OBJECTIVES
To analyze the philosophical, theoretical and methodological conceptions of TIPESC by nurse professors at a federal university, aiming at structuring a proposal for a reference for teaching nursing care.

Ethical aspects
The participants were duly informed about the research and agreed by signing the Free and Informed Consent Form (FICT). To protect the integrity and anonymity of the participants, they were identified by letters from the alphabet A to Q. The project was assessed and approved by the Research Ethics Committee, as required by Resolution 466/12 of the National Health Council, which deals with research involving human beings.

Type of study
Qualitative approach study, of the Convergent Care Research (CCR) type, which seeks to elucidate the complementary relationships between theory and practice, producing knowledge aimed at solving conflicts and problems. The process of developing a CCR is composed of the design phase, when the researcher apprehends the research problem; the instrumentation phase, which allows the researcher to plan all the operational details of data collection, physical space, participants, collection instruments, among other practical aspects; research phase, conferred as an unparalleled moment in the CCR, which allows the researcher, through his active participation, to scrutinize, to probe the possible interfaces, associations and plans before the instrumentation phase and the next phase, which is the analysis phase (5) . Consolidated Criteria for Reporting Qualitative Research (COREQ) was used as a roadmap for reporting.

Study scenario
The research environment was a federal university in the southern region of Brazil, specifically involving the undergraduate nursing course.
of Structuring a philosophical and theoretical framework in the pedagogical project to teach nursing care Bitencourt JVOV, Martini JG, Léo MMF, Conceição VM, Maestri E, Biffi P, et al.

Selection criteria
All 25 nursing faculty members of the Nursing course were invited to a collegiate meeting when the Pedagogical Course Project (PCP) was reformulated. The inclusion criterion was: to participate in all three convergence groups. At the time of data collection, 17 nursing professors participated in the study, 11 doctors, three doctoral students and three masters. The reasons for the non-participation of eight teachers were the leave (for improvement and sick leave), as well as the impossibility of two teachers to remain attending the meetings.

Data collection and organization
Data collection took place in three convergence groups called "Groups of dialogue and analysis of a philosophical, theoretical and methodological framework (the TIPESC), for the practical application of the teaching of nursing care in different practice scenarios", with duration two to three hours for each moment and with the 17 participants included. The chapters of the work of the author of TIPESC, Emiko Egry (3) , were the triggers for the reflections in the group. The reports generated were audio recorded, transcribed and validated by the participants.

Work steps
The CCR was operationalized in the following stages: dialogicity, expandability, immersibility and simultaneity (5) . In dialogicity, the philosophical, theoretical and methodological basis of TIPESC was entered. Then, with the expandability, which provided the deepening of the debates, it was possible to assimilate the content and develop analogies and conjectures towards the operationalization of the method. Subsequently, it became feasible to start the stages of immersibility and simultaneity, when the participating teachers problematized the theory in relation to the practice of teaching nursing care and were able to abstract the concepts imbricated in the TIPESC framework, which represents an important step in obtaining the necessary data for the future structuring of a proposal for a philosophical, theoretical and methodological framework for the desired education and inserted as a guide for nursing care in the PCP.

Data analysis
From the analytical point of view of the CCR, the concepts are divided into processes of apprehension, synthesis, theorization and transfer that can be sequential or not (5) . At the end of the analysis, the elaboration of meanings and discoveries is configured, leading to the reframing that the new concepts provided to the professional as well as to the qualification of the work process developed (6)(7) .

Preliminary questions to the philosophical and theoretical deepening of the Theory of Praxic Intervention in Nursing in Collective Health (TIPESC)
Nurse teachers problematize qualification.
We need to deepen the concepts ... we need to have a clear philosophical part to do nursing. But, on the other hand, it is worth bringing up the speech of an academic from the 5th phase that shocked me: That when entering the academy she had to undress a self to dress as a nurse. So, we must think that, in addition to this teaching based on nursing theories, on the right formulas for nursing, dialectical or non-dialectical, we end up not realizing some situations like these, that each student, or that each professional is one, and which is also imbued with values, concepts and philosophy, theories, in short, life. (M) Report to national theoretical models.
Emiko asks a question about Nursing Theories: it draws attention to the lack of a national model of doing nursing, we take a lot of American theories, and there is nothing national, excluding the reference from Wanda Horta. (F) Conjecture about the conceptions of historicity and dialectics in nursing care. In what way are we able to understand, operationalize, build the path that is able to include the student in this axis. So, we are going to tell them that this course will seek the dialectical process, of formation, of transformation, of coming and going, but they are not seeing this in the formation. [...] We may not realize it, but we were trained in such a traditional model that it is difficult to make the movement. (G)

I need to hear examples so I can feel more, how will you do it in practice. (A)
In the proposal for the construction of the PTS, which is the unique therapeutic project, in the area of mental health, the intrinsic dialectic is not implemented because of the professional who is not dialectical. (F) I think that when we are discussing care based on dialectics, it is up to us to know how the student is feeling and how the teachers are feeling, in terms, who knows, appreciation, sport, living together, I think there is several factors that will influence; we also have to know ourselves as a group. (E)

Theoretical-methodological essay for historical and dialectical teaching in nursing care
The nurse professors discuss the understanding about the categorical divisions present in the proposal of historical-dialectical of Structuring a philosophical and theoretical framework in the pedagogical project to teach nursing care Bitencourt  In the systematization of TIPESC, its operational steps were evident. Thus, the five fixed stages of the referential and the idea of capturing the phenomenon were presented and discussed with the participants. Therefore, it was asked: What to capture? What phenomenon are you talking about? What is the extent of this phenomenon?
What is the tool that we use to look, to capture the phenomenon? In Primary Care, for example, taking the health of women as a reference, this care is part of the family health, which is in a given territory, so I capture the phenomenon from this assessment, but, and in hospital care? (D)

DISCUSSION
Focusing on a philosophical, theoretical and methodological framework inscribed in the pedagogical course projects (PCP) in the health field for teaching their practices imposes on professionals the inexorable conformity with the concepts intrinsic to the framework with a view to their adherence and operationalization, considering, for this, the local, regional and national realities. However, among the nurse professors participating in the research, there is a reflection on the possible ideological inflexibility before a theoretical proposition that the student absorbs as disrespect or even a real violence. Therefore, the nurse professors problematize the structuring of a theoretical-methodological proposal for teaching nursing care, based on the Theory of Praxic Intervention in Nursing in Collective Health (TIPESC), bringing to consciousness the own teacher training and stiffness that are presented in pedagogical and health care actions.
Nursing professionals are still involved in caring for others in a way that is displaced from themselves, as if it were possible to exercise it in a neutral and technical manner, which can result in situations of suffering due to the little appreciation of subjective issues involved in interpersonal relationships (8) , which can still be aggravated when in the presence of a theoretical basis that is detached from the objective reality installed in the health scenario (4) . From this perspective, the participants evidenced the difficulty of nursing professionals to look at themselves and their unmet need to recognize their value as professionals and, above all, as humans. And in the midst of these dense depths, they also demonstrate the conviction that the adoption of national references that reflect the Brazilian reality is an essential condition.
In view of the above, it is conjectured that the evidence presented in the study so far represents contradictions: How will it be possible to teach nursing care based on historicity and dialectics, in which the student is encouraged to seek the unapparent and the contradictory in what the patient and context express, if the teacher/nurse and the student are reduced to the technique, their existential contradictions themselves are ignored and their needs neglected? Thus, it is supposed to install non-conformity between the referential and its feasibility in teaching the assistance methodology that is to be enrolled in the PCP.
Then, in the detail of the TIPESC, a limitation of the group in evidencing in the theoretical and practical scope the dialectical and historical dimensions of the referential was evidenced. The etymological and epistemological clarity (especially of the dialectic) remains incipient in the speeches. The roots that built this panorama, in which philosophical knowledge is not recognized and conceived in professional daily life, refer to the paradigm that dominated and dominates health practices today. Thus, it appears that there is a tendency to compartmentalize and or classify the philosophical conception inherent to the dialectical phenomenon, to the use of light technologies, for example, values imbricated in the National Humanization Policy (NHP) such as: bonding, empathy and welcoming. Hence, the inability to reach the contradictions of the other results, and this lack affects the health status of the population. The NHP undeniably adds value to the relationships between professional, institution and population; however, it does not surpass the current paradigm, being still unable to perceive the dialectic present in everyday human life.
The interaction between philosophical science and health science converges to the scope of "[...] treatment of the human issue given by both", allowing the reflection on the theoretical and methodological considerations present in the "intersection of man being in the world and its conditions of health" (9) . For the authors, developing a "philosophical attitude" allows the professional to refine a reflective discourse and ensure the exercise of questioning about scientific knowledge, these coming from "[...] positivist, Cartesian positions, dominant in health, such as, for example , the crystallized concepts about health versus disease, [...] and the non-relationship between health/society/subject". It is believed that there is a need for a philosophical attitude on the part of the teacher, which supports the epistemological understanding of the framework studied here, which is fundamental for its applicability in the daily teaching of nursing care in general.
The convergence groups undertaken in this research process sought to offer philosophical elements and a collective reflective space to precisely provide a path for the development of the philosophical attitude, meeting the convergent care proposal. This contributes to teacher training, so that, when discussing the philosophical and theoretical aspects of TIPESC in the groups, the necessary transforming elements for the future journey that the group ensured towards structuring a proposal for the use of TIPESC were systematically brought together in teaching nursing care. Finally, understanding dialectics implies looking at its origins. At its root, it was characterized and perceived in speeches that evidenced the power of argument, when looking at a static world, without contradictions, a priori, of established and unquestionable relationships. In the face of historical social transformations, observing the relations in the world of work, between bourgeois and proletarians in their class division, the scope of understanding of dialectics was broadened, when it began to represent the complex and contradictory relations of the world. With this dialectic, a contesting way of seeing the world, the events of life, the real and, in view of this vision, the perception of the contradictions inherent to the movement, to the dynamics of life in a historical context, was established; with that, it started to provide the unstable and to establish the possibility of transforming relations (10) .
In this format, contradiction (dialectic) provides the driving force for changing reality, which, in a continuous process, stimulates transformative mobilization. The dialectical historical reference, which has been deepened in this study by the speeches of the teaching group, is desirable to reformulate the teaching process of nursing care, structured methodologically through the nursing process. What is expected is that both students and professionals will acquire intellectual and pragmatic conditions [supported by a philosophical attitude] to view the patient's world, in its dynamic and historical relations, beyond what is expressed in symptoms or diseases.
Therefore, rehearsing the applicability of the TIPESC framework for the teaching of nursing care, the nurse teachers analyze that it will not assimilate what the dialectic is if it is not internalized, in terms of attitude, what again contributes to the philosophical attitude; nevertheless, the proposal presupposes not only to establish a reference for nursing care, but also, and mainly, a reflection on the existential paradigm [its own self ] and on the [biomedical] paradigm of nursing education.
In this context, we consider the training of students with a focus on this assistance profile, with a view to expanding the concepts of the subject and their dialectical relationships as well as ensuring a position that sheds light on the contradictions inherent to human life, which are reflect in the health-disease process. The improvement of knowledge, which allows a better understanding of the environment and the subject under its various aspects, favors the awakening of intellectual curiosity, stimulates the critical sense and enables the understanding of the real through the acquisition of autonomy and the ability to discern (11) , what seems to us to be profoundly relevant when proposing a curricular transformation to teach nursing care based on historical and dialectical assumptions.
For the purpose of exemplification, considering the theoretical complexity of the framework being discussed and seeking to forge clues to its applicability, in an experience of teaching learning, recent and real, an activity with cancer patients was given the opportunity to rescue the self-image with the support of a photo shoot on the hospital premises. When invited to express their feelings about their participation in the trial, patients expressed satisfaction and positive feelings, indicating a different aspect of the hospital, that of health promotion; however, the response of one of the patients had an impact when he concluded that, even though it was possible to have pleasant experiences in the hospital, they would prefer not to be there. For him, experiencing the hospital or treatment positively was contradictory in relation to their unique demands.
At that moment, the contradiction was externalized, and the dialectical-historical perspective gave the teacher the opportunity to capture such a singular phenomenon and transform it into an object of nursing -thus manifesting a dialectical attitude towards teaching. This experience of photographic activity portrayed an intention of humanized and dialogical care on the part of nursing; however, it was still insufficient in terms of dialectics.
In continuity, the participants, when verifying that preliminary notes, referring to the philosophical aspects of the referential (dialectical and historical), could have been solved, debated on its theoretical bases. In the convergence groups, it was the conceptual categories and dimensional categories of TIPESC, with the objective of supporting the teachers of the course in the structuring of a theoretical-methodological proposal for the teaching of care. Of these categories, the participants stayed in an isolated aspect of the dimensional category, revealing an interest in operating the referential on a daily basis, as is characteristic of nursing and health sciences.
As for the conceptual categories, although the participants did not discuss them, it is still necessary to clarify that they are formed by definitions essential to the performance of nursing interventions, entering the theoretical framework and observing the ideas, historically constructed, around the set of totalizing notions to the development of this care. Its definitions explain how the phenomenon will be understood, once expressed conceptions whose nature is basic in the field of health, such as the concepts of man, society, health and disease, among others (4) . Therefore, due to its essentiality and given the philosophical basis underlying this theoretical contribution of TIPESC, it is reflected, once again, on the philosophical and theoretical distances present in the attitudes of health professionals and which compromise the effective applicability of a referential.
On the other hand, the dimensional categories of TIPESC make it operational, contemplating essential notions for the capture [dialectics] of the phenomenon that will support the nursing intervention, corresponding to 1) totality, 2) praxis and 3) interrelationship between the structural, the particular and the singular (4) . In the research, the participants focused on the dimensional category "interrelationship between the structural, the particular and the singular", expressing a desire to assimilate how to apprehend health phenomena in daily care, based on TIPESC.
The category seeks to identify the different parts of the phenomenon, exposing the dialectic present between the parts and the whole. In the meantime, the structural refers to the most comprehensive aspect of the phenomenon; the private assumes an intermediate position; and the singular, its smallest part (4,12) . In the example previously described on the care of cancer patients, it is possible to glimpse the structural as a hospital institution and its care peculiarities (environment marked by hard and light-hard 7 of Structuring a philosophical and theoretical framework in the pedagogical project to teach nursing care Bitencourt JVOV, Martini JG, Léo MMF, Conceição VM, Maestri E, Biffi P, et al. technologies, by disease, by medical treatment); the private as a group of cancer patients who experience a process of acceptance of the disease and coping (individual and collective); and the singular, which is revealed in the patient who disputes the benefit of the activity, exposing his satisfaction and dissatisfaction through this personal demands. However, this is a possible arrangement among many others, considering the fluidity intrinsic to these elements present in the phenomenon. Teachers mention that perceiving such principles in Primary Care becomes more plausible than in hospital care. Given this observation, we refer to a study whose purpose was to understand the objective reality of non-transmissible diseases and conditions (NTDC) in nursing, guided by the dimensional category "inter-relationship between structural, particular and singular" to propose intervention projects, aiming to understand the social determination of the health-disease process (13) . The authors describe the dimensions as follows: Structural Dimension (legal and political support for workers in the event of illness and accidents); Particular Dimension (the work carried out by the nursing team in the health service, based on aspects such as work overload, human resources, among others) and Singular Dimension (references to DANTs in the workers studied were recognized).
Thus, as the participants themselves concluded, it is necessary to adjust to the application of this category and, in particular, to this interface between the parts and the whole, to each situation, adding that, given the specificity, it is necessary to do the exercise in sense of perceiving each element of this interrelation; reinforces, therefore, that this characterization is not fixed. It appears, therefore, that this same exercise, necessary for the unfolding of health phenomena in Primary Care, must also be conceived in the hospital setting.
Finally, with regard to the referential itself, drawing the methodological description of the proposal, it is emphasized, in relation to this, that the capture of the phenomenon (first stage) is unknown to the participants, however it is expected that professionals of the able to capture the current health phenomenon in the objective reality analyzed. Thus, the philosophical precepts of the theory, based on the HMD, must be revealed through historical and dynamic contextualization of the phenomenon.
The nursing intervention, therefore, is configured based on five operational steps, systematized: a) capturing the objective reality; b) interpretation of objective reality; c) construction of the intervention project in the objective reality; d) intervention in objective reality; e) reinterpretation of objective reality (3)(4) .
"The knowledge of the phenomenon in its historicity and situationality" gives meaning to the capture of the phenomenon in its objective reality. Then, unveiling its dialectical contradictions, its interpretation is conceived; based on the triggered interpretation, the intervention project is elaborated, whose character should designate a wealth of details, "with conceptual definition, objectives, methods, strategies, carried out collectively and with shared responsibility". It is located the moment of the intervention, the development of nursing care that will lead to the last step that reinterprets the objective reality, promoting the "evaluation of the process and the product, seeking the contradictions in the implementation of nursing care". "The stages, before being specific parts of the work process, must be considered as hegemonic and not exclusive, that is, in a given stage, they may be coexisting with other stages, simultaneously" (12) .
In the course of the convergence groups, it was necessary to resolve the anxieties expressed by the participants, when they asked: "What would be the tool to be used to capture a health phenomenon?" and "What phenomenon are we referring to?" In fact, it is not a question of obtaining a tool, an instrument, a technical model that will enable the capture of a health phenomenon, in which the intervention is intended. Truly, the main thing to understand is that the capture of a health phenomenon, whose philosophical reference is conceived from the HMD, implies the development of personal professional attributes that stimulate the fluency of attitudes that express the introjection of the dialectical and historical view, regarding the phenomenon to be captured -the philosophical attitude, to which we refer throughout this text.
So, the phenomenon is exactly the same as that which would intervene in another theoretical and philosophical arrangement; what changes, however, is the paradigm taken to support the practice of care: the biomedical perspective or the historical-dialectic perspective. Nevertheless, the considerations formulated about the phenomenon, its capture and selection, gain the necessary scope for attention to the contradictions inherent to it, observed, in a multifaceted way, when considering its historical dynamism. Finally, when conceiving the capture, through these strategies, the interrelationship between the structural, particular and singular ensures that the phenomenon is marked out according to its totality, revealing the structural processes that determine care, a concern indicated by the participants of this study.

Study limitations
Currently, the group remains in a situation of curricular reformulation and has matured conceptions about the theme, with the aim of adopting TIPESC as a reference for nursing care. Therefore, it is considered a limitation for the proposal of this study the fact that it was not possible to conclude it with the materialization of a final structured product for the revision of the PPCP, exactly because such reformulation was not finished as was the initial purpose. It is added, as a limitation, the needy philosophical basis that is observed in the scope of health professionals, which ends up requiring the development of more studies of this nature in order to effectively reach the objectives, precisely to allow a certain group of professionals achieve a philosophical maturity.

Contributions to the field of Nursing
The transformation and reframing of a practice in view of the consequences of convergent care research corresponds to a potentially desirable target. In this case, the transformation took place through the understandings developed in the convergence groups on the baseline assumptions of TIPESC. These understandings, in addition to fostering the future production of a structured proposal about teaching NP guided by TIPESC, also allowed teachers to establish paradigmatic resignifications in the field of health.