THE UNIFIED HEALTH SYSTEM AS A CROSSSECTIONAL THEME OF A NURSING CURRICULUM O SISTEMA ÚNICO DE SAÚDE COMO TEMA TRANSVERSAL DE UM CURRÍCULO DE ENFERMAGEM EL SISTEMA ÚNICO DE SALUD COMO TEMA TRANSVERSAL DE UN CURRÍCULO DE ENFERMERÍA

Objective: to describe how the development of the cross-sectional theme of the Unified Health System in a Nursing curriculum occurs. Method: qualitative, descriptive and exploratory study. It occurred through the analysis of 17 documents containing teaching-learning plans of a Nursing curriculum in the year 2015. Held in the Nursing undergraduate course of a public university in the South of Brazil for adopting cross-cutting themes in its pedagogical project, one of them being the Unified Health System. For the discussion of data, Paulo Freire's pedagogical thinking was used as a theoretical reference. Results: the expression Unified Health System appeared as a transversal theme in three documents, explicitly in six, implicitly in 16 and absent in one. Conclusion: The Unified Health System permeates most of the course in theoretical-practical activities. Its effectiveness will depend on the intentionality of the teacher in pointing it as a cross-cutting theme of the Nursing curriculum. Descriptors: Education, Nursing; Education, Higher; Unified Health System; Curriculum; Faculty; Teaching. RESUMO Objetivo: descrever como ocorre o desenvolvimento do tema transversal Sistema Único de Saúde em um currículo de Enfermagem. Método: estudo qualitativo, descritivo e exploratório. Ocorreu por meio da análise de 17 documentos contendo planos de ensino-aprendizagem de um currículo de Enfermagem, no ano de 2015. Realizado no curso de graduação em Enfermagem de uma universidade pública do Sul do Brasil por adotar os temas transversais em seu projeto pedagógico, sendo um deles o Sistema Único de Saúde. Para a discussão dos dados, utilizou-se, como referencial teórico, o pensamento pedagógico de Paulo Freire. Resultados: a expressão Sistema Único de Saúde apareceu como tema transversal em três documentos, de forma explícita em seis, implicitamente em 16 e ausente em um deles. Conclusão: o Sistema Único de Saúde permeia a maior parte do curso em atividades teórico-práticas. Sua efetivação dependerá da intencionalidade docente em apontá-lo como tema estruturador e transversal do currículo de Enfermagem. Descritores: Educação em Enfermagem; Educação Superior; Sistema Único de Saúde; Currículo; Docentes; Ensino. RESUMEN Objetivo: describir cómo ocurre el desarrollo del tema transversal Sistema Único de Salud en un currículo de Enfermería. Método: estudio cualitativo, descriptivo y exploratorio. Se realizó por medio del análisis de 17 documentos, conteniendo planes de enseñanza-aprendizaje de un currículo de Enfermería, en el año de 2015. Realizado en el curso de graduación en Enfermería de una universidad pública del Sur de Brasil, por adoptar los temas transversales en su proyecto pedagógico, siendo uno de ellos el Sistema Único de Salud. Para la discusión de los datos, se utilizó, como referencial teórico, el pensamiento pedagógico de Paulo Freire. Resultados: la expresión Sistema Único de Salud apareció como tema transversal en tres documentos, de forma explícita en seis, implícitamente en 16 y estando ausente en uno de ellos. Conclusión: el Sistema Único de Salud permea la mayor parte del curso, en actividades teórico-prácticas. Su efectividad dependerá de la intencionalidad docente en apuntarlo como tema estructurador y transversal del currículo de Enfermería. Descriptores: Educación en Enfermería; Educación Superior; Sistema Único de Salud; Curriculum; Docentes; Enseñanza. Master, Master's Program in Nursing Master's Degree Academic, State University of Londrina / UEL. Londrina (PR), Brazil. E-mail: adjunior_enf@yahoo.com.br ORCID: https://orcid.org/0000-0002-5158-235X; PhD student, Master's and Doctorate Program in Nursing, State University of Londrina / UEL. Londrina (PR), Brazil. E-mail: grazipedrao@hotmail.com ORCID iD: https://orcid.org/0000-0002-38295137; PhD, Master's and Doctorate Program in Nursing, State University of Londrina / UEL. Londrina (PR), Brazil. E-mail: marlivannuchi@gmail.com ORCID iD: https://orcid.org/0000-0003-2421-4532; PhD, Master's and Doctorate Program in Nursing, State University of Londrina / UEL. Londrina (PR), Brazil. E-mail: dellaroza@uel.br ORCID iD: https://orcid.org/0000-0002-7869-540X; PhD, Master's and Doctorate Program in Nursing, State University of Maringá / UEM. Maringá (PR), Brazil. E-mail: ieda1618@gmail.com ORCiD: https://orcid.org/0000-0002-4205-6841 ORIGINAL ARTICLE Barbosa Junior AJ, Perales PGPS, Vannuchi MTO et al. The unified health system as a crosssectional... English/Portuguese J Nurs UFPE on line., Recife, 12(4):930-7, Apr., 2018 931 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i4a235013p930-937-2018 Health education is a complex process involving the apprehension of cognitive, humanistic and affective skills. Nursing undergraduate curricula have undergone several reformulations, breaking with the traditional, specialized, biologistic and disease-focused model of education. In Brazil, the struggles of popular health movements emerged in the 1970s and, in 1979, gave rise to the Sanitary Reform, seeking to build a new health model for the country. The VIII National Health Conference in 1986 had intense popular participation, being decisive for the promulgation of the Federal Constitution of 1988 and leading to the creation of the Unified Health System (UHS). The UHS expanded the concept of health, which has come to be considered as a human right, and the State provides the necessary conditions for its guarantee. In addition to providing care to the individual through the promotion, protection and recovery of health, should provide preventive activities and act in the identification and disclosure of the health determinants and condicioners. When implementing the new System, health education institutions had to include in their curricula the policies, programs and actions to implement this new model. Thus, the need for undergraduate courses to train professionals to consolidate the UHS, since the biomedical paradigm of education imposed difficulties in its implementation, and the training is far from public health policies. With the advent of the National Education Guidelines and Bases Law (GBL) in 1996, minimum curricula were excluded and greater autonomy was granted to educational institutions, allowing the development of innovative pedagogical projects. In order to attend to and sustain the GBL, in 2001, the National Curricular Guidelines (NCDs) for the Nursing undergraduate course were established. This instrument is based on the Pedagogical Projects of the Courses (PPC) and assumes a commitment to the Sanitary Reform and the UHS by promoting paradigm changes in Nursing education. The Nursing course of the study institution underwent seven curricular reforms and, in 2000, implemented the Integrated Curriculum and, in 2009, a new re-elaboration of its PPC was made. In the perspective of the course, nurses are seen as agents of social transformation with political and professional responsibilities. Therefore, education is understood as a social practice promoting the development of nurses in an integral way and committed to the construction of citizenship. The curriculum of this course is organized in 18 interdisciplinary modules. Twelve crosscutting themes are adopted, contents that must be present in all modules and presented through successive approximations, at levels of increasing complexity. The problematizing pedagogy, proposed by Paulo Freire, guides the actions of the Integrated Curriculum, causing students to build knowledge through their relationship with the world. One of the transversal themes of this curriculum is the UHS, developed in the modules through different teaching strategies, so that the student experiences the practices in health services and contextualize them in theoretical meetings so that it can reflect and analyze their social and professional in the construction of UHS. This study will allow us to reflect on the presence of the UHS as a cross-cutting theme in this and other nursing curricula, rethinking pedagogical practices for proposing paradigmshifting strategies in nurses' training. The pillars of Paulo Freire's work are convergent to the discussion of the UHS and to the pedagogical proposal of this Nursing curriculum, allowing a greater deepening of this theme and thus rethinking the Nursing training. When understanding that the training of the nurse professional should be focused on the health needs of the population, with emphasis on the UHS, and the importance of the transversal theme UHS to be addressed in the 18 modules of the course, the following research question was elaborated: The theme Is the National Health System being taught throughout the four grades of this course? In what way? ● Describe how the development of the cross-sectional theme of the Unified Health System in a Nursing curriculum occurs. A qualitative, descriptive and exploratory study was carried out. It occurred through the documentary analysis of 17 planning and development notebooks of the interdisciplinary modules of the Nursing curriculum under study. Qualitative research analyzes complex phenomena, explains or describes events. It considers the subjectivity of the researcher and of those being studied and the relations between the subjects and the world. METHOD OBJECTIVE INTRODUCTION Barbosa Junior AJ, Perales PGPS, Vannuchi MTO et al. The unified health system as a crosssectional... English/Portuguese J Nurs UFPE on line., Recife, 12(4):930-7, Apr., 2018 932 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i4a235013p930-937-2018 The research site was the Nursing undergraduate course of a public university in the South of Brazil because it is a Higher Education Institution that adopts transversal themes in its PPC, one of which is the UHS. The course under study has 18 modules structured in planning and development, referring to the teaching and learning plans, constructed in a multidisciplinary way and reviewed annually. As an inclusion c

Health education is a complex process involving the apprehension of cognitive, humanistic and affective skills. In Brazil, the struggles of popular health movements emerged in the 1970s and, in 1979, gave rise to the Sanitary Reform, seeking to build a new health model for the country.The VIII National Health Conference in 1986 had intense popular participation, being decisive for the promulgation of the Federal Constitution of 1988 and leading to the creation of the Unified Health System (UHS). 3,4e UHS expanded the concept of health, which has come to be considered as a human right, and the State provides the necessary conditions for its guarantee.In addition to providing care to the individual through the promotion, protection and recovery of health, should provide preventive activities and act in the identification and disclosure of the health determinants and condicioners. 5en implementing the new System, health education institutions had to include in their curricula the policies, programs and actions to implement this new model.Thus, the need for undergraduate courses to train professionals to consolidate the UHS, since the biomedical paradigm of education imposed difficulties in its implementation, and the training is far from public health policies. 2th the advent of the National Education Guidelines and Bases Law (GBL) in 1996, minimum curricula were excluded and greater autonomy was granted to educational institutions, allowing the development of innovative pedagogical projects.In order to attend to and sustain the GBL, in 2001, the National Curricular Guidelines (NCDs) for the Nursing undergraduate course were established. The Nursing course of the study institution underwent seven curricular reforms and, in 2000, implemented the Integrated Curriculum and, in 2009, a new re-elaboration of its PPC was made.In the perspective of the course, nurses are seen as agents of social transformation with political and professional responsibilities.Therefore, education is understood as a social practice promoting the development of nurses in an integral way and committed to the construction of citizenship. 8e curriculum of this course is organized in 18 interdisciplinary modules.Twelve crosscutting themes are adopted, contents that must be present in all modules and presented through successive approximations, at levels of increasing complexity. One of the transversal themes of this curriculum is the UHS, developed in the modules through different teaching strategies, so that the student experiences the practices in health services and contextualize them in theoretical meetings so that it can reflect and analyze their social and professional in the construction of UHS. 10 This study will allow us to reflect on the presence of the UHS as a cross-cutting theme in this and other nursing curricula, rethinking pedagogical practices for proposing paradigmshifting strategies in nurses' training.The pillars of Paulo Freire's work are convergent to the discussion of the UHS and to the pedagogical proposal of this Nursing curriculum, allowing a greater deepening of this theme and thus rethinking the Nursing training.
When understanding that the training of the nurse professional should be focused on the health needs of the population, with emphasis on the UHS, and the importance of the transversal theme UHS to be addressed in the 18 modules of the course, the following research question was elaborated: The research site was the Nursing undergraduate course of a public university in the South of Brazil because it is a Higher Education Institution that adopts transversal themes in its PPC, one of which is the UHS.The course under study has 18 modules structured in planning and development, referring to the teaching and learning plans, constructed in a multidisciplinary way and reviewed annually. 12 an inclusion criterion for the analysis of the notebooks, it was used to belong to the year 2015.The modules "Completion Work for Course I" and "Work for Completion of Course II" were excluded from the study.The "Internship" module has two planning books, "Hospital Internship" and "Internship in Collective Health", totaling 17 workbooks analyzed.
The documentary research was carried out from October 2015 to March 2016.An instrument was created to collect data in order to identify information such as the name of the module and the series in which it occurs and the time load of the respective module, looking for the presence UHS theme in the menu, in the thematic tree, competences, performances and abilities, besides the description of the theoretical activities, practical activities and bibliographical references indicated for the students.
It was sought to analyze, in each document, the following situations: if the UHS was clearly present as a transversal theme; if the UHS expression was mentioned explicitly or if the UHS theme was implicitly present.The definitions of the New Aurelian Dictionary of the Portuguese Language 13 were considered: "Implicit-Adj.That is involved, but not in a clear way; tacit, implied." "Explicit -Adj.Expressed formally; clear, developed, explained." For the analysis, the four steps or reading phases were used: exploratory, when the notebooks were read in full, in order to recognize the study material; selective, when they were selected, according to the research objective, the materials of interest for its accomplishment.Subsequently, the analytical reading was performed, using the data collection instrument, ordering the information and seeking answers to the research question, and finally, the interpretative reading was made, making connection with the theoretical reference, to give meanings to the study. 14 order to deepen the discussion of the results, Paulo Freire's pedagogical thinking, based on a problematizing pedagogy, which proposes dialogic education, based on humanization, praxis and critical-reflexive action, was used as a theoretical reference, thus, the need to educate to transform the world and having the professional to make a commitment to society. 15e The analysis of the UHS theme, in the Planning and Development Notebooks of the modules, is described in the tables below, referring to each of the series of the Nursing course under study, with subsequent discussion of the presented data.
The first series of the Nursing course of the university under study consists of four modules totaling 901 hours of theoretical and practical hours.Then, in the table 1, the modules of the first series are presented and the results of the analysis of their planning notebooks.The expression UHS was presented as a cross-cutting theme in the module A University and the Nursing Course, describing the theoretical and practical activities, demonstrating all the cross-cutting themes of the curriculum.The UHS also explicitly and implicitly introduced itself in delimiting its competencies, performances, abilities and in the bibliographical references suggested.The module proposes to discuss the Nursing course, the historical context of the profession, the fields of action of the nurse and the social and economic context in which it is inserted.

RESULTS
In the Health-Disease Process and PIM I module, the UHS expression was presented explicitly and implicitly in all aspects surveyed.The Health-Disease Process module has as one of its objectives: "to know the principles and guidelines of the UHS and the models of health care."The PIM I is an interdisciplinary module, experienced in Basic Health Units (BHU), where students will discuss the work process in Primary Care.In these modules, the UHS is one of its objects of study as competence of the area of Collective Health.
In the module Morphological and Psychic Aspects of Human Being, the UHS was absent in the description of the module.In this module, the objectives are: "the development and the structural organization of the human being, relating their anatomical, tissue and cellular components"; the "promotion of mental health in the care of the human being" and "To present to the students the whole human being as a healthy and healthy individual, inserted in society in his / her most perfect condition of life, 'a homeostatic being'".
In the first series, UHS manifested itself as a cross-cutting theme only in the module that aims to present the curriculum of the university and its PPC.In the specific modules of Collective Health, the UHS expression appears explicitly and the theme implicitly arises in the skills and competences advocated by the respective modules.The competence module of the Biological Sciences did not present the UHS in its planning.It was verified that the UHS expression was not present as a transversal theme in any of the modules of the second series.It was explicitly presented only in the module of the Organization of Health and Nursing Services, stating that "all units of the module are guided by UHS principles".The module is the responsibility of the Department of Collective Health and aims to discuss the history, principles and guidelines of UHS.Therefore, the theme also arose implicitly in the skills and abilities described in its notebook.
In the other modules of the second series, the UHS remained implicit in emphasizing the students' experience in health services, primary and secondary care, in addition to working on epidemiological research, Primary Health Care Programs and health education.As shown in the table, in the third series the UHS was described, as a cross-sectional theme, only in the Health of Children and Adolescents module, in its thematic tree, which also presented the other themes worked on in this module.In terms of skills, performance and skills, the theme implicitly stood out in highlighting practices in health services.
In the Health of the Adult II module, the UHS expression came explicitly in describing its abilities: "discuss in the context of UHS"; "Path of the patient in UHS".In Women's Health and Gender, the UHS theme permeates the module implicitly presenting the National Program of Integral Attention to Women's Health, in addition to working with health indicators and Epidemiology.
Although the UHS theme permeates the modules of the third series, it was observed that a traditional paradigm that prioritizes technical-scientific knowledge still prevails in these modules.In the description of the activities, emphasis was placed on the contents and technical procedures of Nursing, often dissociated from the context of the UHS in which they are inserted.These conditions hinder committed professional training with the promotion of integral health.In the educational process, one must stimulate creativity and stimulate action-reflection resulting in a more humanistic and liberating formation, with respect to the students' autonomy.1,16 The last series of the course has 1,448 hours.Its modules are presented in the following table and the results, discussed in the sequence.From this analysis, the module Completion Work of Course II.The expression UHS was presented, as a transversal theme, in only one of the modules: Nursing Internship -Hospital Area.The UHS expression was given in this way in the description of the six performances and abilities proposed for the module.In its thematic tree, the theme is implicit in bringing expressions such as: "hospital performance", "levels of complexity" and "permanent education".
In the Critical Care Patient module UHS, it is explicit as an ability: "Considering the organization of UHS in emergencies and emergencies", being implicit in the description of activities and in the thematic tree.
In the module Mental Health, Communicable Diseases and Internship in Collective Health, the UHS appears implicitly.In the Mental Health module, the UHS is implied by mentioning as performances: "knowing the Psychosocial Care Network of the municipality; the Mental Health Policy and Harm Reduction ", in addition to appearing, as competences, the National Basic Care Policy (NBCP) and the knowledge of epidemiological profiles.
The Communicable Diseases module also presents in its thematic tree, "Epidemiological profile" and "Organization of the Health Services", but, when mentioning the crosscutting themes to be developed, it is not mentioned UHS.
The Nursing Internship in the area of Collective Health has, as its objective, the students' experience in Basic Health Units (BHU).In its planning notebook, there is a description of the levels of health care and skills to be developed in the primary care services, but the UHS expression does not appear explicitly.
The first year of the Nursing course should provide daily moments of reflection and experiences about the Health System so that students, from the beginning, take on the commitment with the UHS and with society.According to the PPC of this curriculum, the development of the theme must occur through successive approximations. 9r Freire, education is a form of intervention in the world, being the educating an active being, of social transformation.By not including the UHS in the module, the student loses the opportunity to dialogue with the political and social context of health.Education is a political act and modifier of the world and the professional has a commitment to society. 15,16e absence of the UHS theme in the Biological Sciences competence module also reveals the fragmented and specialized nature of teaching and the lack of dialogue with the different areas of knowledge.Even with the pedagogical proposal of the course, the subject under study is not yet described, in the notebooks of the modules, in a systematized form and as a crossectional theme.
With each module, the theme should be contextualized with the competences to be developed and the teacher should point out the need of the formation of professionals for the UHS according to the NCGs. 9 this way, the transversal themes, described in the planning notebooks, would awaken the intentionality that they should be present in the development of each of the modules.By appropriating intentionality for UHS, teachers can create spaces for students to experience the Health System in the most diverse dimensions.
Teachers need to look at human complexity by understanding that the student needs spaces to read the world and its reality in order to rewrite it.From their own experiences, the human being can develop understanding about the world and how it can relate to the environment.This process is called, by Paulo Freire, as "Problematization". 15,16e acquisition of nurses' skills requires the student to incorporate a professional culture that will only take place through dialogue and criticality.Freire says that "teaching requires methodical rigor".This rigor is not related to the transmission of content, called banking education, but to the conditions in which educators and learners learn critically and are subjects of this process, which is not exhausted in the treatment of certain competence.To this education, Paulo Freire calls liberating and is committed to the principles of the UHS and the liberation of men. 1,17ter analyzing the planning and development notebooks of the interdisciplinary modules, through the strategies used to investigate the crosssectional theme Sistema Único de Saúde, it was observed that the UHS expression appeared as a transversal theme in three of the 17 documents, explicitly, in six books and, implicitly, in 16 other documents.In one of the documents, the theme was not present at any time.In some modules, the UHS was present, differently, throughout the writing of the notebooks, which explains the theme presented implicitly and explicitly in the same module.
In general, the modules presented their objectives, competencies, performances and abilities, theoretical and practical activities developed, as well as their bibliographic references.Of the 17 booklets of the modules, four described their menu and nine presented their thematic tree.It was noticed, therefore, that there was no uniformity in the writing of the modules or systematization for such documents existed that were summarized to the description of the schedule of activities.
The modules that brought the UHS, implicitly, did so when using Ministry of Health Programs, evidenced health indicators and epidemiology for various health problems, used official documents and protocols and demonstrated the insertion of students in the most various health services.
It was noticed that the transversal theme UHS is not standardized throughout the course.The writing of the notebooks does not follow a systematization, being absent elements such as menu and thematic tree in the documents and there is a differentiation in the writing of the same in the different areas of knowledge of the university and even among the specialties of the Nursing Department.
Through documentary analysis, it was understood that students experience the UHS theme, especially in those modules that do not specifically aim to discuss their theoretical aspects, relating it to the public health services in which they will hold their theoretical-practical classes.
It was also understood that, the theme permeates most of the modules, allowing students to be immersed in UHS health services and discuss their socio-political and epidemiological realities, aimed at the integral care of the population.
If the UHS transversal theme is implicitly absent or present in the module books, it will depend on the intentionality of the teacher to make the students understand where and when the UHS will be part of the theoretical and structural complexity of the interdisciplinary modules.If this care is not available, the understanding of UHS for students can be limited to a health care model that continues to privilege the technique and prevents its training as a subject and a professional to meet the needs of the population.
To this end, teachers should allow students to approach the object of study by provoking dialogue with their reality and the construction of knowledge.In this way, one can guarantee the commitment to the teaching-learning process by understanding that the students recognize their ideological and political position in teachers, which will guarantee the construction of a praxis directed towards the transformation of realities.
Understanding the UHS as a cross-cutting theme in the training of nurses is to provide an opportunity for the academic community to experience different social realities throughout their course through their experiences in order to build a health vision that goes beyond technical-scientists.Therefore, it is through the deepening of a critical awareness that education can become the basis for the transformation of society and producer of a new social organization, which Paulo Freire calls the "Freedom Practice". 15 is hoped that this study may raise questions about the insertion of SUS into the training of health professionals, in order to awaken new research in different scenarios and realities in Brazil.
It proposes the creation of differentiated learning environments and the understanding that UHS is a space and theme in which students must be inserted, at all times of the graduation, viewing it as a reading and acting scenario, so that they can rewrite it and reaffirm it by assuming its commitment to society.It is important to rethink the educational practice and the relationship established between educators and students to build this environment favorable to the development of the cross-sectional theme Unified Health System.As Paulo Freire states: "No one educates anyone, nobody educates oneself, men educate themselves among themselves, mediated by the world." study was approved by the Committee on Ethics in Research Involving Human Beings of the State University of Londrina, in compliance with Resolution 466/12 of the National Health Council of the Ministry of Health -CNS / MS, under the Opinion no.

Table 1 .
Description of the SUS theme in the modules of the first series of the Nursing course under study.Londrina (PR), 2015, Brazil.

Table 2
presents the modules of the second series of the Nursing course.The second series has theoretical and practical hours of 906 hours.The results and discussion of the analysis of the five modules are presented below.

Table 2 .
Description of the SUS theme in the modules of the second series of the Nursing course under study.Londrina (PR), 2015, Brazil.

Table 3 .
Description of the SUS theme in the modules of the third series of the Nursing course under study.Londrina (PR), 2015, Brazil.

Table 4 .
Description of the SUS theme in the modules of the fourth series of the Nursing course under study.Londrina (PR), 2015, Brazil.