SHARING KNOWLEDGE AND TEACHING EXPERIENCES IN A REFERENCE CENTER FOR LEPROSY

This study aims to report an experience of a curricular internship in nursing based on the investigative methodology in a Reference Center for Leprosy. It is an experience report structured in the description of a series of activities, components of a didactic sequence, whose contents permeate the construction of the care for adults and the elderly with Leprosy and /or other skin and appendages alterations. The educational goals and the teaching techniques used supported the discussion on the construction of knowledge from the perspective of the critical pedagogy and public policies that guide the academic formation in the health area. Among the lessons learned, we highlight the role of intervention and teaching mediation in the learning process, as well as the relevance of the reflective practice as essential and leveraging of transformation in the educational process.


INTRODUCTION
The in training learning for the health area presupposes the production of thought, subjectivity and dialogue that can be developed through the "critical reflection over the real practices of real professionals performing in the health service network" 1 .Thus, "Learning is understood as the student's natural response to the challenge of problematic situations" 2 .The ideas of the "problem solving" or "liberating" education emphasize that learning is a research in which the student, based on a problem, expands his vision: from global to analytic to understanding the problem through theorization.The structure of the problem and its consequences when deeply understood generate hypothesis of solutions that need to be viable 2 .
The organization of educational and learning activities that encourage the active participation of students is extremely important for the development of critical thought and for the practice based on the action-reflection-action.It's through the planning of the activities and the reflective pedagogical practice that the professor determines the quality of the relationship between student, professor and learning object; determines the learning needs and the expectations of what students have to learn and understand; develops the curricular content and the assessment process; analyses the impact of the work on the student's acquisition of skills and abilities.
To Suárez 3 , there is potentiality in the theoretical, methodological and political scopes of the narrative documentation of pedagogical experiences or experience reports.The latter, elaborated by the professor, potentializes both educational and learning issues, as well as administration and assistance ones that can be re-planned to better attend the school public.The author emphasizes the importance of the report is in the discourse that should communicate the experiences that take place at school, like teaching, but also in the free activities, breaks and professor meetings.The stories should be narrated in the professor's own words according to his feelings and beliefs.These reports vitally and practically show what the curriculum in action is.
In this context, this article aims to report the experience of a curricular internship in nursing based on the problematization methodology in a Reference Center for Leprosy, focusing on educational goals, techniques and teaching experiences.

Preparatory step a) objectives, teaching resources, major teaching strategies
This is a descriptive research focusing on the teaching techniques developed during a 45 hour curricular internship in a reference center for Leprosy with eighth term undergraduate nursing students from a Higher Education Institution, in a city of the Middle-west of São Paulo.
The clerkship took place during the second semester of 2009 and 2010.It encompassed 145 students, divided in groups of five participants, who attended the internship during the morning and afternoon.The educational and teaching activities were structured based on the postulates of the liberating pedagogy and on the use of teaching strategies that helped the students understand the health-disease process taking into consideration the Social Determinants of Health (SDH); made the scientific research possible and helped the students understand the group knowledge construction and the process evaluation.
The planning of the activities and of the clerkship project happened in partnership with the technical director of the nursing body of the institution and with the nurses of the continuing education in meetings scheduled during working hours.During the meetings, the aim was the development of an interdisciplinary project by means of joint actions among the trainees, supervising professor, nursing professionals and professionals from other health areas, researchers and service users in order to promote the discussion and the analysis of the care, institutional and professional practices, taking into consideration the resizing of actions.
The main objective of the internship was to plan nursing care for adults and the elderly with skin and skin appendages alterations caused by dermatologic diseases, especially Leprosy.Among some of its specific objectives, we can highlight: to understand the profile of the assistance nurse; know the booklet on the rights of health service users; identify the epidemiological profile of Leprosy in Brazil and in the world; identify how the Health System is organized to offer assistance to the patient with Leprosy and other dermatologic diseases; participate in the care activities of a service specialized in the prevention, recovery and rehabilitation of individuals with Leprosy and other dermatologic diseases; develop the skill of working in a multi-professional team with an interdisciplinary focus; develop the skill of intervention through observation, critical reflection and communication based on ethical principles; perform the health condition evaluation and plan the nursing care in clinical, surgical and outpatient situations.
The contents were: general dermatology, epidemiology and physiopathology of Leprosy and dermatologic diseases of sanitary interest, anamnesis and physical examination of adults and the elderly, anamnesis and physical examination of the skin and skin appendages, nursing process, health-disease process, among others.The resources used in order to develop the contents were: books (Dermatologia, by Sampaio and Rivitti); course books (Manual of norms and routines and techniques of dressings of the ILSL by Roseli Oda); atlases (Leprosy atlases by Diltor Opromolla and Somei Ura); websites (such as the ones from research institutes: Lauro de Souza Lima, Emílio Ribas, Health Institutions); videos (such as the ones from the collection of the Fundação Oswaldo Cruz Health channel); online libraries (Virtual Health Library Leprosy); professional practices, lectures, workshops and courses held at the Reference Center.
The development of the internship occurred in stages.These stages covered the welcoming of the students at the Institution, the diagnostic evaluation, the production of knowledge and the elaboration of the final task.
The teaching techniques were carefully selected with the intention of working the educational objectives and the contents in a critical, reflexive and contextualized way.There were flexibilities and adjustments according to the learning needs.The predominant operations of thought in each strategy were valued and evaluated in a procedural manner.
The students` technical and scientific production was aggregated to the evaluation process and registered on the users` medical records after the professor`s daily evaluation and the validation of the nurses.

b) Educational goals, teaching techniques and description of teaching activities.
Figure 1 shows the educational goals, the corresponding teaching techniques and the description of activities elaborated by the professor to support the knowledge construction.

Description of the teaching activities
Expression of ideas, values, beliefs, knowledge and expectations in performing nursing care to patients and people with Leprosy sequelae.

Group discussions or successive dialogues
Using guiding questions, the professor leads the discussion about the historical, cultural and social aspects of leprosy based on the reality of the students and their experiences with the topic reasoned on local culture, religion and mythology.
Perceive reality, describe situations and acquire knowledge and information.
Field Activities In field activities, the students were able to understand the political and social aspects of the compulsory isolation public policy going through the physical structure of an old colony asylum, discussing the social and psychic relations established, knowing and listening to stories of some residents that experienced the isolation and are currently experiencing the social and urban problems plaguing the former asylums.Visits to the Reference Centre library and the handling of the collection.
Meditate individually and collectively on a topic, with the help of books, publications, Information and Communication Technologies (ICT) and specialized professionals.

Reflection and study circle
Supervised navigation and presentation on the major Leprosy databases (for example: the Virtual Health Library Leprosy) and the Morhan site (Movement of Reintegration of Persons Afflicted by Hansen's disease).After the activities, the students received a study guide for the analysis of scientific papers (elaborated by the professor) to read and analyze critically epidemiological and clinical research on VHL Leprosy.The presentation of the material produced with the application of the study guide led to discussions on the disease in its bio-psychosocial and ecological aspects and on professional practices.

c) Theoretical and methodological reference
The Law of Directives and Bases of National Education (LDB), Article nº 3, advocates that teaching must be reasoned in principles based on the individual and his life in society.Therefore, you can perceive education in the daily action of the men and in the dynamics of the construction of their social reality 4 .
Considering the article, the teaching activities -"situations created by the professors that the student can live experiences considered necessary to lead to intellectual, affective and motor changes [...]" 2 must provide observation, reading and thinking about life and work in the contemporary society.
The role of the professor is to encourage the participation of the student in a bigger number of educational activities -"learning situations created by the professor to increase the probability that students live the experiences necessary to achieve the educational objectives" 2 , since he is the responsible in the teaching-learning process for organizing and decoding the structure of the teaching object in order to articulate theory, practice and reality in a dialectical movement of action-reflection-action.In this movement, the professor helps the student to constantly approach the knowledge and this approximation is facilitated in a real environment of practice, in the internship environment 5,6 .
Masetto 7 emphasizes that internship is "[...] a true space-class time and not only an opportunity to apply some knowledge in the classes." The professor, in this space-class, leads the student to understand how significant learning is and how the student can develop responsibility in that context.
The internship planning, the selection of the teaching and the educational activities related based on theories and curriculum content is an exclusive role of the professor 6 .Therefore, the internship planning cannot be limited to the fulfilling of the internship load advocated by the legislation, to the technical application of mechanical, instrumental, and ritualistic character, or to rules learned in theory 8 .
According to the National Board of Health 9 , the biggest goal of the curricular internship in the health area is the adequacy of the training to the needs of the SUS.It suggests the internalization (including the rural area) of clerkships, boarding schools and residency programs of professionals already trained also willing to increase the coverage, the quality of health actions, the integration between the teaching and the provision of services.
Brazil 10 states the curricular internship in the health area must be supervised by a professor of the course and by a specific professional inserted in the health establishment where the internship occurs.In nursing, the internship occurs in the last two semesters of the course, with a minimum number of hours of 20% of the total course load.It must occur in the basic, medium and high complexity care.
The supervised clerkship is obligatory in the context of professional education and other levels, according to the law Nº 11.788.It gives the students the opportunity of integrating with the world of work, exchanging experiences offered by the socio -professional interaction, acquiring new knowledge, skills, attitudes, values, responsibilities and the ability to make professional decisions autonomously 11 .
Considering the importance of the internship in the training of the student and understanding that only through planning the professor allows the students to interact with the teaching object, we need to conceptualize it.Planning can be understood according to Bordenave e Pereira 2 as "[...] solely a more systematic application of pedagogy ".FORTES et al. 6 states that […] the planning defines the results and the means to achieve them, the performance constructs the results and the assessment serves as a Extended clinic Care and educational activities focusing not on the disease, but on the person.
Individual care based on the clinical method (anamnesis and physical examination of the skin) with sick people and the ones with sequelae of the disease.Nursing care was offered to people who were hospitalized and in ambulatory care in accordance with the Institution Nursing Process.Educational activities related to self-care in Leprosy (face, hands and feet), and the care and treatment of ulcers occurred in each attendance.In the waiting room, the disease was collectively discussed according to the need expressed by the users.
Development of the analytical skill, scientific spirit and preparation to face complex situations and the skill to make decisions through collective study of real situations.

Problem -case study
Selection of an attendance experience, data synthesis and elaboration of a presentation in order to adopt a plan of action -elaboration of a care plan.
verification tool of the planned results that are being achieved, as well a support for decisions that must be taken to ensure the construction of the results.However, not all professor tasks can be fully defined and predicted in advance.In a teaching-learning situation, in a given context, students, professors and the knowledge inter-relate causing unexpected reactions and situations that make professors mobilize knowledge to modify their decisions and actions on the content structuring and management, and on the interactive regulation of the events 12 .
According to Suarez 3 , planned or not, professors and students build at school several experiences full of value for them.It's in the space between the prescription of the curriculum and its practice that the school "actors" (professors, students, and the people who work with the school administration and maintenance) collaborate with each other creating real meaning of the construction of knowledge and the practice of teaching at a given time and place.
Bordenave and Pereira 2 , analyzing the planning of teaching in the perspective of the problem-solving, emphasize the planning is based on the contents of the subject disregarding the expectations of society and the growth of the student; it's accomplished without surveys and research about the requirements of the labor market, the transformations of society and the needs of the community.Regarding the planning of a subject, they state that for the educational goals to be achieved, they need to be clearly and accurately formulated because from them the professor can establish the experiences of learning and teachinglearning activities in order to elaborate the didactic strategy.
To accomplish the goals, the professor needs the students to expose themselves to, or live, certain experiences, able to induce the desired changes on them.Such experiences require certain EDUCATIONAL INPUTS in the form of environmental influences that act on it.Thus, the goals require the student to expose himself to situations and messages, that is, real problems or representations of the problems, facts and theories, formulas and theorems, conflicts and cooperation efforts etc 2 .
Nemirovsky 13 emphasizes a planning model that differs from the transmission model of education, in which the professor organizes the activities in projects and didactic sequences in order to facilitate the student's relation with the teaching object producing significant knowledge.Such model, according to the author, helps the professor to accurately determine which materials, situations or information sources are relevant to the educational construction.Anastasiou and Alves 14 affirm that just informing is insufficient for human education in any area of knowledge.Experiencing and facing difficulties, possible and unviable answers, a multiplicity of pathways and resources are extremely necessary situations for the construction of individual schemes of knowledge.

d) The experience, stages and teaching techniques
Considering the theoretical and methodological reference already exposed, a Teaching Plan for the subject was organized.A didactic sequence was created based on this plan, structured in goals, content, estimated time, necessary materials and equipments, flexibility, development and assessment.The development was divided in four stages.
Stage 1 -Welcoming students: their academic registration was done by the Institution department of education and research; they received explanations about the functioning of the Institution (the limits and scope of its activities) group discussion and internship dynamics.
The group discussion took place in the field, on the first day of internship, before any formal presentation of the Teaching Plan and lesson plan.The guiding questions tried to cover the common sense and each student personal experiences with leprosy and other skin diseases, as well as the expectations in providing nursing care to the elderly and adults with skin alterations and skin appendages.
Regarding the group discussion as a teaching strategy, it promotes a very valuable human educational moment because everyone learns something from each other.Each person, with his knowledge and life story, helps the educational construction of the other, the reading of the social reality and common sense through the contrast of ideas.It is also a very important moment for the professor, especially by being close to students and getting to know their life stories.When the professor meets the students, their stories, personality characteristics, limitations and potentialities, it helps to promote not only academic skills but also the social-emotional development.Suarez 3 states the student-professor closeness is what characterizes the teaching; everything that happens between them in the school environment is valuable to the success of the teaching-learning process.
Stage 2 -Diagnostic evaluation: on the second day of internship, the students participated in a technical visit in the Institution and in the former colony asylum.The professor explicated the political and social aspects of the compulsory isolation public policy, showing the physical structure of the former colony asylum, talking about the social and psychic relations established, learning and listening to stories of some residents who experienced the isolation and raising the current social and urban problems plaguing the former asylums.After the visit, the students were submitted to a test (available on the site Morhan -Movement of Reintegration of Persons Afflicted by Hansen's disease-and adapted by the professor), involving the clinical and epidemiological aspects, the pathophysiology, diagnosis and the disease treatment.The test was reapplied two days before the end of the internship and discussed on the day of the assessment.
Stage 3 -knowledge construction: 3.1 -based on the test result, the professor gave a dialogic lecture on leprosy and other skin diseases at the center of teaching and research premises.The professor sent supplementary material to the students by e-mail and suggested them to visit the electronic collection of Virtual Health Library -Leprosy.In the second half of the third day, students visited the library of the Reference Center, handled the material, received technical instructions and an analysis script of scientific articles (elaborated by the professor) for reading and doing a critical analysis of epidemiological and clinical research in the VHL Leprosy.In this stage, professor and students agreed on 1) daily reflections about cases; 2) researches on VHL database -health and leprosy; 3) selection of relevant studies associated with the problems experienced; 3) use of the script and 4) elaboration of a presentation of the selected article as one of the internship final tasks.
During the execution of the teaching methods, it was possible to integrate videos and e-books in the teaching-learning process.To justify the selection and the importance of presenting the main databases on leprosy and of the supervised and autonomous navigation, we use the text fragments of Garcia et al 15 that emphasize: "[…] students who experience during their academic education moments they can use educational technologies have higher chances of understanding and using these technologies in the future [...]" and Minayo 16 : It is the research that feeds the teaching activity.
Researching is an attitude and a theoretical practice of a constant search and, therefore, is characterized as temporarily finished and permanent unfinished.It's an activity of a successive approximation to the reality that never runs out, constructing a particular combination between theory and data, thought and action ".
3.2 -On the fourth and fifth days of internship, the students experienced the institutional dynamics of new cases, outpatient, hospitalization and longterm institution (individuals diagnosed with leprosy, with rare skin diseases, among other situations), with the professor and the service professionals.They got the main medical treatments, diagnostic tests and therapies through exploiting the environment, resources, equipments and established relations.
3.3 -On the sixth day of internship, students were led to the Hospitalization Units.After the professor's explanations about the information registry in the medical record, and legal and ethical aspects involved in this registration, the students chose a case, handled the medical record and got prepared for the first approach with the individual with skin alterations and appendages.
The students were challenged to apply clinical method (anamnesis and physical examination of the skin) and record the findings.After discussions about the findings and records in a group discussion and with the individual, the professor offered a supplementary reading for a refinement and conceptual and theoretical support.
3.4 -From the seventh day onwards, up to completing 45 hours, the students provided nursing care for hospitalized individuals and those in outpatient care according to the Institution Nursing Process.The professor followed the whole process, discussing about the care plan, intervening technically and theoretically, mediating relations between students, health staff and the users.
Educational and in-service education actions permeated all stages the professionals, the users and their families received all of them well.The actions planned and executed by the students were part of the formative assessment.
Stage 4 -construction of the final task: the students were led to selecting an experience in order to prepare a case study based on references presented and worked by the professor during the internship.The case study was selected as the final task, since it enables a detailed and critical analysis of a real situation susceptible of being investigated, analyzed, argued and transformed, as well as it provides the professor an opportunity to reinforce, complement and enhance the content, favoring the knowledge acquisition and accommodation 15 .

e) Evaluation
The assessment process was not based on the classification and exclusion.The process valued the dimensions: relational, belonging and educational (learning) for the assessment of the acquired skills.
Discussing the skills, without willing to exhaust the subject, is possible to note that the students understood and participated in all activities with assiduity, punctuality and motivation.There were no absences without the presentation of a medical certificate and no student failed.The interaction with colleagues, professor, local health staff and patients was satisfactory.The students were encouraged to exchange information; ask for help; participate in educational activities in service, in the interdisciplinary evaluation, in the art workshop guided by a voluntary and even in the hospital visit.Even with the stigma that surrounds the disease and the patient, all students interacted with the sick person and his family.
Regarding the educational dimension, different learning rhythms of the content were verified by the professor.Some students learned slower, others faster.The previous training of the student, on a technical level, did not significantly affect the development of activities and the pace of learning of the curriculum content.Students without technical knowledge required a little more contact with the professor and some additional resources to understand some of the attendance stages.
The feedbacks were given at the end of each field activity.The proposal of a daily feedback is part of the formative assessment and associated with the objective that in every educational stage, the student results change significantly.It is important to emphasize the time for the feedbacks must be previewed in the daily schedule.
Together, the professor supervisor of the internship, the coordinator of Nursing Course, the technical dean of nursing service and some members of the health team assessed the development of the teaching and lesson plan, as well as the performance of the professor supervisor and of the team directly involved with the trainees, making adjustments in the educational and care process.

f) Lessons learned
Among the lessons learned and the recommendations to replicate the experience, it stands out: the critical vision and the professor sensitivity in the analysis of the educational and teaching-learning process, selecting the field activities that contemplate the educational objectives, the individual learning needs and the planning done with the technical responsible persons of the health service, which bring benefits for both the students and the service, and especially undo technicist and prescriptive conceptions involving the internship.
Regarding the teaching techniques, they need to contemplate the diversity, the different rhythms of learning and should be planned in advance.However, if necessary, they should be adjusted to the educational and situational needs of the students, to the level of the academic development of the group, to the quality of the interpersonal relation in the internship group, between the group and the professor and the service professionals, with the main objective to produce unique, meaningful and transformative educational experiences.
The concepts and contents should be presented more than once, in different contexts and situations, in a playful, interactive and procedural way, so the student can assimilate and acquire knowledge.The elaboration of a final task is relevant, not only for the students to consolidate their learning, but also for the professor who has the possibility to confront the theory with the experienced practice in service, giving new meanings to both, and also rewrite analyzes, interpretations and conceptions.

FINAL CONSIDERATIONS
Writing on the pedagogical practice allows the professor to think and reflect on each decision taken, improve the daily work and adequate it to the students` learning needs.
Elaborating an experience report, the professor questions his planning, the student's achievements, the contents worked, as well as the balance of the assessment and the future actions.The report expresses the quality of the teaching work.Through it, the professor builds "[...] the circle of the teaching quality: "plan, perform, document, analyze and redesign" 17 .
This reflective writing requires time and the professor's willingness for self -evaluation, for sharing his doing, his tensions and interesting situations with his pairs, reinterpreting his pedagogical practice.
One of the limitations of an experience report is the teaching ability and competence in critically evaluating his own performance, his action bases and the context in which he works.These skills and competences are little encouraged in the initial training curriculum and by the support agencies that, according to Barreiro and Gebran 8 , little value the teaching and the research related to the teaching and learning processes.
Each report brings contributions and has the power to promote ideas.In this sense, to make the experience report the strength of the teaching publication would cause significant impacts in the educational process.By encouraging the report, we boost a content to be discussed among professors that, based on their own experiences, develop a critical vision about the school environment, the curriculum, their actions as professors and the teaching as a whole 3 .pesquisa e desenvolvimento profissional.Porto Alegre: Artmed; 2009.

Figure 1 -
Figure 1 -Educational goals, teaching techniques and description of teaching activities.