Gender Category Study : Perspectives of Nursing Interns in Public Health

Results: There were a theoretical enrichment about gender category in overcoming the biases found during the formation process, demystifying normative patterns built around gender and sexuality, becoming necessary to conceptual comprehension in nursing care context, in nurse’s action in Primary Care, in the current social scenario of healthdisease process from identity questions, recognizing subjects’ expression through their subjectivity. Gender Category Study: Perspectives of Nursing Interns in Public Health ORIGINAL


Introduction
The dialog which provokes learning appreciation to themes coming from social manifestation, which looks for equity of rights, is part of an important process concerning political and pedagogic contexts of nursing formation.
Through this perspective, the nursing course of the Centro de Ciências Biológicas e da Saúde (CCBS) of the Universidade Federal de Campina Grande (UFCG) has the following mission: to qualify professional formation to the exercise of nursing, with competency and ability to develop the clinical-epidemiological and investigative thinking in promotion, protection, recovering and rehabilitation of health in the individual and collective plan.Being able to know, intervein and transform the reality in which is inserted, according to ethical, legal, technical, scientific, and humanistic principles [1].
Therefore, it is comprehended that the approximation with the gender theme brings a body knowledge set up by social movements, through which nursing students can enrich and qualify their knowledge, mainly about questions related to patient embracement and humanization.Questions certainly linked to work carried by professional nurses in the Primary Care, since the Primary Care National Politic [2] is guided by universality, accessibility, attachment, continuous care, integrality, accountability, humanization, equity, and social participation principles.
In this perspective, there is an indication [3] to humanization as a transversal politic that breaks and surpasses the boundaries of knowledge/power which occupies different contexts in health.
Likewise, it is observed that there are dominant questions that exert power relations on the body, and on its use, which ends up having its self-patrimony character neglected by analogies that transcend the logic of human social pathway, i.e. live exercising relations with the self and the environment.
Relating to power, Michel Foucault [4] points out it is a set of relations somewhat organized, somewhat pyramidal, and somewhat coordinated.In other words, it may be inferred that power is a tool also used to reproduce meanings that try to explain patterns on social relations characterized by human hierarchy, falling into gender questions, building patterns that intensify these relations through the paradigm of differences.
Moreover, gender will be a problematized category in this study as a convergence point among specific sets of cultural and historic relations [5].
Therefore, systematizing the knowledge from its historical construction in social movements such as Feminist and of Lesbian, Gay, Bisexual, Transvestite and Transsexual (LGBT) is a way, in nursing, to recognize population needs produced through social control, and the conjuncture to problematization of strategies of care for popular segments that claim to be contemplated by the health system.
Thus, by means of the hypothesis of that gender studies, during graduation, are essential for the qualification of nursing care that this work is designed

Conclusion:
Making the nursing students' knowledge about the theme possible has demonstrated to be an operationalization of necessary tools to implement a more qualified assistance in Public Health.
through the following objective: to reflect the student experience from the approximation with gender category and its implications to nursing work in Primary Care.

Method
The literature points out that experiences need to be turned into pages to compose history, to turn into words, and letters.Registers are needed since they are built through human scenarios, rich of meanings and lacking reflection [6].
Thus, the systematization of an experience developed with the gender category during the curricular component Supervised Curricular Internship (SCI) 1 of the nursing bachelor from CCBS-UFCG was built as a report of this reflection.
It is believed in the importance of this report, as the nursing practice with the cited theme may be an object of reflection of care through the rescue, record, assembling, and interpretation of facts resulting in qualified health formation and nursing practice.
Therefore, it is agreed with what the literature portrays [7] when it points out that the systematizing reflection aims to penetrate in the experiences' dynamics, facing live and complex social processes, comprehending their relations from their self-logic, absorbing wisdom that can contribute to theory and practice.
In this perspective, through a descriptive and qualitative approach, five steps guide the method of systematizing experiences adopted in this study [8]: 1.The starting point: The proceeding of the nursing SCI and the experience built from the thematic workshop: gender and health -perspectives to nursing care, held between May and July of 2015 in 05 meetings; 2. The initial questions: How to introduce the gender category in the context of nursing teaching-care?How can the theoretical-prac-tical knowledge of gender studies contribute to nursing practice?3. Recovering of the experienced process: reconstruction of the experienced process from the critic reflective thinking; 4. The background reflection: synthetic description of the experienced process. 5. Concluding points: main conclusions from the experienced learning.Thus, dialectics [9] was used to construct the results of this study since this method takes account of the researcher's trajectory in the search for knowing and finding the self in the construction of the object's knowledge (phenomenon/ investigated fact) which is constructed and deconstructed through interactions with the subject and the object.This is an exercise that allows knowing the human being as historical being that creates contradictions generating conflicts on social relations.
In this perspective, the dialectic comprehends the phenomena on its totality as a dynamic process in continuous social construction, unveiling connections related to the essence of this phenomena [10].
Believing that the gender category should be a problematization object of nursing formation, this report is developed from two categories of analysis/reflection: 1. Operationalization of SCI; and 2. Conceptualizing gender: perspectives for nursing care.
Two important publications were used in the construction of this reflection: the Nacional Politic of Integral Attention to Women's Health [11], and Nacional Politic of Integral Attention to LGBT [12].

Category 1. Operationalization of Supervised curricular internship
According to the Law 11.788 of 25 September 2008 (Brazil), internship is a supervised educational act developed in a work environment which aims the preparation for productive work of student [13].
In this perspective that is built a work semantic which brings to the context of nursing care.It is needed the introduction of relevant themes in the academic education to reach the principles of equity, integrality and universality.
Therefore, it agrees with what is recommended by the National Curriculum Guidelines for Undergraduate Nursing Course (Brazil) when nurses are put as a critical, generalist, humanist and reflexive professionals, and also it requires the courses to include the supervised internship in the curriculum, on Primary and Public Health Care, besides others places, on the last two semesters of Nursing Graduation, totalizing the minimum of 20% of the total course hours.
From many skills and competences that the nurse formation should include (health attention; decision-making; communication; leadership; management; permanent education) some objectives, still based on curricular guidelines, are supported by the formation and they are highlighted in this study, such as, to act professionally; to understand human nature in its dimensions, expressions and evolutionary phases; to establish new relations with social context; to recognized the structure and forms of social organization and also its transformations and expressions; to identify health as a right and dignified conditions of life and to operate in order to ensure the whole assistance understood as an articulated and continuous set of the preventive and curative actions and services, individual and collective, required to each case in all complexity levels of system [14].
Regarding the view of graduation from the humanity principle and understanding this as fundamental to the nursing care, it is observed that the curricular internship should not be lined only by the practice or performance of techniques under supervision.It goes beyond when is contemplated at the Rules of the SCI of the Undergraduate Nursing Course of CCBS-UFCG (Brazil) the need to put the same as a component of course pedagogical project which should be intrinsic to the professional academic graduation as an instrument of articulation between theory and practice [15].
During the SCI, students should progressively work as a nurse, so they can see their limitations and also understand the need of support for the problem-solution that involves the health-disease process and its interventions.Therefore, students would be able to ensure a fundamental set of competences which allows them to be included in the several levels of care.
The SCI 1 is organized in 420 hours and it has as focus of activity the nursing actions at Primary Care scenario from the following general objective: to allow the student to experience the nursing work process in Community Health Care Units (Family Health), applying the theoretical-practical knowledge acquired during graduation [1].
Thus, the belief in the teaching-learning process that combines theory and practice for construction of praxis gave rise to the tutorial methodology for more reliable use of SCI 1, in other words, there is a weekly follow-up to the thematic survey which can outline a nursing practice more consistent and systematized based on the theoretical knowledge that it had not its feasibility in the reliable way during others graduation courses.
The tutorial methodology (Figure 1) can be considered as an alternative to existing learning gaps that can be discussed and reflected even in a curricular component which, mistakenly, is many times placed as specific for the repetition of techniques and the untying of the student with the space of academic reflection.
Therefore, the tutorial is based on three basic tools: the problem, the dialogue and the reflection.Based on this point of view that can consider the need introduced by the students and, consequently, the design of the best strategies to reach the solution of the problem.Thus, the tutorial methodology contributes to acquisition of expected skills of professional future, as well as in the development and improvement of capacity to keep updating itself throughout the professional life in an ethical, critical and with good articulation of pertinent strategies to communication [16].
Moreover, it is placed the need of working with gender theme by the students experiences with this subject on extracurricular method, for example, participation in scientific events, readings that lead to the knowledge of gender category and its relation with health-disease process, and also the need for Public Health to consider it as an important perception in the context of nursing care and in the theoretical perspective that underlines the practice.

Category 2. Conceptualizing gender: perspectives for nursing care
Considering nursing and its holistic integration of care from costumer service, be it community, family or individual, in a complete and complex way from the recognition that everyone should have access to the health system, it is understood that the gender category is intrinsically related to the health-disease process.
It is necessary, in health care, the understanding not only about biological, but also the expansion factors, considering the environmental, socioecono-mic, cultural and political issues.There are examples of contexts that bring in the relations between perceptions of social inequities, psychobiological mechanisms and health situation, based on the conception that perceptions and experiences of people in unequal society cause stress and health damage [17].
In this direction, it can be seen in the historical legacy of the gender category that it does not address a ready and static rationale, but it has dynamics characteristics, constructed and susceptible of transformation, having active and determined subjects, receiving and answering to the marks and social contradictions.Therefore, it is noted the need to understand the becoming 'woman' or 'man' as a process and not as a solved deed settled at birth.The female and male are constructed through feminizing or masculinizing social practices with the conceptions of each society [18].
The gender comprehension, from the constitutive of social relations based on different perceptions between the sexes and on the representations of power relations, is characterized by dominant/dominated form which are introduced as natural and unquestionable [19].
Once, the development of the tutorial by students part of SCI 1 class, started from the following questions: How to introduce the gender category in the context of Nursing education-care?How can the theoretical-practical knowledge of gender studies contribute to the Nursing practice?
It can be answered starting from two interesting justification that fall back in the context of inequity between social classes: The first one points out that in Brazil there is one considerable theoretical production that relates the health-disease process and social class, which reveal the inequalities of access to health institutions by people with lower purchasing power.However, the centrality of the perspective of social aspects of income society limits the understanding and makes it impossible to evaluate and understand certain is- sues of illness or death, for example, the process of feminization [20].This information is corroborated by the literature when it states that gender issues should be part of the determinants of health in the elaboration of Public Policies, being essential the incorporation of the gender perspective in the planning of health actions with the objective of promoting the improvement of life conditions, equality and rights of women`s citizenship [11].
Regarding the inequity between men and women, this experience also is problematized by a second justification: LGBT issues and health.
Therefore, it is stated that the LGBT social movement sought support in health area, so that their demands were met the production of knowledge, social participation, promotion, attention and care, as well as the constitutional guarantee of the right to health [12].
Understanding gender issues as relevant in public health was the first point raised in the activity.This one was done through the group dynamics to facilitate interaction with the theme between among the students, who directed the moment, and the team that followed a perspective of knowledge exchange for the elucidation and construction of knowledge related to the subject through the following pedagogical resources: cartoons, images, news, reports, videos, poetry, social networks interaction, cinema, linguistics and dramatization that were used during five meetings.
Initially, the pertinent issues were raised by the feminist movements through historical and struggle flags from the need that the theme puts in discussion issues of violence and health, access and accessibility to the health services through the argument that the grouping of new ethical and moral values to the personality constructed as well as the incorporation of new behaviors and attitudes before a structure of social and sexual patterns, are strongly influenced by the gender relations, established socially and culturally [11].
Therefore, starting from the appreciation of health as a dynamic object surrounded by socio-historical phenomena, it was understood in the activities, the need of implementation of gender as a category that impacts on the care directed to the relations that are established in the health-disease process and the placement of process of medicalization of female body based on the inequities that it reproduces through contexts that make women vulnerable in the health system.Violence against women can be cited as a question debated among the students of the activity and placed as important aspect in gender relations.
Taking the subject to the LGBT issue, the activity occurred from the conceptual representations that relate gender and LGBT to the issues of health through the following justification: facing all discrimination and social exclusion implies in promoting a social democracy, the laity of the State and, at the same time, demands a broader awareness of health with mobilization around the defense of the right to health and sexual right as a fundamental component of health [12].
Based on that perspective the following questioning was asked to the participants of the activity, relating the differences between gender identity and sexual orientation through the "where can I fit myself?" dynamic which was developed as follow: All the participants should paste into table many terms used in the language that fit as manifestations of gender or the sexual orientation.During the activity, these conceptions were observed and reflected from the book Guidance on Gender Identity: concepts and terms [21].
Sex is biological and gender is social.Moreover, gender goes beyond sex.In this perspective, selfperception and the way in which a person expresses the self socially are chosen to construct the gender.Whether or not we adopt certain models and gender roles, this can be independent of genitals, chromosomes or some hormonal levels.Everyone experiences, in different situations and moments of life, temporary inversions of roles determined for the gender of each one [21].
It is in this perspective that the demystification of the normative standards constituted around the gender and sexuality occurs; in other words, believing that all people are heterosexual and cisgender (identification with the gender assigned at birth) translated, respectively, by the heteronormative and cisnormative behaviors.
Thus, in the health of LGBT people, the equity, integrality and university should be materialized in public policies aiming to confront the consequences brought by the heteronormativity, as a consequence the health professionals take care of patients disregarding their gender identity and sexual orientation.Therefore, the enriching logic of SUS principles -Brazil is broken [22].
Thereby, would this situation be an inheritance caused by a historical imperative built based on standards about what the human being is or how one lives being human?
The words of Judith Butler [23] can be used to answer the question: the body, constituted as a social phenomenon in the public sphere, is and is not of its human being.It is delivered into the world of others, carries its mark, and is formed within social life; only later, and with some insecurity, one can claim the body as a self property, if indeed it ever does.
Thus, it becomes crucial the conceptual understanding in the context of nursing care before nurse actions in the Primary Care in the current social conjuncture of the health-disease process from the issues of identity and recognition of the expression of subjects in their subjectivity.
This affirmation, which corroborates the reflection done in the activities, is part of the logic of comprehension in the universe of gender and LGBT issues that the expression of a social movement is part of a whole political-ideological context of recognition of democracy as an instrument of struggle for emancipation and the achievement of equal rights in which differences are considered in care without reproducing hegemonic norms about the ways of being in the world in the wrong ways that increase the exclusion process and subjects stigmatization.
It was this way that the activities converge to the understanding of gender category and its relations as a social construction that interferes with determinants of work process of nurse in the Primary Health Care, collaborating to an understanding built on the apprehension of a body of knowledge fundamental to the care.

Conclusion
Living in a social conjuncture that considers sexual and gender diversity principle (i.e.diversity of people) as a process that integrate the society is an action in health that goes beyond the biologic approach.This is the fundamental comprehension that human beings, besides their biological body, are also presented as social bodies in need of specific care considering their specificities.
The Unique Health System (SUS) (Brazil)as public patrimony is a primordial tool in the confronting of inequities.It goes beyond: comprehending health as phenomenon of human diversity is to set the system action also considering conditions imposed to women, gender identities, and sexual orientations as social determinants on the health-disease process.
The illness logic is complex.Comprehending health as conjunct influenced by countless dimensions (among them the social), is the perception that it is influenced by hegemonic models that does not take account of empowerment as tool in the fight for rights.
The dialog with the gender category in the nursing formation is portrayed as collection of possibilities for a knowledge field which is still undervalued by academy.It is not seen as an useful thematic in the consolidation of SUS doctrinal principles (Brazil) and, consequently, the inclusion of a systematized care need starting from the differences and the consolidation of a system aligned to population's voice and to questions raised by social movements.
This experience was revealed, greatly, as an opening for consistent reflections about the process of a social construction which is gender and its implications in the context of education-care of nurses in the Primary Care, i.e. understand the service beyond the designation as an entrance for the health system.The recognition of population's need from the adequate embracement of social relation demands, fostered by gender category, is constructed and deconstructed through a dynamic perspective, as the care itself.
The importance of the emphasis and the comprehension of gender relations is highlighted, thus, the service accessibility barriers are put in evidence, leading the construction of strategies targeting evaluation/adjustment of inequities and reducing heath risk/problem generator inequities.
The concluding point of this experience is: the fostering of gender category knowledge to nursing interns of Public Health has shown to be the unveiling of an unknown universe, making the construction of theoretical and methodological tools for qualified Public Health assistance implementation possible.
When the gender category is considered, there are social insertion particularities defined by stereotypes and cultural marks perpetrated in the society resulting in invisibility and excluding processes that generate discriminatory contexts disrupting health access, inclusion, and care.
Therefore, it is expected that this experience contributes to the raising of new reflections around the gender theme in the context of nursing and other sciences, besides the development of practical activities guided by gender relation knowledge as well as the comprehension of the multi-dimensional character of care.

Figure 1 :
Figure 1: Dynamic of tutorial realized in SCI 1 of Nursing Graduation of CCBS-UFCG.Source: Researchers collection.