ACTION RESEARCH ABOUT HUMAN SEXUALITY: A FREIRIAN APPROACH IN NURSING PESQUISA-AÇÃO SOBRE SEXUALIDADE HUMANA: UMA ABORDAGEM FREIRIANA EM ENFERMAGEM

The objective of this study was to describe the trajectory of a contextualized, participatory and dialogical educational action about sexuality. It was a qualitative study using critical action research, in accordance with the theoretical and methodological framework of Brazilian educator Paulo Freire. This investigation included 151 undergraduate nursing students in a public university in the northwest region of the state of Paraná, Brazil, and occurred in March 2014. Of this population, twenty students participated in the thematic investigation phase and nine in the culture circles. All ethical precepts were followed. Based on limit situations, the culture circles addressed the following themes: “The Concept of Sexuality”, “Psychological and Social Dimensions of Sexuality”, and “Comprehensive Care in Sexuality”. The development of dialogical educational action, based on real-life problem situations was presented as a viable path for reflecting on the theme and building new knowledge for care practices involving human sexuality. DESCRIPTORS: Nursing Education; Nursing; Sexuality; Nursing Students. ACTION RESEARCH ABOUT HUMAN SEXUALITY: A FREIRIAN APPROACH IN NURSING PESQUISA-AÇÃO SOBRE SEXUALIDADE HUMANA: UMA ABORDAGEM FREIRIANA EM ENFERMAGEM RESUMO: Objetivou-se descrever o percurso de uma ação educativa contextualizada, participativa e dialógica na temática sexualidade. Trata-se de estudo qualitativo do tipo pesquisa-ação crítica, delineado seguindo o referencial teórico-metodológico de Freire, tendo como público alvo 151 alunos matriculados no curso de graduação em enfermagem de uma universidade pública do Noroeste do Estado do Paraná, durante o mês de março de 2014. Destes, participaram 20 acadêmicos na fase de investigação temática e nove nos Círculos de Cultura. Seguiu todos os preceitos éticos. Pautado em situações-limites, desenvolveram-se Círculos de Cultura abordando os seguintes temas: “Conceito de Sexualidade”, “Dimensão Psicológica e Social da Sexualidade” e “Assistência Integral em Sexualidade”. Conclui-se que o desenvolvimento da ação educativa dialógica, pautada em situações-problemas reais, apresentou-se como um caminho viável para a reflexão da temática e para a construção de novos conhecimentos às práticas de cuidado que envolvem a sexualidade humana. DESCRITORES: Educação em enfermagem; Enfermagem; Sexualidade; Estudantes de enfermagem. Corresponding author: Received: 09/04/2016 Iara Sescon Nogueira Finalized: 05/12/2016 Universidade Estadual de Maringá R. Hélio Jarreta 54 87005-030 Maringá, PR, Brasil E-mail: iara_nogueira@hotmail.com http://dx.doi.org/10.5380/ce.v22i1.46281 Original article 1Nurse. Master’s student. State University of Maringá, Paraná, Brazil. 2Nurse. Master of Nursing. State University of Maringá, Paraná, Brazil. 3Nurse. Antioquia Mission. Araçariguama, São Paulo, Brazil. 4Nurse. Ph.D. in Education. Professor, State University of Maringá, Paraná, Brazil. 5Pedagogue. Ph.D in Education. Professor, Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil. 6Nurse. Ph.D. in Sciences. Professor, State University of Maringá, Paraná, Brazil. Cogitare Enferm. 2017 Jan/mar; 22(1): 01-09 INVESTIGACIÓN-ACCIÓN SOBRE SEXUALIDAD HUMANA: UN ABORDAJE FREIRIANO EN ENFERMERÍA RESUMEN: Se objetivó describir el itinerario de una acción educativa contextualizada, participativa y dialógica en la temática sexualidad. Estudio cualitativo, tipo investigación-acción crítica, delineado siguiendo el referencial teórico-metodológico de Freire, con un público objetivo de 151 alumnos matriculados en curso de grado en enfermería de universidad pública del Noroeste del Estado de Paraná, durante marzo de 2014. De ellos, participaron 20 estudiantes en la fase de investigación temática, y nueve en los Círculos de Cultura. Se respetaron todos los preceptos éticos. Pautado en situaciones límite, se desarrollaron Círculos de Cultura, abordando los temas: “Concepto de Sexualidad”; “Dimensión Psicológica y Social de la Sexualidad”; y “Atención Integral en Sexualidad”. Se concluyó en que el desarrollo de la acción educativa dialógica, pautada en situaciones-problemas reales, se mostró como un camino viable para la reflexión de la temática y para construir nuevos conocimientos a las prácticas de cuidado que involucran la sexualidad humana. DESCRIPTORES: Educación en Enfermería; Enfermería; Sexualidad; Estudiantes de Enfermería. Iara Sescon Nogueira1, Célia Maria Gomes Labegalini2, Karen Fernanda Ramos Pereira3, Ieda Harumi Higarashi4, Sonia Maria Villela Bueno5, Vanessa Denardi Antoniassi Baldissera6


INTRODUCTION
Professional education aims to train students to be aware of their social duties and produce qualified professionals (1) .In terms of healthcare education, professionals are expected to understand humans in their environment and the factors that influence the health-illness process (2) .However, Brazilian nursing education faces barriers to this intent, as it has historically been based on the biomedical model, in which nursing care is centered on technical procedures, with little recognition of human multidimensionality (3) .
In this context, current educational movements seek to resignify the praxis of care.In this direction, sexuality has been included as part of the nursing curricula, especially within the scope of women's health and sexual education for adolescents (1)(2)(3)(4) , expanding the dimensions of health care and health promotion.Consequently, sexuality education can help improve flaws in professional practice (4)(5) .
Unfortunately, the topic of human sexuality tends to be addressed in an improvised and informal manner, or with a focus on neutrality, prohibitions, and human desexualization (4)(5)(6) .This undermines nursing education (6) , as it helps perpetuate personal myths, beliefs, and taboos that do not contribute to proper social management of the theme (6) .This demand for education implies a learning process that counters traditional teaching precepts that privilege the transmission of knowledge from educators to students, a model that distances educators from the reality experienced by students (7)(8) and prevents the necessary criticality to transform knowledge and practices.
To break with the model of traditional education, in the 1970s, Freire developed the concept of dialogical and emancipatory education, which is based on authentic dialogue to develop critical thinking around a concrete fact, capable of reshaping knowledge and practices.Freire affirmed that reading the world through words was not enough to turn men and women into thinkers and engage them in reconstructing their reality.Such transformation occurs through action mediated by education in the context of action-reflection-action (7) .
The Freirian approach privileges dialogue in the learning process, as it conceives that knowledge can only be constructed in interaction between men guided by their concrete reality (7) .Anchored in this theoretical and methodological framework, this study sought to realize a dialogue-based educational proposal that would culminate in the collective construction and reflection of practices by students themselves (7) .Thus, a priori, the research question was: What would the construction of a dialogical and emancipatory education action about sexuality with nursing undergraduate students be like?To answer this question, this study described the process of developing a contextualized, participatory and dialogical educational action about sexuality with nursing undergraduate students.

METHOD
Cogitare Enferm.2017 Jan/mar; 22(1): 01-09 This was a qualitative study based on a critical action research approach that aimed to seek the concrete reality about the topic of sexuality, its explanations, and overcome naïve knowledge through the development of educational actions by the researchers and research participants (7) , called research actors.
With the goal of changing acts of knowledge and practice (7) involving sexuality, the researchers proposed the theme, but it was up to the actors to survey their experienced reality and develop the educational actions in a participative and contextualized manner.This process enabled dialogical and participative investigation and action (9) .
The study included 151 undergraduate nursing students at a public university in the northeast of the state of Paraná, Brazil, in any year of study, who volunteered to participate, as required by the critical action research framework (7) .
All of the nursing undergraduate students were verbally invited to participate during class breaks.Inclusion criteria were: being a student duly enrolled in the institution's undergraduate nursing program and giving consent.Of these, twenty responded the questionnaire (thematic investigation), selected via intentional sampling, as they demonstrated interest in the theme.Later, nine of these students participated in the culture circles (CCs), as they felt comfortable in a group discussion about sexuality.
The CCs were developed according to Freire's theoretical and methodological framework (7) .This includes three interdependent phases: thematic investigation; codification/decodification, and critical unveiling.
Thematic investigation was developed using an open-ended questionnaire created by the researchers to gather data about participants and their conceptions about human sexuality.The purpose of this phase was to survey how the participants understood the proposed theme so that dialogue could occur in the direction of their reality.
To validate the thematic investigation, a previous analysis of the questionnaire enabled the researchers to capture the theme as represented by the participants.This analysis culminated in the definition of limit situations conceptualized as real-life problem situations (7) that could be overcome by the reflection of those who are part of them.
The researchers made a list of the limit situations and presented them to the participants so that they could either recognize or refute them during CCs.Thus, the educational action was developed through CCs, understood as dynamic spaces for learning and knowledge sharing.In this way, subjects come together in the education process to critically unveil what is of interest to the group (7) .
The CCs took place on two consecutive days in March 2014 for a total of six hours to validate the thematic investigation conducted in the previous phase and realize the coding/decoding and the critical unveiling that compose the adopted research itinerary.
It is worth noting that not all those who participated in the thematic investigation were present at the CCs, as they occurred at different times and some declined the invitation.Thissituation did not hinder or harm the study.To comply with ethical principles and methodological rigor, the study continued with the participants who showed interest.
The limit situations were validated at the CCs as concrete reality and informed the choice of generative themes that would then be coded.Codification occurred when students were given the opportunity to talk about the chosen generative themes, revealing their thoughts and knowledge about sexuality and the limits of such knowledge.In this phase, the researchers asked questions to deepen their understanding of what the students thought and knew about the generative themes.These coded themes were decoded and recognized through a critical and reflexive process.This resulted in the emergence of a current, real and practical situation and came up with proposals to overcome it (10) .
Decodification took place through a discussion aimed to inter-relate common and scientific sense, enabling participants to conduct a re-reading of and, consequently, transform their world view.In this phase, discussions were guided with questions that stimulated reflection about the theme in debate form.
The dialogue developed among research actors in this process was authentic -critical and reflexive.This enabled the process of critical unveiling, which occurs through the going back and forth between previously-held to recently unveiled concepts, thus realizing the action-reflection-action movement and transforming reality (7,10) .
The present study originated from an institutional student research project called "Research action in educational demands in the nursing context" (Protocol 401/2013).It was approved by the permanent Human Research Ethics Committee of the State University of Maringá, on August 28, 2013, as per resolution no.375.459/2013, and abided by all ethical precepts set forth in Resolution 466/2012 of the Brazilian National Health Council (11) .It was developed with a Study and Research Group for Health Education Practices (GEPPES), registered in the National Council for Scientific and Technological Development's (CNPq) research directory.

RESULTS
Characteristics of the subjects and the trajectory of the educational action Twenty undergraduate students participated in the initial thematic investigation phase, age ranging from 18 to 24 years, mean age 20.2.Of these, 19 were female (95%) and one was male (5%); 19 were single (95%) and one was married (5%).Four were in their first year of undergraduate studies (20%), four in the second (20%), five in the third year (25%) and seven in the fourth (35%).
In terms of place of residence, 15 students resided with their parents or family members (75%), three in student apartments (15%) and two lived by themselves (10%).All of the students (100%) reported that they did not work, thus being financially dependent.With regards to income, eight participants (40%) did not answer, those who responded (n=12/60%) reported an income between 1 and 16 minimum wages.Most students were catholic (N=11/55%), followed by evangelical (N=8/40%); and one student (5%) reported having no religion.
Nine students participated in developing the educational activity, eight on the first day and seven on the second -with different participants on each day.Eight students were female (89%) and one was male (11%).In the Freirian methodology, limit situations are part of the thematic investigation phase and were defined by the researchers before the culture circles based on the preliminary analysis of the participant's discourse as recorded on the questionnaires (Chart 1).

Limit situations Excerpts describing them
Sexuality is perceived in its multiple facets and reduced to genitality.

To me, sexuality is the act of feeling pleasure for another person and having sexual relations with them or masturbating. (P2) Sexuality is a set of feelings that result in an action.(P3)
Undergraduate nursing education about human sexuality is weak.

I still haven't been prepared much on this topic in my undergraduate studies. I've only learned about contraceptives and some approaches. (P1) In my opinion, the program does not prepare us much on the issue. (P10)
The theoretical preparation on the topic was superficial, and whatever we built we developed during our internships.(P18) Nursing practice related to human sexuality is realized through orientation.

[...] Guiding people on the risks of unsafe sex and how to prevent these risks. I intend to do this whenever I can and especially when the person shows signs of being sexually active.(P2) [...]When I meet with adolescents or even adults I ask them if they have any questions, if they are sexually active, and I try to provide guidance about contraceptive methods and answer any questions. (P10) [...] If these people receive guidance about a reality they experience and preventing risks, their physical health will not be impacted or harmed. (P15)
Based on the limit situations (Chart 1), an educational action was created through the CCs to enable emancipatory dialogue based on codification/decodification and critical unveiling.This educational action was called "Sexuality: eye-to-eye dialogue", referring to the idea of contextualized, participative and dialogical education.The process undertaken during the culture circles is presented below, in the order of the activities conducted, based on the triggering limit situations.
The first CC started with a presentation of group members and a summary of their expectations on participating in the activities.The answers mainly included the idea of increasing knowledge on the subject, answering questions on the theme, and recognizing the importance of the content in their professional lives.
Next, the circle drafted a contract that established group rules during the activities, which was written on a poster board and remained visible throughout the CC activities."Keeping doubts to oneself" was chosen by the participants as an undesirable situation and "confidentiality", a desirable one.
Next, a group activity was conducted to reveal the participants' knowledge on sexuality, validating the thematic investigation developed through the questionnaires.
In this activity, students were given three pieces of paper with different colors and meanings (green: affirmative answer, red: negative answer, and yellow: did not answer/does not know) so that they could indicate their knowledge regarding the statements presented by the researcher.The statements were written based on the limit situations that emerged in the thematic investigation and included: Sexuality can be reduced to a sexual act; Sexuality begins at puberty; the role of nursing in sexuality is to intervene in people's lives in terms of preventing sexually transmitted diseases and providing contraceptive methods; It is important to talk about sexuality in nursing; and Sexuality defines the roles of men and women in society; among others.These statements enabled greater contact with an expanded dimension of sexuality.
The participants demonstrated a more expansive concept of sexuality than previously identified in the questionnaires.They expressed additional knowledge and recognized the psychological and social dimensions of sexuality; even so, the biological dimension was more pronounced.Thus, research actors confirmed the limit situation and unraveled the other phases of the research itinerary, as shown in Figure 1.The expected outcome of the unveiling process was for participants to construct a new concept of sexuality and, to this end, the generative theme "concept of sexuality" was chosen.The educational strategy was a group activity conducted during the CCs, allowing for codification and decodification.On half a sheet of sulphite paper, the participants wrote down a word, that in their opinion, was related to sexuality.Next, the words were attached to a board and were correlated to their respective aspects: biological, psychological and social, which reflect the different dimensions of human sexuality.
Next, the group was divided into pairs to construct a new and broader concept of human sexuality, encompassing all of its dimensions.The new concepts were then dialogued among all of the actors and critically unveiled, demonstrating deep transformation in the way of thinking about the theme and its incorporation into nursing practices.
In terms of the biological dimension of sexuality, the group dialogued about correlated themes such as anatomy, physiology and genetics.The hormonal and genital transformations that accompany adolescence and senility were broadly discussed, including personal and professional experiences.Participants considered the biological dimension as relevant to healthy development, but the discussion also unveiled its relationship with myths, beliefs and taboos, pointing to the other dimensions of sexuality.In this sense, emphasis was given to the importance of the nursing approach and the development of current nursing practice, which tends to focus on the biological aspects to distinguish between normal and pathological.
The goal of the second CC was to dialogue about academic training, presenting the previously established limit situation for validation.Considering the reflections already expressed in the first CC, the actors defined the psychological and social dimensions as the most fragile and that needed to be overcome.For this reason, they were elected as generative themes and the focus of emancipatory dialogue, whose process is shown in the flow chart below: To trigger reflection and dialogue, the second CC began with an activity about the psychological dimension, called: "Relaxing and strengthening self-esteem" (Figure 2).This activity focused on the "self" so that they could feel their body and its particularities.The researchers prepared the setting, dimmed the lights, and played relaxing music.All of the participants were instructed to relax their body, sit in a comfortable position, and relax their body and mind.This activity also helped the participants to experience the psychological dimension in focus, recognizing their own sexuality and feelings.
Soon after, an activity was conducted with the participants in a circle.They were given a box with the question "Who do you see?" and a mirror so that they could reflect about themselves and their process of self-knowledge.
At the end of the two activities, the participants described their feelings and most reported never having participated in activities directed at their particularities and the importance of their individuality.They dialogued about the importance of this activity for self-recognition and being able to recognize the other in nursing care related to sexuality and demands regarding intimacy and individuality.
Next, activities related to the social dimension were conducted, with the goal of enabling shared reflection and unveiling.The participants were invited to choose an animal with characteristics similar to theirs.The individual characteristics mentioned were classified as either female or male.Based on this, dialogue focused on gender issues, social roles and social impositions for men and women.
The goal of the last CC was to critically unveil the problem situation called "Nursing practice related to human sexuality is realized through orientation".This limit situation was validated by the actors and developed based on a collective definition of the generative theme "health promotion and comprehensive care approach", as shown in Figure 3. Participants expressed that dilemmas related to human sexuality are faced not only by nurses during their professional practice, but also students during their academic activities in clinical practice and internships.This concrete reality, indicated by the group, was coded into conflicting experiences and controversial situations lived by them regarding sexuality, among them: physical and/or mental disability, male menopause, sexual health education in schools, men's health, sexual exploration, homosexual relationships, and sexual violence.Thus, the unveiling showed that nursing practice must encompass all of the dimensions of human sexuality.
At the end of the CCs, participants assessed the educational process.They reported that the experience had been fruitful, as it helped them revisit their way of thinking and conducting professional practices related to sexuality, presenting new possibilities.Furthermore, they approved of the methodology, which was new to them, and praised it for "avoiding the same old" in terms of dominating educational practices in the academic context.

DISCUSSION
Limit situations are barriers imposed on people's lives when these lack critical thinking about the world surrounding them, and when they are not overcome, tend to restrict their conduct (7) .Thus, for emancipatory educational actions, they represent a trigger for critical unveiling, which starts by recognizing their existence.These situations contain the generative themes that serve as the basis for reflection and then overcoming such limitations (7) , as occurred in this study with the theme of sexuality.
However, creating conditions for dialogue is an essential condition and is only possible when planned.From this perspective, it is important to establish a contract among all the actors involved, as was done in this study, since it confers importance to what is agreed upon, consisting of rules and limits defined by those involved in a participative action (7,10) .Such definition allowed the researchers to construct a space of authentic dialogue, based on the certainty of the sense of belonging and responsibility for developing their own criticality and that of others.The contract strategy, adopted at the beginning of the first CC, was an important step to favor dialogical participation.
Theme codification through the group activities helped strengthen dialogue and enabled the researchers to learn about the reality of the participants (2,10) .Moments of critical unveiling occurred when participants gained critical awareness of their reality, which led to them proposing initiatives and actions (7) involving the dimension of sexuality in nursing care.
Throughout the activities, it was clear that the participants did not have a global understanding of the concept of sexuality, one in which it is understood as an individual and constitutive factor of human personality, indissociably integrated with other aspects of life.Thus, it relates to biological, psychological, social and spiritual aspects of individuals and is not limited to corporeity, sexual intercourse, or mere sexual characteristics (3) .For this reason, the study included different dialogical strategies so that the actors could unveil the concept according to their way of expressing themselves, their attitudes, and ways of relating with others, both in their love and sexual lives, and their social life (3,12) .
The students had a frank dialogue about the biological, psychological and social dimensions of sexuality, appropriating a newer and more expansive perspective, which up to then was unfamiliar and not recognized.Such conceptual emancipation allowed the participants to recognize the comprehensiveness that constitutes human beings.They were led to acknowledge these dimensions not only in themselves, both as individuals and health professionals, but also in the patients part of their nursing practice (3,13) .This was made evident in the CC aimed at the psychological dimension of sexuality,which was permeated by dialogue.The actors expressed the need to reflect about themselves and their particularities, recognizing that this dimension of sexuality relates to subjectivity (3,14) .Thus, it is not always observed in nursing practice.
In the CC that proposed dialogue about the social dimension of sexuality, the participants discussed and reflected about gender issues that determine the social construction of the male and female sex.They unveiled that this aspect rests with culturally established power relationships and are constructed by society (6,15) .In this phase of the education action the participants exchanged knowledge and recognitions and became active transformers in the learning process (7) .This participative approach is in line with committed and professional training for addressing human sexuality in nursing care.It can enable nursing professionals to collaborate to the social management needed for collectively constructing the theme, which can cause a positive impact in terms of prejudice, homophobia, and sexual violence.
During the activities, especially when approaching the social dimension of sexuality, the researchers observed that social constructions still place women in a fragile and vulnerable position.However, men also suffer from this social influence.Participants also placed more emphasis on female characteristics, which was probably due to the predominance of women in the group.
Studies and discussions about sexuality in the academic and professional context of nursing are scarce.When they exist, they are restricted to the biological and pathological perspective (6) , displaying gaps that deserve further research.
Providing undergraduate nursing students with debate and reflection about comprehensive health care, which includes human sexuality, enables the development of a critical point of view and a sensitive attitude towards the theme, equipping future professionals to provide comprehensive health care.The effect of such reflection is not limited to their training, but serves as an instrument throughout their professional care practice (6,16) .
In this study, naïve knowledge, in the sense of superficiality, was replaced by critical knowledge (7) , with deep reflections about professional nursing conduct in the context of sexuality, so necessary nowadays.

CONCLUSION
This study demonstrated that nursing students conceived sexuality as reduced to genitality and that their undergraduate training on this theme is poor.Thus, nursing practices related to human sexuality are based on providing biologicistic orientation, as indicated by the participants.
Being familiar with these perceptions was essential to plan and develop an educational action adapted to the students' context and based on the premises of dialogicity.Freire's research itinerary enabled the collective construction of knowledge and criticality of professional practices, via codification/ decodification and critical unveiling.The participants recognized this approach as innovative and favorable to changing paradigms and taboos, stimulating the teaching and learning process, with the potential to be implemented already in undergraduate activities.
Developing the dialogical educational action based on real-life problem situations enabled participants to reflect on the theme, constructing new knowledge and care practices involving human sexuality.
Limitations of this study include the impossibility of performing the entire dialogical process with all of the participants.The researchers first raised the theme through questionnaires; however, not all of the respondents participated in the following phases.