Preceptorship in nursing-midwifery: a training-intervention in health work

Objectives: to analyze how certified nurse-midwives identify preceptorship in a nursing- midwifery enhancing course conducted by the Universidade Federal Fluminense as a possibility of training to promote institutional support and intervention. Methods: a descriptive, exploratory research with qualitative approach. Six certified nurse-midwife preceptors from the Nursing-Midwifery Enhancing Course participated in the study in 2019. Two public maternity hospitals in Rio de Janeiro were settings of the research. Individual interview and thematic content analysis were used to collect and analyze data. Results: exchange of knowledge between preceptors and trainees encouraged learning and reflection stemming from delivery and birth, contributing to expansion of autonomy and professional leading role in training, health care, and management. Final Considerations: collective meetings that promote work analysis and value the performance of certified nurse-midwives have led to intervention processes and institutional support in maternity hospitals in Rio de Janeiro, Brazil.


INTRODUCTION
The use of strategies to empower, or improve people in the workplace has been used by management in health institutions due to the need to foster dialogues and experiences that approach the practical reality. It also seeks to avoid unnecessary displacements and raise operationalization of actions engaged with the perspective of qualifying processes of change in daily work.
In the context of delivery and birth, the World Health Organization (WHO) (1) (2)(3) . Thus, they signal permanent need to institutionalize a model of delivery care, whose health practices qualify a less interventionist and more humanized care network (4)(5) .
To strengthen action and training continuity, MoH has invested efforts from initiatives in partnership with the Universidade Federal Fluminense (UFF) and the Universidade Federal de Minas Gerais (UFMG), in order to operationalize Nursing-Midwifery Enhancing Courses (NMEC 1 ) across the country (6)(7)(8) .
In 2017, MoH, the Ministry of Education, the Instituto Fernandes Figueira da Fundação Osvaldo Cruz, the Brazilian Association of University and Teaching Hospitals, the Brazilian Hospital Services Company, and UFF had as initiative to implement the project entitled Enhancement and Innovation in Care and Teaching in Midwifery and Neonatology (Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia, abbreviated APICEON/MoH). The project expanded enhances qualification of health care, management, and training in university hospitals and teaching maternity hospitals (9) .
As the importance of this training process is founded, which has encouraged changes in the midwifery model in SUS across the country, it becomes clear the need to look at the operational performance of practical field supervision and certified nursemidwives, who act as preceptors in NMEC financed by MoH and carried out by UFF.
It should be considered that the methodological proposal used as a support to improve care and teaching in midwifery, from APICEON/MoH, brings in its theoretical anchorage the warning to also take into account the potentialities of individuals in order to improve communicative interactions, active in-service professional participation, and the capacity to mobilize towards changes in a perspective of work co-management (10)(11)(12)(13) .
However, the central problem is the mismatch or existence of gaps between the ways of carrying out preceptorship under the traditional teaching logic and the current proposal operationalized in SUS. However, according to the continuing education based on public policy, which dialogues with training-intervention models, we seek to problematize the work processes in health by providing analysis, reflections, dialogues, and service and professional training participation (14) .
Giving meaning to social and institutional relations through reflective dialogue and exchange of experience and knowledge makes it possible to reduce pedagogical distancing between care professionals, training, and management. To make teaching-learning movements based on their own work situations is to call for resources invested in meetings and dialogues to operate reflected practices capable of transforming realities in the daily life of institutions.
In other words, this approach, whose theoretical model is anchored in the critical-reflexive-dialogical conception and in the collective learning process, enables professional engagements responsible for raising reflections on one's own performance and implementing ways of intervening in workplace and health education. Thus, the dialogical theory of reflection and action proposed by Paulo Freire makes it possible to base practices of subjects who, from a collaborative perspective, meet for the transformation of the world (15) .
Preceptorship refers to a more experienced worker's performance who is concerned with a future professional's education, thus admitting the need for several skills to identify weaknesses and encourage trainee participation (16) . It is a support process that occurs when a more experienced person works alongside another in order to provide clinical support and guidance in favor of teaching and learning new skills, with a view to taking over an independent and quality professional practice (17) .
Therefore, preceptorship commitment needs to go beyond transfer of information, demonstration of procedures, organizational surveillance and technocratic qualification. It must also imbue itself by working on reflections that refer to social, cultural, and power aspects.
In this case, the preceptorship developed by certified nursemidwives in delivery and birth in maternity hospitals in Rio de Janeiro (RJ), from conducting NMECs across the country, should be open to the conception of work as an activity and service relationship that, in a certain way, dialogue with NHP and the Continuing Education in Health Policy (Política de Educação Permanente em Saúde, abbreviated PNEPS) (18) . To some extent, this function needs to be encouraged to make a link between teaching/training, care/assistance, and management of teaching maternity hospitals based on professional dialogue, supporting the collective analysis of health work (11) .
The work of preceptorship in midwifery can and must be linked to the concept of institutional support. It aims at the production of subjects in relation to work and points out aspects about form of organization, in-service autonomy, and communication/dialogue between care and management professionals and training.
This perspective of training based on co-management strategies and dialogues on work can contribute to encouraging political-methodological processes that enhance active participation of care and training of professionals in order to act as institutional supporters. Collective involvement to ensure the of Preceptorship in nursing-midwifery: a training-intervention in health work Alves VH, Pereira AV, Dulfe PAM, Vieira BDG, Silva LA, Fontoura AMT, et al.
means for training/teaching/preceptorship ends up providing conversations about work that, in turn, contribute to the induction of new ways of producing subjects/teams (10,(12)(13) .
In this context, they can contribute by mediating situations of tension and institutional conflicts, allowing to foster changes in daily relationships through movements that allow balance of forces and power, mutually influencing conviviality at work and in education (19) .
They provoke the possibility to reorganize performance and ways of exercising management that, to some extent, characterize tools to strengthen midwifery (17) . Its theoretical perspective is the concepts of education-intervention as a field of collective analysis of health work (10) and Paulo Freire principles (15) . Such principles underlie a reference that articulates pedagogical practice in transforming reality, representing in this study the spaces of preceptorship and co-management in maternity hospitals (12)(13) where NMEC/MoH/UFF were performed.

OBJECTIVES
To analyze how certified nurse-midwives identify preceptorship in a NMEC conducted by the Universidade Federal Fluminense as a possibility of training to promote institutional support and intervention.

Ethical aspects
The Research Ethics Committee of the Hospital Universitário Antônio Pedro of UFF approve this study, under Opinion 3,434,805/2019, as provided for in the Resolution 466/2012 of the Brazilian National Health Council (Conselho Nacional de Saúde). After presenting the scope of the research, participants were invited to compose their workplaces. To preserve their confidentiality, anonymity, and reliability, the interviewees received an alphanumeric coding (e.g.: P1... P6), in addition to ensuring voluntary participation by signing the Informed Consent Term.

Type of study
This descriptive, exploratory, and qualitative research was guided by COREQ (20) , having as participants certified nurse-midwives preceptors from NMEC funded by MoH and conducted by the Escola de Enfermagem Aurora de Afonso Costa of UFF.

Study setting
The setting comprises two public maternities in Rio de Janeiro, one linked to the Municipal Health Department (MHD-RJ) and the other to the Fundação Municipal de Saúde de Niterói, which were a practical field of NMEC (MoH/UFF).

Data collection and organization
The participants considered eligible for the study should meet the following inclusion criteria: being certified nurse-midwives, preceptors from NMEC/MoH/UFF, servants of these maternity hospitals with specialist registration at the Regional Nursing Council-RJ (Conselho Regional de Enfermagem). Those who were on vacation or licensed due to health reasons were excluded, as well as of the eight (8) eligible, six (6) certified nurse-midwife preceptors participated, since two (2) were on medical leave. The data collection period occurred in July 2019.
Semi-structured interview was used with questions about perceptions of certified nurse-midwife preceptors from NMEC/ MoH/UFF about continuing education along the lines of trainingintervention for certified nurse-midwives. The interviews lasted approximately 30 to 50 minutes, being recorded with digital resources and transcribed in full. They were performed individually according to pre-agreed time in reserved places in maternity hospitals, where the researcher remained silent so as not to intervene in the process of collecting information.

Data analysis
The reports were analyzed through content analysis in the thematic modality (21) , whose phases were: 1) pre-analysis of the statements; 2) exploration of the material and treatment of the results; 3) inference and interpretation.
Simple computerized resources were used to organize and encode the material (colorimetry in Microsoft Word ® ), which made it possible to elect the following Signified Units: Perception of certified nurse-midwives about the practice of preceptorship; Characterization of preceptorship as institutional support and intervention; Changes in the institution's work process; Exchange of knowledge and experiences; Expansion and strengthening of professional performance. The following thematic nucleus emerged: Preceptorship in the UFF's Enhancing Course as a possibility of training with a view to institutional support.
This way it becomes possible to identify two thematic categories: 1) Participation of certified nurse-midwife preceptors in delivery and birth as possibilities for institutional support and intervention; 2) The role of certified nurse-midwives in the training process: ways of preceptorship that increase visibility and professional performance.

RESULTS
The group composed of six (6) certified nurse-midwife preceptors from NMEC/MoH/UFF were between 28 and 53 years old. They had on average seven (7) years of experience working in nursing-midwifery and attended specialization courses in midwifery in public institutions in the State of Rio de Janeiro, completed in an average period of five years. The statements of certified nurse-midwives about preceptorship in an update/ enhancement course financed by MoH made it possible to identify perspectives of intervention and institutional support in delivery and birth, and to expand autonomy and professional leadership.

st Category -Participation of certified nurse-midwife preceptors in delivery and birth as possibilities of institutional support and intervention
Looking at training process in the setting of delivery and birth, from the preceptorship performed by certified nurse-midwives of Preceptorship in nursing-midwifery: a training-intervention in health work Alves VH, Pereira AV, Dulfe PAM, Vieira BDG, Silva LA, Fontoura AMT, et al.
in maternity hospitals following APICEON/MoH, practical fields of NMEC/MoH/UFF in Rio de Janeiro, allowed considering the work with the perspective of strengthening collectives and changing the institutional daily reality. In a relationship of reciprocal implications, it was possible to observe that, from the follow-up previously carried out by the course management team in maternity hospitals, preceptorship was encouraged to perform differentiated training and provoke changes that would generate different meanings in institutional relations.
On the one hand, it can be observed that the group referred to the changes caused in the work process of the institution that welcomes enhanced certified nurse-midwives from other states. On the other hand, they pointed out that the changes observed and discussed in the field of care would also be able to affect and contribute to transform the units of origin of professionals who were updating/enhancing through participation in the course: The whole unit ends up getting involved in the proposal... it is notorious to notice that there is a provocative movement to change the work process of the institution that receives the trainees, as it ends up involving the entire team, both health professionals and administrators, the reception/concierge even the people in the cafeteria... (P1) However, they pointed out that these changes, specifically those involving the medical category, have still been experienced with some resistance: All this process carried out by nursing-midwifery... we can't get this process done at the unit as a whole... we can't get the medical team to work on this logic of humanized labor assistance... our big problem today is to make the unit respect a care protocol humanized integral to delivery and birth... teamwork. (P1) However, resistance is not unilateral, since certified nursemidwives from other Brazilian states bring with them something that confuses with this reluctance which, in turn, distances them from the relationships among the team, culminating in this reciprocal resistance that becomes the object of dialogue and analysis in the training process. It can be seen from the following reports that, even though experiencing situations of tension and change, professionals were encouraged to dialogue about their daily lives during and after the time in which training practices occurred. They also reflected on the reciprocal influence that had repercussions on the unit's training process, because, in a certain way, care and management professionals also learned and exchanged experiences with the coming of workers from other places in the country. Such influences were mentioned from APICEON/MoH and NMEC/MoH/UFF strategies through the need to look at the workplace with the perspective of dialogue regarding it in the institutional daily reality. Certified nurse-midwife preceptors pointed out that, after the beginning of the course, the goal of organizing meetings of/among workers to discuss the daily life of performance in maternity hospitals was a commitment of care/assistance, management, and training professionals. In addition, they highlighted the importance of support from APICEON/MoH, in this case, the seal of the same, which made it essential to guarantee the intervention process. Initiatives from the federal level encouraged changes. This involvement, especially in relation to the request for a greater presence of the university/MoH, has encouraged the exchange of knowledge and experiences among in-service workers and implemented a movement in favor of expanding collective meetings in the perspective of thinking about work with belonging and not as a repetition of tasks and guarantee of protocols. In this case, these meetings provoked the activity of reciprocal changes in the context of training, management, and care. The following reports show that the way of relating to work in institutions begins to be experienced in a more inventive and collaborative way, contributing to reflect and dialogue about daily practice: This movement, which instigates work analysis processes, stimulates the understanding that using it from the workers themselves, in the sense of providing assistance and ways of teaching/training reflective, contributes towards expanding transformations beyond institutional walls. Thus, reciprocal changes can occur both in the relationships between professionals who are already in maternity hospitals and receive enhanced certified nurse-midwives, as well as in the institutions that sent these specialists to the course:

The incentive we have by the institution, I think it is very personal... it is when you like what you do, when you want all women to have this respectful assistance with the use of technologies... with respect. So, you want this to spread to the other institutions. (P5)
Understanding that indication was made from an institutional commitment between management, APICEON/MoH, and enhanced certified nurse-midwives, raises the possibility of individual and collective commitment, as explained in the following statement: Intervention for those who come, for those who propose to modify this model that is accustomed, and be able to transform the workplace when it returns... in-service change. Or just to strengthen the practice [...] there will also be intervention in ourselves, in management, in everything. (P6) Therefore, when enhanced certified nurse-midwives who came to attend the enhancing course return to their home institution must find support, in order to ensure individual involvement and collective engagement in the processes of change.

nd -The role of certified nurse-midwives in the training process: ways of preceptorship that increase visibility and professional performance
As for the performance of preceptorship at the course financed by MoH (2018-2019), it was possible to identify that certified nurse-midwife preceptors expressed a consolidated teachinglearning relationship through effective monitoring of delivery and birth. Therefore, preceptorship actions were configured from the professional practice itself.
By effecting the direct exemplifying of professional performance, certified nurse-midwife preceptors used dynamic teaching-learning resources such as cardiotocography, suture, dystocia management, bleeding complications, aromatherapy, and discussion of protocols. Sharing up-to-date scientific knowledge aroused reflections on the part of some interviewees, who, to some extent, contributed to strengthen the image of certified nurse-midwives in the working relations in the course's maternity hospitals or exemplify positions of professional independence in the relationship with enhanced certified nurse-midwives. The relationships of preceptors allowed us to experience exchanges of knowledge between professionals from different realities of the country. Both the groups of certified nurse-midwife preceptors and enhanced certified nurse-midwives are instrumentalized to act differently in the course's maternity hospitals and, respectively, in the institutions of origin. It was also possible to record that nurses perceived that the preceptorship actions under the influence of NMEC/MoH/UFF, to some extent, strengthened their own professional performance. To implement the activities directed by the course, it was necessary to carry out a preceptorship exercise through collective discussions and reflections on the problems related to practice and those imbricated to work and continuing education.
In this context, preceptorship made it possible for certified nurse-midwives to get closer to the other professionals and managers of the institutions receiving the course. It also promoted meetings that, in a way, contributed to reflect on daily practice.
In a correlated perspective, the interviewed group understood that preceptorship was also developed through the involvement of certified nurse-midwife preceptors with management and other professionals. Also, the focus would be to mediate relationships with a view to operationalizing the course and boosting processes that contribute to structural changes.  In turn, preceptorship can also help in strengthening the autonomy of certified nurse-midwives in the relationship with the team.
We get a little more questioning, the management has to modify to be able to meet what we need in-service. It was detailed that this process of expanding the performance and professional autonomy of these specialists, based on the preceptorship in a training course, had as a proposal to carry out actions that characterized intervention. In a way, they caused changes related to institutional work, with a view to the need to meet NMEC/MoH/UFF guidelines.

DISCUSSION
Due to the fact that they are developing preceptorship activities in a course financed by MoH (NMEC/UFF), certified nursemidwife preceptors, enhanced certified nurse-midwives and other professionals had the need to organize the ways of representing competencies that, in a certain way, allowed dialogues with quality expectations in the training process. Developing the ability to analyze workplace and ways of co-managing from collective practices between and with different professionals made it possible to assess real work situations as a privileged space for training and intervention (11) .
Showing strength to create teaching-learning relationships, based on limitations imposed by difficulties in structure/environment and work relationships influenced by the historical corporate mode of action in health due to collective interprofessional actions (22) , was also a daily effort performed by certified nursemidwife preceptors in order to guarantee competent training processes. Their activity can contribute to updating of technical knowledge and continuous improvement of quality.
Therefore, this action, which takes into account the reference of external standards of safe practice based on scientific evidence (17) , similarly to simulation-enhanced nurse (6)(7)(8) , also enables to qualify processes of institutional support and intervention in midwifery (23) .
It is worth mentioning that each maternity unit that was in the capacity of executing programmed actions saw APICEON/ MoH as a practical field opportunity for the improvement of certified nurse-midwives from teaching hospitals across the country demonstrated effort. This was done in order to share co-management and training processes interrelated with daily practice, with a view to transforming the work process.
According to the Toolkit for Strengthening Professional Midwifery (2014), support for the improvement or continuous enhancement of quality in midwifery services should provide contribution. Such services must aim for these institutions to commit themselves to assess practices and provide evidence that the activities can be compared with external safety standards, enabling recommendations for the qualification of care (17) .
In this perspective, certified nurse-midwife preceptors, when experiencing participative and collaborative actions, gradually inserts into her practice of health care and training, the understanding of institutional support, as a more energizing role than expectative in the process of potentiating institutional changes.
With regard to the training component, professionals not only facilitated the dialogical access to the management, but also provoked the possibility for the manager to position themselves effectively in the face of the existing tensions in the transformation process that were being listed. After all, dealing with professional conflicts, questions, criticisms, and strangeness caused certified nurse-midwife preceptors to incorporate different forces and identify peers, especially with/ within the scope of management, to mediate daily mismatches (19) .
Change processes related to professional practice itself were experienced resulting from the need to maintain a closer relationship with management and other team professionals. Thus, commitments, confrontations and mediations in the field of ethical-aesthetic-political values were revealed, which enhanced training with intervention similar to the devices that support decision-making in the care organization process (10,24) .
In this way, managers and other professionals perceived themselves faced with the need to solve problems and deal with conflicts, in view of the dialogical-reflexive perspective that was being encouraged in collective meetings with a view to boosting institutional change, from APICEON/MoH and NMEC/MoH/UFF. Thus, not only did they incorporate the interest in sharing examples of competence and innovation, but they also enabled dialogues with the pedagogical proposal of the course. This proposal provoked the critical exercise of collective discussion to try the method of intervention and institutional support in maternity hospitals, starting from the analysis of daily work in dialogue with Paulo Freire theoretical principles (15) .
This collective work also represents a place of debate, possibilities and negotiations and, therefore, it is impossible to strictly follow prescriptions/norms, considering that tensions and contradictory enable different meanings to daily relationships in institutions, in a way, contribute to foster processes of change.
Based on scheduled meetings that guaranteed conversations about everyday problems and difficulties, it was possible to use work to experience training/improvement situations from risk classification, through delivery and birth, to discharge in the puerperium. In this way, certified nurse-midwife preceptors had been operating between of Preceptorship in nursing-midwifery: a training-intervention in health work Alves VH, Pereira AV, Dulfe PAM, Vieira BDG, Silva LA, Fontoura AMT, et al.
the institutional norm and the renormatization of work processes in a dialogical-reflective relationship in line with the principles of inservice education and the co-management segments. They allowed themselves to reinvent modes of preceptorship, getting involved in support and intervention activities based on the analysis of work, contributing to the transformation of professional life (12)(13)25) . In turn, the training path highlighted here, intrinsically related to the modes of management and health care, was pointed out as a strategy that contributed to analyze the ways of work and training in the researched maternity hospitals. Moreover, it made possible collective exchanges of experiences, taking into account the dialogue between technique and human action in an analytical and reflective perspective. Thus, carrying out these activities enabled institutional support strategies, supporting intervention practices in the work process in the units (11) .
Therefore, notes, which referred to the actions carried out in the course of updating the service of enhanced certified nursemidwives from all regions of the country, allowed for training based on dialogues and reflections about the daily life in the units of origin of these professionals and the maternities practice field of NMEC/MOH/UFF.
From the exchange of knowledge and experiences, the exercise of preceptorship via NMEC/MoH/UFF made it possible to experience practices that were considered positive to the extent that the use of activities dialoguing with active methodologies in the teaching-learning process, in this case through workshops held in service, allowed certified nurse-midwife preceptors to print a dynamic character in the development of enhancement. Thus, the preceptorship performed by certified nurse-midwives was experienced through discussions about real daily situations, promoted with each group of the course.
The causes and ways of looking at the problems were identified in order to understand and solve them collectively, in addition to ensuring quality in training and continuing education. This perspective, similar to research that dialogs with NHP, confirms contribution to changes in reality. It emphasizes the participatoryemancipatory character of the subjects who appropriately reflect and analytically analyze everyday situations, sharing knowledge production (10) . Thus, both care and training, and management professionals began to be invited to rethink their own practice, corroborating indissociability between NHP (2) and PNEPS (18) .
In this situation, activities were organized in meetings, whose participation of certified nurse-midwife preceptors allowed to broaden the collective view on the complex institutional relations and to move structural transformations in dialogue with the process of training and co-management (12)(13) . Furthermore, preceptorship was considered an interesting tool to raise reflections about the importance of alternating the place of speech in the coexistence between workers, prioritizing a culture of reciprocal interests in the organization and interactions in the workplace (10) .
To meet the training/improvement needs, there was an intrinsic expansion of attitudes associated with the professional autonomy process, which, in a way, were interesting in solving problem situations related to the development of enhanced certified nurse-midwives. Certified nurse-midwife preceptors, anchored in collective meetings, with a view to intervention and institutional support, managed to expand institutional communicative and dialogical connections. Such connections not only reduced the inequalities of power (19) , but also, in a way, raised outcomes that ended up increasing the visibility of professional competence in the NMEC/MoH/UFF-related service.

Study limitations
The limitation of the present investigation stands out in the absence of systematized records of the activities performed by preceptorship in the maternities involved, such as absence of reports of participation in meetings and preparation of protocols.

Contributions to nursing
Anchoring teaching-learning relationships through technicalscientific knowledge and updated evidence-based practices raises assessment processes about interventions considered contemporaneously unnecessary in birth and delivery and the process of institutionalization of the certified nurse-midwife's professional practice and qualification of care.
Moreover, the present reflections contributed to strengthen the contemporary image of nurses (26) and to expand their professional autonomy in midwifery, especially in maternity hospitals that were places of practice of NMEC/MoH/UFF across the country.

FINAL CONSIDERATIONS
Certified nurse-midwife preceptors contributed to in-service training of other nurses specialized in midwifery as a possibility of using improvement/updating in favor of institutional support and intervention in developing work of maternity hospitals, settings of this investigation.
Therefore, it is opportune to characterize that teaching-learning relationships, when experienced in a dialogical-critical-reflexive way from exchanges of information and practices based on updated evidence, they raise self-assessment processes. Such processes, in turn, expand not only the certified nurse-midwife trainee's autonomy in maternity hospitals, which were the fields of practice, but of institutions across the country that sent nurses to perform NMEC, funded by MoH and carried out by UFF in Niterói, Rio de Janeiro, Brazil.
With this regard, sharing knowledge between preceptors and trainees beyond technocratic repetitions and encouraging collective meetings, from a perspective of democratic co-management, provides opportunities to analyze training, care/assistance, and management work, which characterized intervention and institutional support.