Supervised internship in undergraduate nursing courses in the State of São Paulo, Brazil*

Objective: to analyze how nursing courses in the State of São Paulo, Brazil have operationalized the supervised curricular internship and to identify those that approach the recommendations proposed by the National Curriculum Guidelines. Method: a quantitative, descriptive-exploratory study. The sample consisted of 38 course coordinators. The data collection instrument was developed based on the Curricular Guidelines. Data collection took place electronically and, for data analysis, descriptive and inferential statistics were used. Results: the undergraduate schools have developed internships for a mean of 860.4 hours in primary and tertiary care settings, with learning based on professional practice being the main teaching method. Formative assessment is the predominant mode of assessment, and nurses from health institutions participate in 44.7% of courses. The mean score obtained was 3.1 points (scale from 1 to 5), with the evaluation processes used being the most influential factor (p<0.001). Conclusion: the courses have partially met the educational legislation regarding the hours and participation of professionals from health institutions granting internship field, which can compromise the quality of training and the safety of care.


Introduction
Discussions and reflections about the direction of Nursing Education have intensified in the last two decades, driven mainly by economic and social changes worldwide (1) . The effectiveness of clinical teaching for the training of nurses, their individualization, pedagogical innovations, the participation of professionals from health institutions that receive students in internship situations and the satisfaction of students with their learning have been questioned by researchers (2)(3) .
In Brazil, the training of nurses has been widely debated by educational institutions, bodies representing the class and the government, which has generated numerous opinions and resolutions. Several points of disagreement have been elucidated over the years, however, other problems seem to generate greater discomfort, such as the development of Supervised Curricular Internship (Estágio Curricular Supervisionado, ECS) in health services (4) .
Higher Education Institutions (HEIs) organize their training processes based on the National Curriculum Guidelines (Diretrizes Curriculares Nacionais, DCNs) for undergraduate nursing education. This establishes the desired professional profile, its essential competences and determines the minimum curricular structure, in which the student must take theoretical and practical disciplines throughout the training and, at the end, 20% of the total hours of the undergraduate course must be directed to the development of the ECS (5) .
The ECS has a central role in the training of nurses, because it aims to give the future professional greater mastery of the practice, articulation of knowledge and fundamental actions to instrumentalize the working process of the profession (6) . In addition to presenting itself as an integrating instrument between the HEIs and the Health Institutions, it is a curricular component that allows for the insertion of the student in the real world of work, mediated by the figure of the teacher and tutored by the professional nurse who works in the scenario where the teaching practices (4)(5)(6) .
It is possible to state that the nurse is the professional who can guarantee the sustainability of universal health systems, given the expertise in care and the ease in inter-professional relationships.
Training processes that guarantee theoretical knowledge and, especially, mobilization of cognitive skills in professional practice can guarantee an individual-centered approach, leadership, technological skills, effective communication with social participation, practice improvement processes, safety, teamwork and cooperation, care coordination and quality improvement (7) .
The ECS is configured as a strategy that aims to insert the professional future in the contexts where the profession is developed, without filters or controls, as it is presented, guaranteeing training for the mobilization of cognitive, psychomotor and affective skills necessary to work in complex health systems (3,(8)(9)  nursing courses (5) as a theoretical framework. It is self-applied, with 13 items distributed in two parts.
The first includes three variables used to obtain information about the HEI: administrative dependency

Results
The    Table 3 shows the linear regression, t test and identification of the level of significance used to analyze the influence of the variable in the results obtained. National studies have shown that there has been an increase in private institutions in the last ten years, with a growth of 122% (14) .
This study showed the variability of hours both for the course as a whole and for the hours devoted to the development of the ECS. For nursing education in Brazil, a minimum of 4,000 hours (5) is determined, and this requirement is met according to the mean found.
Regarding the hours of nursing courses developed in Europe, it is observed that, although there is a diversity of curricula, in most of the higher nursing schools, the student, in order to complete the first training cycle (degree), takes three to four years of formal education, and the minimum hours must not be less than 4,600 hours. It should be noted that 50% of this hours should be devoted to clinical teaching, that is, clinical practice in health units (4,(15)(16) , more than double the ECS hours required in Brazil (5) . However, the offer of clinical practices is also a challenge for the European countries, because the number of hours devoted to the clinical practice has varied between 30 and 60% of the total course load, showing the non-compliance with European legislation (16) . proportional to the improvement in the quality of patient care and the reduction of adverse events (17)(18) .
The hours for the training of nurses are distributed by the DCNs in various teaching strategies. In the initial years of the course, the student is instrumentalized through theoretical classes, simulated practices and clinical practices and there is no clear definition of the hours that should be allocated to this type of education (5) . What has been observed in the state of to influencing students' confidence, their sense of belonging and respect for the user (4,16) .
Data from this study showed that, although 860.4 hours, on average, are dedicated to the development of ECS activities, there were courses that offered less than half the hours determined by the DCNs (5) . that the integration of academy-service within and outside the walls is still incipient and that there is a strong dissociation between theory and practice (14) .
As for the places where the activities of the ECS are operationalized, it is noted that the two major scenarios of the SUS are being contemplated: primary and hospital care. In European countries, to be recognized as a field of clinical learning, health institutions must demonstrate specific criteria related to facilities, including equipment and human resources, the quality of the educational environment determined through audits and positive feedback received from independent accreditation bodies, which monitor the entire nursing education process (16) .
It was observed that, for the development of that can guarantee the resolution of common healthdisease processes (14,19) .
In Brazil, there are few studies describing teachinglearning methods and methods used with students in internship situations. Active methods aim to ensure meaningful learning for students, but do not direct how their supervision should occur, both by the teacher and by professionals from health institutions. The Clinical Supervision methodology, used outside Brazil, has proven to be a robust tool when the objective is to support the development of cognitive, psychomotor and affective skills. It aims to direct and organize the teacher-student-professional teaching triad, being an interesting alternative to compose the teaching methods employed (4) .
Emphasizing the potential of evaluation in the regulation of the quality of teaching and, consequently, of professional training, it was observed that in this study the question that had the greatest impact on the results obtained by the participating courses was about the processes of evaluation of learning used during the ECS. The assessment of student learning is a planned, systematized resource, which aims to obtain and analyze data on students' knowledge and skills, which can enable the measurement of teaching processes and generate triggers for improvement actions (20) .
The teaching models that presuppose learning including the student himself, as the center of teaching and learning activities (21) .
Less than half of the participants in this study clearly stated that there is the participation of the professional in the ECS activities, being reinforced by nursing courses when they declare that students are directly supervised by the teacher. The participation of nurses from the health institutions in training processes has been a controversial subject and, historically, difficult to be transposed (22) . The DCNs describe the need for the effective participation of professionals in the programming and in the student supervision process in the health services where the internships (5) are developed. However, the Federal Nursing Council allows nurses to participate in planning and supervising students in the ECS activities (22) . It is considered that the nurse has a fundamental role in the insertion of the student in the internship fields, as it raises discussions about the problems experienced in professional practice, in addition to being the profession itself being carried out concretely, ensuring more significant learning (19) . In other countries, the nurse actively participates in the training processes, acting as preceptor of undergraduate students, which gives him the autonomy to plan with the teachers the activities that will be developed, supervise the development of professional skills and actively participate in the evaluation processes (22) . It is a consensus among the European nursing schools that clinical teaching is not carried out without the participation of nurses, as they encourage self-criticism, self-supervision, and reflection on work processes (4) .