Supervised Internship: attributions and limitations from the perspective of nursing supervisors, faculty advisor and managers

Internado Curricular Supervisado: atribuciones y limitaciones desde la perspectiva de la enfermera supervisora, asesora de la facultad y gerente

ABSTRACT

Objectives:

to describe the attributions and limitations in internship nursing supervisors’, faculty advisors’ and managers’ work in the process of carrying out Supervised Internship in nursing education.

Methods:

a qualitative exploratory-descriptive research. Interviews were conducted between February and July 2018 with 26 participants: four managers, nine faculty advisors, six primary care nursing supervisors and seven hospital care nursing supervisors. Data analysis was performed using the Content Analysis technique.

Results:

among the main attributions are participation in the organization of the field, mediation between educational and health institutions, presentation of the world of work; as limitations are the high number of institutions in the field, work overload, lack of commitment or lack of didactic preparation towards student education.

Final Considerations:

we evidenced the need to (re)define and clarify everyone’s roles and (re)think the integration strategies for monitoring students.

Descriptors:
Nursing; Education, Nursing; Nursing Education Research; Training Support; Health Human Resource Training

RESUMEN

Objetivos:

describir las atribuciones y limitaciones en el desempeño de enfermeras supervisoras de internado, asesoras de facultad y gerentes en el proceso de realización del Internado Curricular Supervisado en la educación de enfermería.

Métodos:

investigación cualitativa exploratoria descriptiva. Las entrevistas se realizaron entre febrero y julio de 2018, con 26 participantes, como cuatro gerentes, nueve asesores de la facultad, seis enfermeras supervisoras de atención primaria y siete enfermeras supervisoras de atención hospitalaria. El análisis de los datos se realizó mediante la técnica de Análisis de Contenido.

Resultados:

entre las principales atribuciones, se destacó la participación en la organización del campo, mediación entre instituciones educativas y de salud, presentación del mundo del trabajo; como limitaciones, el alto número de instituciones en el campo, la sobrecarga de trabajo, la falta de compromiso o falta de preparación didáctica en cuanto a la formación de los estudiantes.

Consideraciones Finales:

se evidenció la necesidad de (re) definir y clarificar los roles de todos y (re) pensar las estrategias de integración para el seguimiento de los estudiantes.

Descriptores:
Enfermería; Educación en Enfermería; Investigación en Educación de Enfermería; Apoyo a la Formación Professional; Capacitación de Recursos Humanos en Salud

RESUMO

Objetivos:

descrever as atribuições e limitações na atuação dos enfermeiros supervisores de estágio, docentes orientadores e gestores no processo de realização do Estágio Curricular Supervisionado na formação do enfermeiro.

Métodos:

pesquisa qualitativa exploratória-descritiva. Foram realizadas entrevistas, entre fevereiro e julho de 2018, com 26 participantes, como quatro gestores, nove docentes orientadores, seis enfermeiros supervisores da atenção básica e sete enfermeiros supervisores da atenção hospitalar. A análise dos dados ocorreu pela técnica de Análise de Conteúdo.

Resultados:

dentre as principais atribuições, destacaram-se a participação na organização do campo, mediação entre instituição de ensino e de saúde, apresentação do mundo do trabalho; como limitações, o elevado número de instituições no campo, a sobrecarga de trabalho, descompromisso ou falta de preparo didático para com a formação discente.

Considerações Finais:

evidenciou-se a necessidade de (re)definir e clarificar os papéis de todos e (re)pensar as estratégias de integração para o acompanhamento dos discentes.

Descritores:
Enfermagem; Educação em Enfermagem; Pesquisa em Educação de Enfermagem; Apoio ao Desenvolvimento de Recursos Humanos; Capacitação de Recursos Humanos em Saúde

INTRODUCTION

Throughout nursing training, in addition to theoretical and practical contents, the inclusion of Supervised Internship (SI) in the curriculum must meet some requirements, such as performance in general and specialized hospitals, clinics, basic health services and communities, and must be carried out in the last two semesters of the course(¹). Still, it must total at least 20% of the course load and be ensured, not only by the effective participation of nurses in the health services where it is developed, but also through the guidance of a professor(¹).

For its feasibility, it is essential that all people involved recognize the importance of this moment for nursing students’ education, as well as enabling and valuing the sharing of knowledge and experiences that may emerge during the development of SI. This reflects not only on the assistance provided to the community, but also on the team work process in which students are inserted. “Teaching-service integration is an indispensable element to renew the way of thinking about training and a true approximation with the real scenarios of practice in health and nursing”(²).

When starting SI, students dive into the action of the professional universe of nurses(³). Thus, the exercise of “being a nurse”, as well as the outlining of the professional identity of students, are materialized at this time and, for this to occur in a manner consistent with the expected profile of a generalist nurses, it is essential that all parties involved perform their roles effectively and committed to the training of these students. It reinforces the importance of discussing the responsibility of education and health sectors in the training of health professionals(⁴).

Nursing students represents the central object of this formative stage. However, even if the development of SI is the result of several partnerships, integrations and factors that the subjects involved cannot control, the meaning and use of this experience are strictly associated with students’ adaptability and commitment to their learning. Nursing supervisors play an important role in SI, thus representing the link between university and internship(⁴). It also stands out for its active role in monitoring students, often serving as a base, while professors play the role of mediator, assisting in theoretical support. The presence of a professor, throughout graduation, must occur assiduously, whether in classrooms or in the laboratory, or in practical activities developed in health services. However, during SI, professors take on a different role from that played so far, through a leave, enabling students to be closer to nursing supervisors. However, this does not detract from professor accountability at this stage.

Through the practice experienced in SI, students confront the theory learned in graduation and this enables their improvement and the development of critical thinking to act more effectively in the labor market(⁵). However, for the inclusion of students in health services, which are consistent with the reality that will be experienced, several articulations between the services and the educational institution are necessary. Thus, in addition to the role of nursing supervisors and faculty advisors, there are managers, who are subjects that enable the articulations and movements to materialize the realization of SI. “The quality of education that is intended requires the involvement of the various actors that make up the training process”(⁶). In this training process, studies have highlighted and the relevance of SI in the training of professionals nurses(²-⁵).

Given the importance of training qualified professionals, the relevance of reflecting and knowing the path taken is highlighted, which enables these students to practice professionally. For this, scientific research that knows the reality of nurses’ training is essential to understand all the phenomena involved in this process. Thus, exploring the views of different subjects immersed in these realities, there is the possibility of (re)thinking and (re)structuring the training process of nurses, with a view to improving and consequently advancing the profession. Thus, it is essential to know the potentials/attributions and limitations that go beyond this stage, since each institution is located in a place, presenting its particularities, not only in relation to the reality of the local community, but also to the teaching offered.

OBJECTIVES

To describe the attributions and limitations in internship nursing supervisors’, faculty advisors’ and managers’ work in the process of carrying out Supervised Internship in nursing education.

METHODS

Ethical aspects

The research was approved by an Institutional Review Board, as recommended by Resolution 466/2012 of the Brazilian National Health Council (Conselho Nacional de Saúde). In order to ensure confidentiality, each participant was identified by the letters “MA” (managers), “IFA” (internship faculty advisors), “PC INS” (primary care internship nursing supervisor) and “HC INS” (hospital care internship nursing supervisor), followed by alphanumeric coding, according to the sequence of interviews.

Study design

This was a qualitative, exploratory-descriptive study, using the Consolidated criteria for reporting qualitative research (COREQ) instrument from the Equator network.

Study setting

This study was developed in an undergraduate nursing course at a federal university in the countryside of Rio Grande do Sul. SI workload in this setting totals 840 hours.

Data source

Participants in this study included managers, primary care and hospital care nursing supervisors and faculty advisors of the educational institution. Exclusion criteria were established for all groups: being on vacation, reports, retirement, maternity leave, or any other kind of absence from activities during the period of data collection. To establish the quantity of the sample of participants referring to nursing supervisors and faculty advisors, a previous survey was carried out in terms of internship commitment in the period between the first semester of 2015 and the first semester of 2017, in order to determine who were the responsible in that period.

Regarding managers, there were representatives from the educational institution, as well as from hospital care and from Primary Health Care, totaling four participants, corresponding to all eligible managers.

For the selection of faculty advisors, the following inclusion criteria were established: being effective professors of the course under study and having supervised at least three students, identifying a total of 25 professors. Of these, 23 were permanent professors and 17 had supervised at least three students. In applying the exclusion criteria, two had retired, two were on leave at the time of collection and one had access to the study project. Thus, after applying the inclusion and exclusion criteria, the participation of 12 professors was initially estimated. However, nine professors participated in the study, as two did not show interest in participating, and, with one professor, there were several scheduling attempts, but without success.

As for the health services, represented by SI hospital care and Primary Health Care nursing supervisors, the participation of one representative per health unit/sector was established, considering as an inclusion criterion having supervised the largest number of students in the pre-established time frame, considering at least three students. In hospital care, of the 91 nurses who supervised internships, referring to 18 sectors of an institution, 25 nurses, corresponding to nine sectors, had supervised at least three students. For this purpose, one representative per unit was considered, initially estimating the participation of nine nurses. Of these, one had retired and, with another, there were several unsuccessful scheduling attempts. In both cases, there was no new participant who met the criteria in the sectors in question. Therefore, seven nurses participated in the study. In Primary Health Care, a total of 24 nurses were identified from 18 health units. After applying the inclusion criteria, the participation of 11 nurses was estimated, however one was away, two did not show interest in participating in the study and two there were several unsuccessful scheduling attempts. Thus, the participation of six nurses was effective.

Concluding the details of the selection of participants, the sample with the final corpus, for analysis of the study, was composed of 26 (100%) participants: four (15.38%) managers, nine (34.61%) faculty advisors, six (23.07%) Primary Health Care nursing supervisors and seven (26.92%) hospital care nursing supervisors.

Data collection and organization

Data collection took place between February and July 2018. Interviews were conducted through a semi-structured script, in which the questions that guided the study included: what is the process of carrying out SI like? Describe your experience in carrying out your supervision with students who performed/are performing SI. What is the role of nursing supervisors during the SI performance? How can the presence of an internship student influence the health service? Do students feel prepared to experience SI? How do you identify the educational institution’s participation in this stage? And from the health institution? How do you evaluate students who were doing internships under your supervision? Do you notice/perceived any difficulties students had during internship? As a supervisor, did you notice any difficulties? In your opinion, what is the importance of SI in the training of nurses? Could you describe the positive points in carrying out SI, if any? Could you describe the limitations in carrying out SI, if any? If you could suggest something to change in the process of carrying out the internships, what would it be?

At the end of each interview, an image was used, as shown in Figure 1. This image, created by Wilson and illustrated by Long, presents several subjects without gender and race, arranged in a tree, open to interpretation and has the objective of enabling discussions, as well as stimulating deep reflections on any topic. The author suggests, for the use of the image, to start with general questions until the realization of deep questions about the approached theme(⁷). Thus, they were asked to indicate which subject(s) of the image represented their role in the development of SI, inviting them to explain the reason for their choice. The use of this image was essential so that each one could make a self-reflection about the role played in this process.

Figure 1
Image used to conclude the interview

It is noteworthy that four pre-tests were carried out with individuals belonging to the studied groups, who were not selected through the inclusion and exclusion criteria, being two health service nursing supervisors and two faculty advisors. That said, the invitation to participate in this study was carried out, in person, via e-mail and through telephone calls. The interviews took place individually and were previously scheduled, according to the availability of date, time and place preferred by participants, seeking to ensure the quality of the material to be collected, as well as guaranteeing the interviewee’s privacy and confidentiality. The interviews were recorded and, in turn, transcribed, in full, right after they were carried out. The duration of the interviews varied between 22 minutes and 1 hour and 17 minutes, totaling 15 hours and 30 minutes.

Data analysis

The process of organizing and analyzing the data was carried out in stages, firstly, the sociodemographic data underwent a systematization, allowing to know the profile of the group of participants. These data were grouped and described using descriptive statistics techniques, based on their presentation with frequency and percentage.

The data analysis process, together with the discussion and interpretation of material from the transcription of speeches, is based on Bardin’s Content Analysis technique. According to the author, content analysis is characterized as a set of “communications analysis techniques” in which it essentially considers subjects’ speeches(⁸). This analysis technique is divided into three chronological poles: pre-analysis, material exploration and treatment of the obtained results and interpretation.

The pre-analysis allowed for the organization and systematization of ideas, as well as a resumption of the research’s initial hypotheses and objectives. A succinct reading/text skimming of the interviews was carried out, aiming to identify the core meanings of the material, concomitant with the highlighting process (marking). Material exploration, in turn, was characterized by a phase in which the material‘s raw data were coded, in order to reach the core of understanding of the text. At this stage, an in-depth reading of the qualitative material was carried out, proceeding to identification and extraction of registration and context units, in order to start the process of grouping by similarity. For this, reading and chromatic highlighting were performed for the registration units, in accordance with pre-established similarity grouping. For the context units, excerpts from the interviews were underlined and those most representative were selected to compose the results of this study. The interpretation of results is approached by the author as a moment in which the raw data are submitted to statistical operations, in order to become meaningful and valid and to highlight the information obtained. Five categories emerged: “Students and Supervised Internship from participants’ perspective: attributions and limitations”; “Nursing supervisors and Supervised Internship: attributions and limitations”; “Faculty advisors and Supervised Internship: attributions and limitations”; “Managers and Supervised Internship: attributions and limitations”; “The image and identification of roles of people involved in Supervised Internship”.

RESULTS

Characterization of study participants

To describe the characterization of participants in relation to gender, age, time and educational institution, degree and length of experience in the service, there was a division according to the groups participating in the study.

In the group of participants referring to IFA, nine (100%) were female. The age ranged between 30 and 62 years old, three (33%) were between 30 and 40 years old, two (22.2%), between 41 and 50, and four (44.5%) were between 51 and 62 years old. Regarding the training institution, seven (77.8%) were from public institutions and two (22.2%), from private institutions. As for the time since training, there was a variation between 11 and 35 years, in which three participants (33.3%) had between 11 and 15 years of training, another two (22.2%), between 16 and 25 years and four (44.5%), between 26 and 35 years of training. As for the degree, all participants (100%) were PhD. Regarding the length of experience in the service, three (33.3%) worked at the educational institution between four and 15 years and the other six (66.7%), between 16 and 33 years.

As for the characterization related to PC INS, six (100%) were female. The age ranged between 30 and 62 years, of which four (66.6%) were between 30 and 40 years, one (16.7%), between 41 and 50 and one (16.7%), between 51 and 62 years old. Regarding the training institution, two (33.4%) were from public institutions and the other four (66.6%) from private institutions. As for the time since graduation, there was a variation between 10 and 31 years, four (66.6%) had between 11 and 15 years of graduation and the other two (33.4%), between 16 and 31 years of graduation. As for the degree, four (66.6%) were specialists. Regarding the length of experience in the service where data collection took place, four (66.6%) worked in the service for a period between three and 10 years and two (33.4%), between 11 and 21 years.

In the characterization of HC INS, six (85.0%) were female and one (15.0%), male. Age ranged between 29 and 39 years, of which two (28.6%) were between 29 and 31 years old and the other five (71.4%), between 32 and 39 years old. Regarding the training institution, five (71.4%) were from public institutions and the other two (28.6%) from private institutions. As for the time since graduation, there was a variation between seven and 15 years, two (28.6%) had between seven and 12 years and the other five (71.4%), between 13 and 15 years of graduation. As for the degree, six (66.6%) had performed some type of specialization. Two (28.6%) participants held a master’s degree. It is noteworthy that one (15.0%) participant was taking a professional master’s degree and another (15.0%) was taking a PhD in nursing. Regarding the length of experience in the service, which ranged between three and 10 years of experience, among participants, five (71.4%) worked in the service for a period between three and five years and two (28.6%), between six and 10 years.

Regarding the characterization of the last group of participants referring to MA, three (75.0%) were female and one (25.0%) was male. As for age, which ranged between 30 and 62 years, two were (50.0%) between 30 and 40 years, one (25.0%), between 41 and 50 and another (25.0%), between 51 and 62. Regarding the training institution, all (100%) were from public institutions. As for the time since training, there was a variation between seven and 35 years, in which two (50.0%) were between seven and 15 years, one (25.0%), between 16 and 25 and the other (25.0%), between 26 and 35 years after graduation. As for the degree, three (75.0%) were PhD. With regard to the length of service in the service, it ranged between two and 15 years, with two (50.0%) working in the service in a period between two and five years and the other two (50.0%), between six and 10 years.

Students and Supervised Internship from participants’ perspective

As for students’ role at this stage, four (15.38%) mentioned co-responsibility for training. As for the factors that enable better use of SI, three (11.53%) participants highlighted that students’ motivation is crucial. Still, the performance of extracurricular activities was characterized as empowering by four (15.38%) participants.

It depends on students’ motivation [...] there are students who want to be there [...] others are just there to study a subject to complete the course. (IFA 02)

It depends on the profile of each one, but those who have assistance scholarships arrive with a different vision, and those who don’t will start from scratch. (HC INS 02)

Among the limitations, three (11.53%) participants reported that students did not arrive at SI with minimum preparation, another nine (34.61%) participants reported that students arrived at SI without developed skills. Five (19.23%) participants reported that students were little committed to SI:

Practice is a very flawed thing; they don’t correlate practice with theory. (PC INS 03)

The technical part is quite lacking and there are students who arrive without having done the basic procedures [...] there is still a lot of preparation. (HC INS 01)

Some that we see that they don’t commit much or that they keep doing things for the sake of doing, because they need to do it. (IFA 06)

Nursing supervisors and Supervised Internship

Regarding nursing supervisors’ role, 10 (38.46%) participants characterized the monitoring of students, guiding and conducting their actions in the service routine. Six (23.07%) participants attributed the insertion of students into the world of work. Six (23.07%) participants mentioned, among nursing supervisors’ duties, to provide students with the opportunity to develop autonomy. As for students’ knowledge, four (15.38%) participants reported that, initially, they sought to recognize students’ “levelling”:

The field nurse works together, but he takes a short break so that the eighth semester student can actually do the exercise as a nurse. (IFA 08)

Nurses’ role is really to show what professionals’ routine is like, in the workplace in which they are inserted. (PC INS 03)

The first thing I need to know is what level of knowledge he has [...] I wait for what he will do with the freedom I give, within what he needs to develop. (PC INS 05)

With regard to the limitations faced by nurses, one (11.11%) professor and one (14.28%) hospital care nurse reported difficulties that some nurses have to understand their role as educators. Among the highlighted limitations, eight (30.76%) participants mentioned the absence of SI professors in monitoring students.

And not everyone is used to the fact that this is a teaching hospital and that we also have this obligation to teach. (HC INS 03)

I don’t see myself in this role much, no matter how patient and didactic I have [...] I don’t see myself much in this part of teaching, teaching, internship supervision, so for me it wasn’t very easy. (HC INS 05)

The professor comes very little to the unit. [...] eventually come to the unit, just do the assessment [...] it’s logical that we can call at any time, of course we can, but even the student misses, right, having more someone together. (PC INS 06)

Faculty advisors and Supervised Internship

Faculty advisors’ role during SI as a mediator among the subjects involved in this stage was mentioned by nine (34.61%) participants. Three (11.53%) mentioned visits to internship fields to dialogue with nurses.

The professor will guide how this process should be developed, identifying the needs of this student [...] identifying needs for improvement. (MA 02)

My role is to mediate this that sometimes there is conflict between student and nurse. It is performing mediation [...]. (IFA 05)

When asked about the limitations experienced, six (66.66%) professors reported difficulties in monitoring students during SI. Among the reasons that make it impossible for professors to monitor students, five (55.55%) professors mentioned the overload of activities in the institution, referring to their inclusion in the Graduate Program activities.

We have difficulties in monitoring this student. We even go to the field, talk to the nurse, have news, call, but I don’t know if we have found a good measure in this regard [...] this is still a weakness, as we have a high demand. (IFA 04)

One downside to this is our activity overload. (IFA 02)

Because we take on a lot of graduate studies, we have “n” things to do, the internship is also an activity, but we end up prioritizing other activities, other than the supervised internship, and then it’s up to the committee [...]. (IFA 08)

Managers and Supervised Internship

As for managers’ attributions at this stage, the need to get involved with the discussions and necessary procedures, to mediate the development of SI, was mentioned by three (75.0%) managers. Moreover, the attribution related to the resolution of conflicts that arose was mentioned by three (75.0%) managers. Still, one (25.0%) manager mentioned his role in evaluating the development of SI in the service.

Our presence is constant in these discussions [...] the role of management is initially to maintain the organization understanding that they are problems, and we have to reach a common consensus. (MA 02)

Both the voice of professors, students, and the voice of nursing supervisors inside, so we try to make this interrelationship. (MA 04)

We usually get together, so, at the end of the semester, and do this assessment together, it’s not a closed thing. (MA 03)

Regarding the limitations experienced by managers, two (50.0%) managers mentioned the number of institutions in the city that had a high demand for fields to develop their practical activities. There were also situations involving health service professionals who are not receptive to students in their scenario, this limitation was mentioned by one (25.0%) manager.

One of the complicating factors is that we now have a very recent discussion on profitability, we have several institutions in the city, several undergraduate courses, and not only undergraduate courses, but also those at the technical level that are using the spaces. (MA 02)

Things come to me, for example, like: “on that floor, so-and-so, they don’t want to receive students, because they are overloaded, they just want a student”. (MA 04)

The image and identification of roles of people involved in Supervised Internship

In the image, the subjects indicated by numbers two and three are close to the root, at the base of the tree. These subjects were indicated by 13 (50.0%) participants. Numbers 11 and 12, who are hugging and sitting on one of the branches of the tree, were mentioned by seven (27.0%) participants. Numbers 16, 17 and 18, which comprise three subjects on a standing tree branch, where subject number 17 is superimposed on subject number 16’s shoulders and number 18 is beside the two with outstretched arms, were indicated by three (11.5%) participants. Some reflections about subject number 21 were also carried out by two (7.69%) participants. It is noteworthy that this subject is in the image sitting on a branch of the tree with arms crossed, showing a face indicating dissatisfaction/sadness. Subject number 10, who was nominated by one (3.84%) participant, is standing at a middle height of the tree, with his arms outstretched and with an expression of joy.

With number 2, because I’m here to leverage, to make everyone grow and move forward. To give everyone an opportunity. (PC INS 02)

The figure of 2 [...] the one who drives this articulation. (MA 01)

Or 11 or 12. Because, like, it’s not down there, it’s not up there, they have to go up and it depends on the other, nobody IFAs anything alone, it’s no use being up there like 20 is, alone. (PC INS 01)

This 16 here, trying to take everyone on our backs, because it’s very tight [...] we ended up embracing the world to try to give the best assistance possible. (PC INS 04)

I identify with 16, 17 and 18, [...] we all need each other [...] as companionship, as a partnership with the student and tending towards ascension. (HC INS 07)

DISCUSSION

Motivation is one of the determining factors for increasing learning, in addition to being a precursor for reflection and criticality of the issues addressed(⁹). Therefore, students’ motivation stands out as a driver of several possibilities for professional development, both theoretical and practical. As mentioned by participants, it is essential that students understand that their training process IFAs not depend only on the educational institution and service professionals in which the SI is being developed. Learning during SI can occur both in the presence of a nursing supervisor and a professor or in their absence(¹⁰).

Trainees must be co-responsible for their training and, from the moment they identify themselves as leaders in this stage and in their future professional activity, there is an incentive in the permanent search for knowledge. Thus, both in the presence and absence of the subjects who lead students in SI, motivation influences not only the overall development of activities, but also the permanent search for knowledge. This enables students to seek improvement in their future professional life, due to the constant need for updating to guarantee qualified assistance.

With regard to extracurricular activities, including the modalities of assistance scholarship and/or experiences, they were mentioned as a differential in training, positively influencing SI. These opportunities to complement the training enhance the development of SI, as students reach this stage instrumented in different ways, so their vision allows a critical and directed look at the private activities that nurses must perform.

As noted in the reports, the unpreparedness of students evidenced during the SI may be based on their training process. Weaknesses related to the development of technical procedures weakened/limited the overall process of performing SI, as students used this moment to improve their technical skills, often losing the possibility of experiencing other dimensions of nurses’ work. Or still, students arrive at SI imbued with theoretical knowledge, often without having experienced it in practice, or when they do, they have limitations to correlate both. “The internship should encompass the skills acquired during the teaching-learning process in graduation”(¹¹).

The absence of commitment and responsibility during SI is a delicate situation, since students are forming their professional identity and, consequently, these characteristics may be part of their future professional practice. SI aims to train nurses committed to an identity and visible representation to the different social spheres, in order to achieve recognition of the profession(¹²). The academic’s lack of interest and theoretical unpreparedness to carry out the internship were also difficulties reported by nurses, resulting in impairment in the way the internship was developing, correlating to students’ conduct(⁵). Students’ profile and their commitment are directly proportional to their achievement during this stage. In particular, experimentation and the exercise of management, leadership, communication and supervision may be impaired or even absent in this opportunity, constituting a limitation of SI(¹³). In contrast, in a study carried out in Iran, dissatisfaction of nursing students with clinical training in the period prior to the internship was identified(¹⁴).

The supervision performed by the service nurse and their role, considering the monitoring of students who are inserted in their daily routine, is an indispensable role for the training of new professionals. Nursing supervisors “contribute substantially in the training of the subject, who, depending on the way they conduct their activities, may or may not fill gaps in practices and knowledge”(¹⁰). Thus, after a period of adaptation, observation and recognition, for both nurses and students, it is possible to plan activities and demands, according to students’ development and evolution.

Also, through nurses’ role, there are aspects that will only be experienced and may incorporate meanings and reflections in students’ training, if professionals effectively insert the reality of the service, enabling the necessary autonomy, according to the context. The development of skills and competences for professional practice is correlated with the development of autonomy. However, for this, nursing supervisors and the team in which students are inserted must enable their routine to develop in view of this perspective. “SI favors the increase of autonomy, before the team, care responsibility, in short, professional maturation with valuing the relevance of the entire training process”(¹⁰).

In order to establish collective and individual activities, which may be related to educational, care or management actions, it is essential that an overview of students’ profile is carried out. For this, nursing supervisors seek to know students’ level through dialogues and observations, and, based on that, to conduct and plan SI activities. It is necessary to respect students’ profile in the teaching and learning process, in a realistic way, so that they can identify that their particularities are preserved. Thus, it is important to raise the main strengths and weaknesses of students and encourage them to recognize them and reflect on them, enabling the development of their activities based on the necessary evolution that contain the requirements for their future professional performance.

SI is a determining step and, considering that nursing supervisors’ role is highlighted at this moment, the recognition of their attributions in supervising students is crucial. Quality education cannot be done without a legitimate partnership with health services. However, there are several obstacles in the effective participation of nurses in the services in the teaching processes, preventing students from actively participating in the production of health work(¹⁵). The implementation of learning requires a workplace structure composed of genuine professional support, confidence and the opportunity for experience in order to overcome simulated situations with real life(¹⁶).

The absence of a faculty advisor was mentioned by nursing supervisor, reporting that students felt lost in the face of this new stage, as well as reporting a unified responsibility by the service professional. Due to the range of responsibilities, in a study carried out, many nurses felt that supervision made their routine even heavier, believing that this was an activity that should be taken on by a professor(⁵). In this context, an important issue arises: nursing supervisors can master their managerial and care work process and have didactic-pedagogical knowledge to contribute to students’ education. The polarization between those who teach and those who do impairs the theory-practice relationship, whether in the dimension of care or teaching(¹⁷).

Regarding professors’ role, they should act indirectly, assisting in the theoretical conduction of an action plan developed by students, through which there is the planning and implementation of an action that contributes to the routine of services. Still, it is up to professors to mediate between subjects involved, stressing that their presence in the fields, through dialogue with nursing supervisors, is essential to understand students’ evolution. “Professors must facilitate the development of SI, especially in the introductory phase of students in the practical scenario, approaching the nurse responsible for the unit and clarifying their role in the development of this component”(¹⁰).

Monitoring during SI through visits, meetings and dialogues with the service’s students and nurses is essential. Students understand that they still have support from the educational institution, but at the same time, they need to have autonomy for the development of this stage. Therefore, the insertion of teaching in services, represented by the figure of the student, requires that mediation be carried out between those involved, which must be performed by faculty advisors, who needs to be resolute, when necessary, as well as enabling the solution of adversities, without weakening the integration between those involved. It is noteworthy that the internship committee also has as attributions the performance of mediations, which is represented by professors from the educational institution, performing mediations with managers and following students in their practical fields and by holding periodic meetings. However, faculty advisors must mediate this movement with students who are monitoring and request assistance from the internship committee when there is a need for intervention. Thus, professors must “know how to educate, approaching, listening, respecting, interacting and dialoguing with students”(⁴).

In a study carried out, graduates and seniors describe that limitations that permeated SI could have been mitigated and/or avoided with the presence of a professor(⁴). Therefore, it is identified that the absence of a professor during this period can compromise the development of SI. Even though it is characterized as a stage of greater autonomy, in which students must feel more “comfortable” to exercise their future profession, the educational institution is still co-responsible for their training. The difficulties in monitoring students result from the range of activities of nurses and the low number of professors to guide them(⁵). However, there is “a need for greater rapprochement and rapport between professors and nurses, to make the SI direction clearer”(⁴). Hence, it is necessary for faculty advisors to understand their important training role in the articulation of theory/practice and critical-creative reflection with the dilemmas, conflicts witnessed by students in face of the weaknesses or insecurities they present, even in SI, because they are in the training process.

Educational institutions and their respective professors need to reflect and reframe their roles in strengthening the integration of teaching, service and community(¹⁸). Based on this assumption and assuming it as a reality experienced by teaching and service, several points are identified that can limit and reduce the quality of SI. When students seek their advisor professors to invite them for follow-up, it is expected that professors understand their role in the training process, committing themselves through planning with students.

The current context of educational institutions with regard to the high demand for knowledge production is understood as inconsistent, due to the number of faculty in relation to the promotion of research. However, professors’ commitment to professional training is identified as urgent, and planning strategies should be established so that students who are in this complex, delicate and crucial stage for their training and do not feel helpless.

As verified in the managers’ statements, their engagement must be constant in the participation and construction of mediations, through dialogue, as demands and weaknesses arise that need to be improved and resolved, when possible, to maintain the relationship with the fields. The conflicts that permeated the construction, implantation and implementation of SI contribute to its consolidation, even if the installed conflict generates instability(¹²).

Among the reports, there is a movement regarding the evaluation of the development of insertion of students in the fields. Thus, at the end of each semester, meetings were held with nurses from the services and representatives of the educational institution to carry out assessments and provide feedback to all those involved. These initiatives enabled integration movements between education and service, as clarifications and agreements were made so that all parties could benefit. The internship is essential for academic training, as it helps in the growth of professionals who participate in supervision and can be even more efficient with the strengthening of ties between academia and the health service(⁵).

The lack of infrastructure and human resources is a reality of health services and, added to this, there is demand from fields of various educational institutions to carry out practical activities. Considering the role of managers as mediators between health services and educational institutions, the main conflicts and difficulties in bureaucratic procedures are experienced by them. However, it is noteworthy that, even considering the need for fields for training professionals in the health area, it is essential that these places allow experiences with quality and that overcrowding IFAs not limit the work process of professionals working in the services, as well as the assistance provided. A better understanding of the potential of SI contributes to important changes in interprofessional work, and the manager with a comprehensive view of health care allows them to be efficiently implemented.

The analysis made it possible to understand the attributions of each subject in this process, as well as the need for each one to understand their role in nurses’ education and to conduct them with responsibility and lightness. Ending the interview with the image (Figure 1) allowed participants to deepen their reflections on their role during SI. Participants identified themselves with subjects in the image who were at the base of the tree, relating to the responsibility to encourage students at the beginning of their professional life. Also, they identified themselves with subjects associating their role with companionship, teamwork and shared action to achieve the common goal. At the same time, there were reports of participants who identified themselves with subjects who consider themselves overworked. In a study carried out in Sweden, it was identified that, in order to explore a learning space and its potential, it is necessary to evaluate it in its entirety, including interpersonal relationships, as well as their more or less favorable interactions(¹⁹). A shared network that is responsible for the training of health professionals is needed, consisting of teaching-service-management-social control, i.e., the training quadrangle(²⁰).

Study limitations

It is considered a limitation to contemplate the view of nursing internship supervisors, faculty advisors and managers, not including students and users of health services, since both are directly involved in the development of SI.

Contributions to nursing

The contributions of this study to nursing focus on the relevance of reflecting and understanding the training process of nurses and all the actions and reflexes that transcend their path, especially SI, in view of its prominence during nursing education. However, to analyze the development of a complex stage such as SI, we pay attention to the need to know the perspective of everyone involved, understanding that the responsibility for nursing education is not restricted to the educational institution, since several subjects also actively participate in this moment.

FINAL CONSIDERATIONS

For the development of SI to take place in an effective way, the commitment of all involved in their role in these relationships is essential. Among them, there is the direct supervision of service nurses, who monitor and lead students on a daily basis in their routine within the service, introducing trainees to the world of work. Also, through the indirect guidance of faculty advisors, there is a mediation between the institution and the health services, in which professors theoretically assist and intervene in conflicting situations, when necessary. The mediation performed by managing bodies occurs at the organizational level, through the planning and dimensioning of students in health services, helping, whenever necessary, in the face of conflicts and carrying out assessments with those involved.

The object of this study is a complex phenomenon, which moves according to the participation of different subjects, inserted in different scenarios, resulting from reflections of the education trajectory. The roles of everyone involved in SI complement each other, in this way, when one of the parties IFAs not perform its function according to the requirements and demands of the SI development. Weaknesses can reflect not only on students’ education, but also on the assistance provided by the services they are inserted. The data presented refer to the urgency of (re)definition and clarification of everyone’s roles as well as the (re)thought of integration strategies for monitoring students throughout this period.

• FUNDING
  This research was funded by the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) - Financing Code 001.

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Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Maria Itayra Padilha

Publication Dates

• Publication in this collection
  02 Feb 2022
• Date of issue
  2022

History

• Received
  07 Mar 2021
• Accepted
  05 Aug 2021