Perceptions of academic and practitioner nurses regarding the teaching-care partnership in primary healthcare units

Abstracts

This study aimed to present the perceptions of academic and practitioner nurses regarding the expectations, objectives and difficulties of teaching-care partnerships. This was a case study with a qualitative approach case study, among 16 academic and practitioner nurses who were working together in primary healthcare units. Semi-structured interviews were conducted, followed by use of the content analysis technique and interpretation based on a model for interorganizational relationships. There was a positive perception of the partnership, with regard to the training and continuing education objectives. The practitioner nurses viewed the students’ assessments as a problem and were concerned about users. It was concluded that balanced formalization and mutual understanding between the parties is needed, in order to reduce the inherent differences between education and care, while seeking to put users in a central position.

Teaching-care integration; Brazilian National Health System; Nursing; Technical cooperation

Este estudo objetiva apresentar a percepção dos enfermeiros da docência e da assistência sobre as expectativas, objetivos e dificuldades na parceria ensino-serviço. Estudo de caso de abordagem qualitativa, com 16 enfermeiros docentes e assistenciais, que atuam junto a unidades básicas de saúde. Realizaram-se entrevistas semiestruturadas, analisadas com técnica de conteúdo e interpretadas à luz do modelo de relações interorganizacionais. Houve avaliação positiva da parceria, a respeito dos objetivos da formação e da educação permanente. Os enfermeiros assistenciais veem a avaliação dos alunos como um problema e se preocupam com os usuários. Conclui-se que deve haver formalização equilibrada e entendimento mútuo entre as partes, visando diminuir as diferenças inerentes entre o ensino e o cuidado e buscando a centralidade no usuário.

Integração docente assistencial; Sistema Único de Saúde; Enfermagem; Cooperação técnica

El objetivo de este estudio es presentar la percepción de los enfermeros de la docencia y de la asistencia sobre las expectativas, objetivos y dificultades en la alianza enseñanza-servicio. Estudio de caso de abordaje cualitativo, con 16 enfermeros docentes y asistenciales que actúan en unidades básicas de salud. Se realizaron entrevistas semi-estructuradas, analizadas con técnica de contenido e interpretadas a la luz del modelo de relaciones inter-organizacionales. Hubo una evaluación positiva de la alianza en relación a los objetivos de la formación y de la educación permanente. Los enfermeros asistenciales ven la evaluación de los alumnos como un problema y se preocupan por los usuarios. Se concluye que debe haber una formalización equilibrada y un entendimiento mutuo entre las partes con el objetivo de disminuir las diferencias inherentes entre la enseñanza y el cuidado y buscando la centralidad en el usuario.

Integración docente asistencial; Sistema Brasileño de Salud; Enfermería; Cooperación técnica

Introduction

In an effort to consolidate the Unified Health System (SUS), different strategies and policies were developed, among them, a set of actions related to health professionals’ training. In 2001, there was an important milestone with the creation of national guidelines and rules for health professionals’ curricula, approved by the National Board of Education (CNE). They aimed at the professionals’ training with a generalist profile, capacity to promote changes and guide training for the realization of the system’s leading principles.

Therefore, it is possible to highlight the integrality among SUS principles that combines workers and assistance levels in order to respond universally and with resolution to the social needs in health. In addition, it absorbs the understanding of making health care as a collective action and not as a fragmented work. Thus, the focus is shifted to the training within SUS health units by integrating teachers and students to the professionals’ working world. They share their knowledge through the teaching exercise; then, it becomes a place that produces both knowledge and experience.

At the federal level, the integration framework for teaching and service occurred with the creation of the Interministerial Commission for Labor Management and Health Education linked to the Ministries of Education and Health. That committee implemented various programs such as the National Reorientation Program for Professional Training in Health (Pró-Saúde) and the Educational Program of Working for Health (PET-Saúde), among others. Then, it seeks to enable a greater integration between undergraduate courses and local health departments. Such integration is favorable for professionals’ training within health units in primary, secondary and tertiary levels, and also guided by the integrality perspective. After more than five years, the implementation of Pró-Saúde and PET-Saúde has promoted a process of changes in undergraduate courses in the health area and its services throughout the country².

Some studies^3-4 point out challenges still to overcome, particularly, in health units of primary care, after creating conditions in the strategic plan. The challenges relate to differences in the courses curriculum organization involved in practical scenarios, how to hire some teachers, class rotation, students-teams integration and lack of human resources in the service. Also, they associate with the work process organization for production, students’ reception by the services and incipiency of health permanent education in services.

Another Brazilian study on physicians’ training within the primary health care⁴, and even highlighting a successful experience, escapes from a discussion on relations between agents involved and institutions’ organization that occur in the contexts of care and education. On the other hand, in order to improve nursing practice and teaching the literature review⁵ shows that the leaders of both parties should work together because the creation of models designed by the Academy for practicing were unsuccessful.

Given the reality of an Undergraduate Nursing Course awarded with Pró-Saúde, and after, with PET-Saúde, it is worth considering the need to know how nurses directly involved in the teaching-service partnership, in basic health units, evaluate the relation and what expectations and problems they experience in that interaction. Therefore, the present research aims to show nurses' perception of teaching and health care about expectations, goals and difficulties in the teaching-service partnership in primary care units, where there are undergraduate nursing students.

Theoretical reference

The paper bases on the model for Cooperative Interorganizational Relationships⁶. Such model places relations in cyclic processes, with phases of negotiation, compromise and execution, in which decisions are made horizontally and with equity. The relationship between organizations is not analyzed at a fixed point, but in its dynamicity within a temporality. Among its proposals, it is possible to find the understanding congruence between parties as an element that could increase probabilities for completing a negotiation. Psychological contracts, i.e., the relationship between agents, also increase probabilities of establishing formal commitments for cooperation. In addition, if there was a significant imbalance between formal and informal processes, the probability of problems and partnership dissolution would grow.

Several studies applied that model in relations analysis between universities and organizations in the technology industry⁷ and interactions between universities and media companies⁸. The interorganizational relationships in health care appear as a way to meet new needs that involve new health actions. Partnership activities also relate to the survival and/or improvements to them⁹.

In the same line, another model based on the previous one¹⁰ emphasizes that, in partnerships, there is a need for formalization. It can be done through contracts, rules and other procedures established in meetings and workshops, which in its periodicity becomes a dynamic process in constant construction.

That formalization also creates mechanisms for interpersonal relations, focusing the attention on the relationship, articulating, discussing and reflecting about parties’ collaboration. It also increases interaction through mutual dialogue and knowledge, reducing the impact of erroneous judgments on partners. Such mechanisms directly influence partners’ ability to understand the collaborative meaning of interorganizational relationship and their goals. The understanding has caused a reduction of comprehension problems in organizational relationships, which appeared from differences in culture, experience and, above all, structural differences in each organization. It helps to overcome uncertainty and distrust in the early stages of the partnership, cases of discontinuity and changes in the people involved. However, the authors warn that an excessive formalization is also harmful because reduces flexibility and creativity.

Therefore, it is possible to understand that relationships established through the Pró-Saúde implementation and operationally deployed between assistants and professors’ nurses, in the primary health care units, constitute a partnership between organizations. They include, in this case, a municipal health department and a university through an undergraduate nursing course.

Methodological approach

Qualitative nature research of a case study type, in depth, of cooperation between an undergraduate nursing course and a municipal health department.

The nursing program is linked to a Brazilian Federal University of the South, founded in the 1960s. Since the 1980s, the institution has developed subjects, in its curriculum, to perform training courses and practical classes in basic health units. Currently, students begin their activities, in the units, since the first semester, and they gradually widen their participation until the end of the course when they perform part of the supervised training in those places. The municipality of this study has about 400,000 inhabitants and is divided into five sanitary districts. Students from all health care courses of the University spread out and develop practical activities in such areas.

Data collection was held in the second semester of 2012 through 16 interviews with eight professors-nurses and eight assistants-nurses linked to eight basic health units and distributed in five different health care districts, in which the teaching-service partnership developed. Interviews were recorded and transcribed. The inclusion criteria were teachers who work in practical activities and traineeships, in different course disciplines and nurses who receive and supervise students in units of origin. Professors and nurses with less than six months of activity did not participate. Among the existing units, it was possible to choose those in which there is a constant presence of undergraduate nursing students. The authors performed data collection by using a semi-structured script, which included a survey of expectations and goals, as well as the partnership evaluation at the health facilities mentioned.

Data were analyzed according to directed technique analysis of interviews content¹¹, constituting the following units: expectations, perceptions about objectives achievement and partnership problems. Data interpretation was based on the theoretical model adopted and related studies. The NVivo 8.0® software was used to support data analysis and organization.

This research results from studies carried out on the theoretical orientation axis (research adjusted to the local conditions), associated with the Reorientation National Program for Professional Training in Health (Pró-Saúde) of the Ministry of Health, Phase I - Nursing area. It followed recommendations of the Resolution 196/96 of the National Health Board, with guarantee of anonymity, free and informed consent of the respondents, approved by the Ethics Committee under opinion number 2186/11.

Results and discussion

Among the interviewed, 100% of the professors are women and 25% of nurses are men. Professors’ ages were between 24 and 56 years old, and nurses’ ages ranged from 27 to 52 years old. The percentage of 75% of teachers graduated between 1979 and 1985 and 25% between 2006 and 2010, with a teaching dedication ranging from 8 to 26 years. Among nurses, 87.5% graduated between 2000 and 2008 and 12.5% in the 1980s, with a working time of 3-12 years, in the primary health care.

Results and their interpretation were organized into three categories: expectations, goals and difficulties on teaching-service partnership, in primary care units.

Expectations about the teaching-service partnership

Both nurses and professors state that teaching and service expectations are different. However, they estimate that these differences are gradually decreasing since there is more dialogue between the parties, after the Pró-Saúde implementation. They consider that during practical activities to take care of people, expectations dilute and become similar. "It is not what we are living today. Our expectations about the groups, in a general way, are the same [...] but I think expectations go together "(E3).

Professors’ expectations about the service center around requirements for students’ learning such as accessible professionals who receive students with attention and allow their interaction with the local team. Furthermore, they expect to find favorable conditions for education, especially in relation to demand. "In relation to the professors, we also hope to meet affordable people who can help us develop training activities, persons receiving students with more attention" (D8).

The health team reception and learning opportunities are critical, according to a report in a survey with medical students¹². The report reveals that in order to attract future professionals to the primary care, it is necessary to “fascinate” them and an active participation in the work process. Thus, the local team involvement has a great relevance.

On the other hand, nurses understand that the health unit is just a training field for teachers and students while for the team, is a labor area. They also reiterate that many members of the health unit team think that students, in a way, should help to address the lack of professionals. "Some of them think that students could help more [...]. There is such expectation, but we have to work on that. Each one has to see what is legal because students cannot overcome the lack of professionals [...]” (E7).

There is a similar perception corroborated by another study³, in which for educational institutions, health services are only internship opportunities, and health services consider students as manpower. According to that paper, changing that perception from both parties is a real challenge in the teaching-service integration.

Objectives of the teaching-service partnership

The partnership objectives, in the professors-nurses perception, are linked to what they consider as their work essence, i.e., to strengthen teaching-learning within the practical reality. "Improving education quality, assistance and bringing students to the reality itself by joining practice and theory" (D2).

Similarly, nurses understand that the partnership goal is to contribute to strengthening the student’s teaching-learning process. For them, such strengthening directly reflects on a better quality of academic education and assistance offered by the health service to the system’s user. Nurses recognize that students’ presence makes them, as professionals, to keep up to date and face new challenges, which contributes to a permanent learning.

The partnership goal is for students to come here and learn in daily work as much as possible for their professional practices, while professionals also improve their knowledge, and also learn what can happen in that daily practice (E1).

Regarding the partnership's objectives scope, all the professors proved to be optimistic and stated that there are teaching improvements at the primary health units in which they work. They said that the partnership was improving gradually. It works with no problems in some semesters, and there are some conflicts in others. Furthermore, 70% of nurses were in favor of the partnership's goals scope. They also understand that there are good interpersonal relationships between the local team with teachers and students, and patients enjoy the students’ attention. Only one of the nurses highlighted the topic of learning opportunity. However, they mention that there is not always feedback from teachers and students to the team on education goals achievement, at the end of the semester.

These data show that professors embrace goals related to the student’s learning and nurses consider the health unit operation with the students’ presence and also mention the user’s satisfaction. According to the standard adopted¹⁰, the partnership goals common understanding plays a central role in the collaborative effort between parties and allows different views and expectations of the relationship to achieve congruence. It reinforces the argument that partnership results should focus not only on teaching, but also in the relationship with people assisted and satisfaction of all parties involved⁵.

As for the factors leading to the partnership success or failure, local team receptivity and communication were cited as fundamental by the professors. Teachers mention concerning responsiveness that since many nurses graduated from the same course it facilitates professors and students reception. They emphasize as important the user acceptance of students’ presence to the partnership success. Nurses highlight the need for communication between parties, and they also point out as a key element for partnership success the responsibility and commitment shown by professors and students. It is possible to see the importance of psychological and informal agreements for the partnership⁶.

Only two teachers commented on the influence of Pró-Saúde and Pet-Saúde programs in the relations among teachers, students and the primary unit team. According to them, such influence is due to the existence of financial resources for projects, which encouraged the development of different actions, including the creation of a Teaching-Service Department along with the Municipal Health Secretary. Thereby, it is worth noting the formalization that occurred at the strategic level for the projects’ implementation such as financial resources and formal contracts, although most respondents did not mention them, plays a significant role at the local level. It increases the balance between formality and informality in the relationship established⁶.

Difficulties about the teaching-service partnership

Difficulties and problems found in the partnership resulted in similar and different expressions between nurses and professors.

Professors with extensive experience in basic health units mentioned that, in a general way, some semesters are more conflictive than others. They believe it is a dynamic process, with fluctuations related to the context involved, and it depends on what happens with local team and students who each semester brings different expectations and characteristics. Teachers also mentioned the high professionals’ turnover at the health units, which hinders the establishment of links and good relations.

Similarly, nurses reported as a partnership problem the constant change of temporary professors, in relation to monitoring practice activities. About these changes, some teachers have no experience in primary care and even having some experience, they do not know the work process and do not get involved either. They state it creates insecurity in the health units’ team, and for that reason, they do not let students and teachers perform activities with the system users.

Nurses and professors agree that a reduced health team along with a large number of users hinder local staff involvement with students.

These data suggest that discontinuities caused by substitutions between teachers and nurses create problems in the interorganizational cooperation because there are differences in structure, culture and experiences¹⁰ within both parties’ realities. One of the adopted reference assumptions indicates that if the relationship consolidates trust between parties will increase, informality and flexibility make understanding flow along with the action, represented in this study by theoretical-practical education and user’s care. Nevertheless, when there are substitutions of agents involved the relationship uncertainties return, informality and confidence levels, which already existed, are broken, and the partnership heads for dissolution or requires a new round of negotiations and commitment establishment for enabling its execution⁶.

Teachers and students suffer from such disruptions that affect the balance between formality and informality.

They emphasize that, many times, go through an unfamiliar territory because they have to share an unknown environment and rely heavily on the local team reception.

You feel in the team that the unity "has been imposed" [...], then, it does not facilitate the student’s access from the point of view of actions, in the unit. Neither students nor teachers can clearly understand that situation; however, it is possible to realize in a veiled way that hampers students’ access to the activities (D3).

Teachers and nurses reported that in the lack of communication lies the conflicts root for a successful teaching-service partnership. One of the communication failures is about the course curriculum knowledge. In teachers’ opinion, nurses do not understand practical activities objectives and internships of students from different subjects since the first semester, in which the student only performs a territorial approach. In the last semester, the student is taking a compulsory curricular training and he needs to perform all the activities of the nurse, in his professional practice. "Nurses and staff do not know the curriculum or how teaching works because we did not invite them, or there was no such involvement" (D5).

They state that activities to be performed by students are guided in regular meetings at the health center, at the beginning of each semester. However, with team members change there is a discontinuity, and things get lost quickly.

On the other hand, nurses who receive students from different subjects since the first semester of the nursing course, complain about the difficulty of understanding the complexity level of students’ activities. Then, the team is often unaware of whether or not delegates certain activity for the student because it ignores what he can develop.

In addition, integration problems among different courses activities such as medicine, dentistry and nutrition, which work in the same basic unit, generates actions overlapping and more work for the team.

Nursing comes to perform a territorial approach, in a particular moment, and we ask the community agents to monitor that. Then, nutrition and medicine comes after that [...]. There is no schedule to make such things happen at the same time in order to avoid performing the same thing 4, 5 or 6 times, in the same semester (E7).

The university problem, with its various courses on health, in organizing internally and performing interdisciplinary teaching is an obstacle in the teaching-service relation, which is also pointed out in another study³. That fact allows reflecting what extent such interorganizational cooperation constitutes an equity relationship at the health units’ level. In order to enable negotiations equity has to base on exchange and reciprocity⁶.

The students’ evaluation process as a problem in the teaching-service partnership and cause of conflicts was raised only by nurses, especially in relation to students in the final stages of the course and taking the obligatory traineeship. During these stages, nurses directly supervise their activities, and teachers guide and monitor them indirectly. According to the nurses, they often get very lonely in the teaching task.

[...] Professors, especially in the last semesters, follow very few practical activities here in the unit, and students stay only under professionals’ responsibility; however, nurses are not teachers! They do not have an education didactic or methodology (E1).

The problem increases when nurses face students who are not very interested and react negatively to criticism and suggestions. They also assert that the assessment instrument does not address practice reality. "The service is responsible for the student and that generates a significant controversy because nurses have to grade students. Very often, the student is immature because they only want to get a good grade, they want to pass and do not accept any criticism "(E3).

The problem with students’ evaluation process, appointed only by nurses, shows that local health teams also analyze the educational institution. Data reveal that nurses are developing a significant educational action often without adequate instrumentation and in a solitary way. The theoretical reference adopted^6,10 shows the individual's role importance in the interorganizational cooperation because even with contracts the work is done by people, and they have institutional roles. At the same time, such functions are full of subjectivity, and there is also a personal role. The perfect congruence between institutional and individual roles favor the relationship between formality and informality, increases confidence and helps to resolve conflicts. On the contrary, when the individual does not meet his expected function he becomes a significant partnership dissolution element.

At the local level of health care, in which effectively happens care and education, the problems mentioned in this study are also the same shown in the literature^13-15. In a general way, living difficulties between two worlds, care and education, focus on common goals. It is possible to say that, in fact, health organizations focus primarily on users’ assistance and educational organizations center their attention on teaching and attending students. Nevertheless, both foci merge in activities performance at the health unit. Thus, there are intervening factors in the teaching-service integration that need to be discussed as they represent limits for desired advances¹⁶, including organizational aspects of courses routines and health institutions.

The theoretical framework of this paper indicates that, for every relationship, it is necessary to estimate a mismatch function in which difficulties can be addressed for partnership’s solution and survival¹⁰. In this context, relations between both worlds teaching and service need to be created and maintained. They have to be considered as a longitudinal and dynamic process that requires constant rounds of negotiations, commitments and implementation in order to promote equity and efficiency in the partnership⁶.

Such equity implies a continued construction of an understanding environment between parties. Therefore, it is necessary to formalize, with rules and controls, regular meetings, reports, goals setting and results assessment in health facilities where teaching happens. Moreover, at the strategic level, formalizations are significant for the occurrence of parties’ joint participation, enabling clinical nurses to take part in curriculum discussions and elaborate criteria evaluation, among others. Similarly, professors should expand their space for participation and share at the health facilities organization.

While it may include a restrictive component, formalization¹⁰ allows creating mechanisms for boosting debates, forcing deliberations and reflections to generate a collaborative sense of partnership. That collaboration sense is going to reduce understanding problems for cooperation between institutions. In addition, it is going to provide for health professionals, professors and students, in the same space, a truly integrated work, avoiding a forced relationship without discussion of problems and; therefore, with no possibility of mutual commitments and negotiations. Even with professionals’ rotation (teachers and nurses), the need for interacting with more formal moments provides greater understanding and reduces uncertainty, mistrust and misjudgments between parties. If the health unit team has better understanding of the course curriculum, for example, it will provide bigger learning opportunities for students. In a similar way, if nurses participated in the assessment tool preparation they would have greater motivation to share their knowledge and more certainty to perform the activity.

Finally, in order to make professors and nurses share expectations, information and knowledge in a horizontalized way to find partnership¹⁰ collaborative meaning, it is essential that the health system user becomes the center of professional activities¹⁴. User’s centrality should contribute to maintaining the balance between formality and informality in a steady flux of negotiation, commitment and implementation⁶.

Such assertions confirm the revision⁵ article’s finding on teaching-service partnership in nursing, identifying the following prerequisites for an effective partnership: trust, a shared vision of goals and open communication. The positive results presented seem to be in the direction suggested by the literature, that is, a real health service-teaching integration should compose converging and complementary intentions of an institutionalized form¹³.

Final considerations

Expectations, goals and difficulties about teaching-service partnership suggest a significant increase in the relations between University and Health Municipal Secretary through the formalization of Pró-Saúde and Pet-Saúde, on the nursing undergraduate course.

Understanding professors and nurses’ perception about teaching-service relationship, within basic health units, showed that both parties make a positive evaluation of desired goals achievement. Teaching success is the most important aspect for teachers. Nurses recognize benefits for teaching and their continuing education; however, they add as good partnership requirements the absence of problems at the unit organization and user’s satisfaction in the student’s presence.

Despite advances occurred in the university interaction through the nursing program and municipal health department, with the implementation of Pró-Saúde and PET Saúde programs, data show there are still challenges to face such as student’s evaluation process. Due to expectations differences at the health unit level, data also point to the creation of convergence mechanisms. Therefore, there is a need for spaces that enable both parties to share ideas.

The constant changes of agents involved (nurses and teachers) generate discontinuity and contribute to partnership uncertainties. In addition, they provoke decrease of learning opportunities for students. Then, a little formalization is necessary to increase mutual understanding between parties, providing integration with the practice reality at primary care units and reducing structural and cultural differences inherent to care and nursing education.

Finally, it is possible to conclude that interorganizational relationships, comprised of cyclic and dynamic ways, have significant characteristics and stages that contribute to interpreting better local reality and propose partnership adjustments. It is recommended a research extension to include also the student and user’s perceptions on teaching-service partnership in order to offer new contributions for that relationship interpretation.

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• Translated by Roberto Galeano

Publication Dates

• Publication in this collection
  Sept 2015

History

• Received
  05 May 2014
• Accepted
  28 Nov 2014