Interprofessional education in teaching-service-community integration practices: perspectives of professors in the health area

Abstract

Objective

to know the challenges inherent to interprofessional education in teaching-service-community integration practices from the perspective of professors in the health area.

Method

a descriptive and exploratory study with a qualitative approach. Data collection took place between September and December 2021, in a Higher Education Institution from the central region of Rio Grande do Sul. The research participants were eleven professors who coordinate internships in the Collective Health scope. The data were submitted to Discursive Textual Analysis.

Results

as main challenges, the data pointed out the scarce integration moments, the restricted physical space in the services, some professionals' resistance to work in teams and the schedules of the academic practices. On the other hand, the programs that induce training for the Unified Health System and the existence of a Collective Health collegiate group proved to be strategies to promote interprofessional education.

Conclusion

it is concluded that interprofessional education still faces obstacles to its strengthening; however, there are already initiatives that demonstrate potential for teaching-service-community integration.

Implications for the practice

the study can contribute to identifying the challenges inherent to interprofessional education and, thus, enabling strategies in the context of training and work in health, from an interprofessional perspective.

Keywords:
Primary Health Care; Health Education; Professional Training in Health; Interprofessionality; Unified Health System

Resumo

Objetivo

conhecer os desafios da educação interprofissional nas práticas de integração ensino- serviço-comunidade na perspectiva de docentes da área da saúde.

Método

estudo exploratório descritivo com abordagem qualitativa. A coleta de dados ocorreu entre setembro e dezembro de 2021, em uma Instituição de Ensino Superior da região central do Rio Grande do Sul. Os participantes da pesquisa foram onze docentes coordenadores de estágios no âmbito da saúde coletiva. Os dados foram submetidos à Análise Textual Discursiva.

Resultados

os dados apontaram como principais desafios os escassos momentos de integração, o espaço físico restrito nos serviços, a resistência de alguns profissionais em trabalhar em equipe e os horários das práticas acadêmicas. Por outro lado, os programas indutores da formação para o Sistema Único de Saúde e a existência de um grupo colegiado de Saúde Coletiva, se mostraram como estratégias de fomento à educação interprofissional.

Conclusão

conclui-se que a educação interprofissional ainda enfrenta entraves para o seu fortalecimento, contudo, já existem iniciativas que demonstram potencial para a integração ensino-serviço-comunidade.

Implicações para a prática

o estudo pode contribuir para a identificação dos desafios da educação interprofissional e, assim viabilizar estratégias no contexto da formação e do trabalho em saúde, na perspectiva interprofissional.

Palavras-chave:
Atenção Primária à Saúde; Educação em Saúde; Formação Profissional em Saúde; Interprofissionalidade; Sistema Único de Saúde

Resumen

Objetivo

conocer los desafíos de la formación interprofesional en las prácticas de integración enseñanza-servicio-comunidad desde la perspectiva de los profesores del área de la salud.

Método

estudio descriptivo y exploratorio con enfoque cualitativo. La recolección de datos ocurrió entre septiembre y diciembre de 2021, en una Institución de Educación Superior en la región central de Rio Grande do Sul. Los participantes de la investigación fueron once profesores que coordinan pasantías en el ámbito de la salud pública. Los datos fueron sometidos a Análisis Textual Discursivo.

Resultados

los datos indicaron que los principales desafíos fueron los escasos momentos de integración, el restringido espacio físico en los servicios, la resistencia de algunos profesionales a trabajar en equipo y los horarios de las prácticas académicas. Por otro lado, los programas que inducen la formación para el Sistema Único de Salud y la existencia de un grupo colegiado de Salud Colectiva demostraron ser estrategias para promover la educación interprofesional.

Conclusión

se concluye que aún hay obstáculos que impiden el fortalecimiento de la educación interprofesional, aunque ya existen iniciativas que demuestran potencial para la integración enseñanza-servicio-comunidad.

Implicaciones para la práctica

el estudio puede contribuir a identificar los desafíos de la educación interprofesional y, de esta manera, viabilizar estrategias en el contexto de la formación y el trabajo en salud, desde una perspectiva interprofesional.

Palabras clave:
Atención Primaria de la Salud; Educación en Salud; Formación Profesional en Salud; Interprofesionalidad; Sistema Único de Salud

INTRODUCTION

Interprofessional education (IPE) is defined as an activity that involves two or more professionals who learn together in an integrative way, with a view to qualifying health care.¹ It is configured as a strategy capable of improving health care quality from collaborative practice in the teamwork process. This scenario favors training processes enabled to establish more collaborative relationships between health professionals.²

The concept of interprofessionality is increasingly being discussed with health policies, with regard to the public and private sectors. The necessary discussion is not only linked to the methods and processes, and the concept and its path are still little discussed and their use in the work or training practice is still accompanied by ignorance, if not simply treated as synonymous with the terms “multiprofessionality”, “multidisciplinarity” and “interdisciplinarity”.³

In addition, the predominance of the biomedical care model, based on individual consultations, without articulated and interprofessional interventions, impairs the possibilities of advancement towards IPE. In turn, this has proved to promote changes in the health professionals' practices and training models, as it constitutes a collaborative practice focused on users, and no longer on services and professionals.⁴ For this reason, the World Health Organization sparked an important movement starting in 2010 by launching the Framework for Action in Interprofessional Education and Collaborative Practice. The document exerted influences in the most diverse parts of the world, with the objective of providing ideas and stimulating strategies that aid IPE.⁵

In this context, Primary Health Care (PHC) is configured as a strategic scenario of professional training for the Unified Health System (Sistema Único de Saúde, SUS), as it is understood both as a care level and as a management model that aims at coordinating assistance in the care network in a longitudinal, comprehensive and interprofessional way.⁶ Incorporation and implementation of new methods, objects, practices, contents or policies developed for PHC covers a collective strategy among the different actors involved.⁷ Thus, the inclusion of students in health services enhances the teaching-service-community (TSC) integration, considering that they should be active agents of changes in the health practices since their initial training.

In Brazil, TSC integration is one of the elements that drives the movement of changes in health professionals' training and constitutes a strategy for qualification of the SUS. Regarding IPE, it has been one of the devices to effectively implement TSC integration and, in this scenario, teachers' training for interprofessional education plays an important role in the movement of changes in the courses' curricular matrices. Such being the case, it is necessary to develop qualification programs, as well as to stimulate integration spaces between professors, students and health professionals.⁸

In this context, the Work for Health Education Program (Programa de Educação pelo Trabalho para a Saúde, PET-Saúde) is part of the set of actions included in the plan for the implementation of IPE.⁹ The Community University where the study was carried out has been participating in the program since its inception, having integrated all its editions, which has fostered integration movements in the locoregional care network. Considering the professors' role in this change process, the following question arises: What challenges still need to be overcome to achieve interprofessional education in teaching-service-community integration practices, according to professors in the health area? In order to answer this question, the study aimed at knowing the challenges inherent to interprofessional education in teaching-service-community integration practices, from the perspective of professors in the health area.

METHOD

The study is characterized as exploratory-descriptive, structured in a qualitative approach. Qualitative research seeks to answer very specific questions, involving perceptions about topics, motivations, aspirations, beliefs and values. Consequently, it explores phenomena that can hardly be quantified or reduced to variables.¹⁰ To carry out the research, the recommendations set forth in the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed.

The study was developed in a Higher Education Institution (HEI) from the central region of Rio Grande do Sul. This HEI participated in the National Program for the Reorientation of Health Professionals' Training (Pró-Saúde) and, since then, has been developing projects linked to PET-Saúde, in which it has participated since the first edition. During development of this study, the HEI was participating in PET-Saúde Interprofessionalidade (PET-Health Interprofessionality) and, currently, PET-Saúde Gestão e Assistência (PET-Health Management and Assistance).

Participation in programs that induce the reorientation of professional training fostered the creation of the Center for Studies and Practices in Collective Health, comprised by professors, students, preceptors and managers of the Municipal Health Department. In a collegiate way, this Center plans the inclusion of undergraduate students and residents in the health care network, in addition to working on the elaboration of projects for submission to research promotion agencies and the Labor Management and Health Education Department (Secretaria de Gestão do Trabalho e da Educação na Saúde, SGTES).

It is noted that the municipality has its own flow for the formalization of agreements with universities, similar to the Organizational Contracts for Public Action in Teaching-Health (Contratos Organizativos de Ação Pública Ensino-Saúde, COAPES). Therefore, the agreements provide for the elaboration of shared work plans between services and universities, counterparts for the municipality and planning/monitoring of teaching-service-community integration activities. However, considering the municipality Primary Health Care coverage of 49.39%, it became difficult to allocate approximately 5,500 internships in the health services, territorializing the universities in a single space, although discussions about a regional COAPES have not been exhausted.

The study participants were the professors who are part of the Center for Studies and Practices in Collective Health, which represent the Health Area courses: Nursing, Medicine, Physiotherapy, Nutrition, Occupational Therapy and Psychology, comprising a total of twelve professors. It is noted that this is the total number of professors who are part of the aforementioned Center, although one of them was not available to take part in the study during the data collection phase, totaling eleven participants. The inclusion criterion was as follows: acting as a representative of undergraduate courses in the group of professors from the Center for Studies and Practices in Collective Health. In turn, the exclusion criterion was being distanced from their professional activities during data collection.

Data collection took place at the university itself, both in person and also remotely through the Microsoft Teams app, and the interviewees were invited to participate in the research through contacts via institutional email. Nine interviews were conducted remotely and two in person. The collection procedure took place from August to October 2021, through a semi-structured interview script that addressed issues referring to the challenges of interprofessionality and to strengthening the TSC integration from an interprofessional perspective. The interviews were conducted by a scientific initiation scholarship fellow attending the last semester of the Course, with a grant from the National Council for Scientific and Technological Development (CNPq), under the guidance and preparation of the researcher responsible for the study, with extensive experience in qualitative studies. Nonexistence of power relationship between the study participants and the interviewer is noted. In addition, the interviewer has no direct relationship with the participants, not attending classes taught by the interviewees.

The Free and Informed Consent Form was applied during data collection. The interviews were audio-recorded, lasting a mean of 30 minutes and, after the meetings, the testimonies were transcribed and validated individually by the interviewer in charge of data collection. The interviews were analyzed by a validation and reflexivity team, comprised by four researchers who are members of the Social Entrepreneurship in Nursing and Health Research Group, in addition to the study interviewer. Data analysis took place through the Discursive Textual Analysis (DTA) process. This technique refers to a methodology that analyzes ideas of qualitative origin in order to produce new knowledge. DTA requires the development of four interrelated stages: disassembly of the texts; establishment of relationships; capture of the new emerging; and construction of a self-organized process.¹¹

Initially, the research team disassembled the texts (content of the transcripts) or unitization process, examining them in their specificities, dividing them with the intention of generating constituent units. After this stage, it was sought to establish relationships, also referred to as categorization process. Relationships were built between the units emerging from the texts, culminating in the formation of sets with close components, resulting in the categories. While capturing the new emerging content, a textual structure constructed by the categories was produced, which sought to interpret the phenomenon under study. Although they were organized from the categories, the emerging theoretical constructions sought to go beyond assemblies or syntheses, as they resulted from a dynamic process that sought new interpretations.¹¹

The ethical aspects were observed, according to Resolution No. 466 of the National Research Council, dated December 12^th, 2012,¹² in addition to respecting the dignity of the research subjects, and the study was approved by the Research Ethics Committee under number 2,449,070. In order to have their identity preserved, the professors were identified according to their testimonies by means of the “PR” code, followed by a corresponding numbering that ranged from one to eleven (PR1, PR2, ...).

RESULTS

Three categories emerged from the data analysis, namely: Creation of interprofessional education spaces in the Collective Health field; Reorganization of the theoretical-practical scenarios; and Strengthening the Teaching-Service-Community integration from an interprofessional perspective.

Category 1 - Creation of interprofessional education spaces in the Collective field

In this category, it was possible to evidence the perception of the different professors about the importance of guaranteeing spaces aimed at integrating the courses for the discussion of theoretical-practical frameworks and planning for integrated actions. It is noted that, during the data collection period, the professors were committed to the constitution of a professional education in health laboratory, whose main objective is to strengthen interprofessional education through the socialization of successful experiences and the proposal of actions in the practice scenarios according to the IPE assumptions. It is considered that one of the first positive actions of this space was the approval of another project in the Management and Assistance edition of PET-Saúde. In this sense, the data reinforce the professors' understanding of this alternative representing a powerful space for IPE in the University:

[...] I think that the very idea of the laboratory is a strategy to qualify interprofessional education, which is to create a space so that professors and students from various courses can sit down and plan actions, write, discuss projects and evidence experiences that worked [...] (PR 10)

[...] I think that maybe the laboratory is for this, so that we can get to know a little about the colleagues' projects, and see what each one is doing and see some connection points [...] (PR 2)

Also in this category, it was possible to identify that the creation of interprofessional academic disciplines can favor IPE in the scenario under study:

[...] I believe that the creation of interprofessional disciplines, such as Interprofessional Actions, which is a mandatory component of the Nursing, Physiotherapy, Nutrition and Dentistry courses, in addition to that of Professional Safety in Health in pandemics, optional, favor and stimulate interprofessional education. But we need to think of more possibilities like such. (PR 1)

In addition to the aspects identified above, as strategies still under construction, the professors mentioned the challenge related to the physical spaces for practices in health scenarios. Added to this, the different schedules of the course academic disciplines were also mentioned as an element to be rethought:

[...] the scenarios have small physical space, so this is also a difficulty that in a way sometimes doesn't allow the integration between different training core [...] (PR 5)

[...] I see that there's not much integration, in some units the courses and residencies are more alone or the schedules don't match either [...] (PR 2)

Category 2 - Reorganization of the theoretical-practical scenarios

In this category, the professors mentioned interprofessionality as a major challenge to be faced, as the courses still remain very restricted to their cores, which hinders collaborative practice. In addition, according to the data presented, health services are also not prepared for these interprofessional actions. During the interviews, the professors reported that certain courses are not seen as part of a whole, or even that the professionals still cannot integrate with courses other than their training core:

[...] I think that we still have a lot to advance in the sense that we're still very much in our cores, needing some reorganization of courses and residencies so that more interprofessional actions happen [...] (PR 2)

[...] it's not easy because the field work process itself is not prepared for these interprofessional actions. [...] (PR 4)

In the professors' view, the need to reorganize the dynamics of the courses permeates the review of the schedules of the academic practices, as many courses are not in the practice fields. However, the fact that the physical structure presents inadequacies, as already mentioned, may be perpetuating this difficulty:

[...] we often end up facing difficulties with the schedules, also the issue of physical space, sometimes the units don't hold more than two, three courses [...] (PR 1)

[...] one difficulty I see is that it doesn't match the schedule, there are students that go to the same place, but those attending one course go on Tuesday and those from other courses go on Wednesday [...] (PR 11)

Category 3 - Strengthening the Teaching-Service-Community integration from an interprofessional perspective

In this category it was possible to identify that there are already some advances in relation to IPE strengthening, although it is a movement under construction, permeated by countless challenges. The professors reported the importance of TSC integration for the effective implementation of interprofessionality, considering that the students are inserted in contexts with increasingly complex needs:

[...] the academic practices in Primary Care, for example, are of paramount importance both for the students that are doing the practices there and for the community as well, I notice that both parties gain care quality. [...] (PR 5)

The professors highlighted that the HEI has expanding TSC integration as one of its objectives and is always seeking to expand its partnerships with the services. Institutional research and extension projects and those funded by research funding agencies, as well as the Collective Health Center itself, proved to be strategies for expanding TSC integration and interprofessionality.

[...] the institution believes a lot in this work and makes a very large investment in these actions and in this view of Collective Health, so I think that continuing with this Collective Health group that already exists, seems essential to me. [...] (PR 9)

[...] in the 10 years of PET-Saúde, there's been an increase in integration with health services and interprofessional education strengthening. Another point is that there's been an effort from the institution, from some working groups, I think that Collective Health is very important in this scenario of trying to foster the increase in internship practices, research/extension projects by the University and agencies, final undergraduate papers and MSc and PhD research (PR 2)

The professors also highlighted the successful experiences with the Health Work Education Program (PET-Saúde), in a decade marked by development, to strengthen interprofessional education.

[...] it was from PET-Saúde that we ended up being part of it, an experience thinking about strategies and actions together, I think that these situations end up bringing us closer and making us able to think together with the courses (PR 1)

[...] PET encouraged this a lot, assisted in this process so that the students thought articulated actions, knew the others' work [...] (PR 9)

As seen, the professors included in the study report that inducing programs such as PET-Saúde represents effective strategies for the consolidation and expansion of TSC integration and interprofessional education.

DISCUSSION

As mentioned in the professors' testimonies, the creation of an IPE laboratory is shown as a tool for the qualification and effective implementation of interprofessionality. Teamwork and collaborative interprofessional practice are essential in overcoming a training model based on the multiprofessional or uniprofessional panorama, which has shown many limitations in the teaching of professionals.¹³,¹⁴ These laboratories for IPE are tools that seek this integration of different courses aiming at interprofessionality. Studies carried out inside laboratories can be conducted in order to achieve several objectives, such as collecting data from research studies, favoring knowledge of different instruments and promoting theoretical deepening on a given topic, among others.¹⁵

The physical structure of health services where the academic practices occur was listed by the professors as a difficulty for the effective implementation of interprofessional education. This finding is in line with the study carried out at the São Joaquim Basic Health Unit, which identified that the difficulties encountered for the effective implementation of interprofessionality were closely related to the physical space.¹⁶ Other studies highlighted that the physical structure appeared as one of the components that impair the interaction between students from different areas; however, it should be considered that grouping students and health professionals in the same environment is not efficient to define an educational method in an interprofessional way.¹⁷,¹⁸

According to the professors, another powerful space for promoting IPE are the interprofessional academic disciplines from the first semesters of the undergraduate courses. Interprofessional education needs to be planned from the teaching-learning process, so that it is guided by the assumptions of interprofessionality in order to offer opportunities to improve the relationships between members from different health courses.¹⁹

The results evidenced that the interprofessional academic disciplines shared between the courses proved to be a powerful space for promoting IPE and that, in this logic, they need to be expanded. A recent research study indicates that the organization of most courses, with emphasis on academic disciplines focused on the performance of professional centers and centered on the professors, is one of the impediments to integration during training.²⁰ In order to stimulate interprofessional education and collaborative practice in Brazil, it is necessary to be attentive to resistance, including the risk of repeating self-regulation and biomedical approach traditional concepts and examples since, even with the advances achieved, there is still reluctance to break away from the current training model.²¹,²²

The practice scenarios are configured as a major challenge for the effective implementation of interprofessionality. Most health services are not prepared for interprofessionality to take effect. A study conducted in Brazil points out that in the training of health professionals, the discussion by academic disciplines is still a reality predominantly in the scope of undergraduate and graduate studies, with regard to interprofessional work.²³ It is necessary to mobilize the practice scenarios so that they are active agents of interprofessionality and strengthening of the SUS.²⁴ In addition to that, an aspect that was strongly evidenced by the professors' testimonies is related to the schedules of the academic practices, which do not provide meeting moments in the practice scenarios. However, it is necessary to think of alternatives that go beyond the opening hours, which support active and participatory methodologies for interprofessional work processes.²³

The data of this research are in line with studies that reinforce the need for advances in interprofessional education in Brazil. Thus, a number of studies show that TSC integration may be able to promote an exchange of knowledge and experiences that reproduce new knowledge. In addition to the establishment of bonding and social participation, this knowledge exchange is fundamental for the work process to be user-centered.²⁵,²⁶

As the data revealed, TSC integration was portrayed as an alternative to qualify training, care and work in the SUS scope, being an important tool for IPE. A study carried out with students that took part in PET-Saúde identified that the program enabled them to get closer to the population's health problems and made them prepared to act on complex demands.²⁶Pró-Saúde and PET-Saúde were designed with a view to introducing interprofessional education into health undergraduate courses, as well as the teaching-service integration.²⁷ Such strategies have been seen as central elements for encouraging interprofessionality in health training.

CONCLUSION

The research allowed understanding the main challenges still existing for the effective implementation of interprofessional education. As already mentioned, among the difficulties highlighted by the professors, there is absence of integration moments across the knowledge cores, the physical space as a barrier to interprofessionality and some professionals' resistance to work as a team, in addition to the mismatched schedules of the academic practices. On the other hand, the training-inducing programs for the Unified Health System and the existence of a Center for Studies and Practices in Collective Health to foster integration proved to be strategies to encourage interprofessional education.

It is therefore concluded that interprofessional education still faces obstacles to its strengthening; however, there are already initiatives that demonstrate potential for teaching-service-community integration. The study can contribute to identifying the challenges inherent to interprofessional education and, therefore, to visualizing strategies in the context of training and work in health, from an interprofessional perspective. The study has the limitation of having been developed from the professors' view, requiring further research studies that explore the perspectives of students, workers and health and community managers. Thus, further research is indicated that may portray the difficulties of interprofessional education in other contexts and regions of the country.

• FINANCIAL SUPPORT

  Scientific initiation scholarship granted to Angelica Lucion Farinha by the National Council for Scientific and Technological Development (CNPq) to the research entitled “Teaching-Service-Community integration in Primary Care: Building interprofessionality in the training of health professionals”. Guided by Juliana Silveira Colomé. Process No. 138057/2020-6.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  12 May 2023
• Date of issue
  2023

History

• Received
  13 July 2022
• Accepted
  09 Mar 2023