Preceptor’s perceptions about the teaching-learning process and collaborative practices in primary health care

Las percepciones del preceptor sobre el proceso de enseñanza-aprendizaje y las prácticas colaborativas en la atención primaria del salud

ABSTRACT

Objective

To analyze the perceptions of preceptors about the teaching-learning process, as well as the strengths and weaknesses to implement collaborative practices in Primary Health Care.

Method

Qualitative study carried out between October and December 2019 with 96 preceptors (surgeons- dentists, nurses and doctors) of the Family Health Strategy. Data were collected with the use of a questionnaire and submitted to Content Analysis, using the Maxqda-2020 software.

Results

Three categories were highlighted: 1. A new know-how needs to be taught to those who teach, 2. teaching and assisting in the preceptorship process and 3. person-centered approach: paradigm for collaborative work reveal difficulties and tensions in the preceptor work and collaborative practices.

Conclusion

The study identified the need to qualify preceptors with new approaches for the development of the teaching-learning process, for teamwork and collaborative interprofessional practices in the context of Primary Health Care.

Keywords
Primary health care; Preceptorship; Teaching; Learning; Interprofessional relations

RESUMEN

Objetivo

To analyze the perceptions of preceptors about the teaching-learning process, as well as the strengths and weaknesses to implement collaborative practices in Primary Health Care.

Método

Qualitative research, carried out between October and December 2019 with 96 preceptors (surgeons- dentists, nurses and doctors) of the Family Health Strategy. Data were obtained through a questionnaire and submitted to Content Analysis, using the Maxqda-2020 software.

Resultados

Three categories were highlighted: 1. A new know-how needs to be taught to those who teach, 2. teaching and assisting in the preceptorship process and 3. person-centered approach: paradigm for collaborative work reveal difficulties and tensions in the preceptor work and collaborative practices.

Conclusión

The study identified the need to qualify preceptors with new approaches for the development of the teaching-learning process, for teamwork and collaborative interprofessional practices in the context of Primary Health Care.

Palabras clave
Atención primaria de salud; Preceptoría; Enseñanza; Aprendizaje; Relaciones interprofesionales

RESUMO

Objetivo

Analisar as percepções dos preceptores acerca do processo ensino-aprendizagem, bem como as fortalezas e as fragilidades para implementar as práticas colaborativas na Atenção Primária à Saúde.

Método

Pesquisa qualitativa, desenvolvida entre outubro e dezembro de 2019 com 96 preceptores (cirurgiões-dentistas, enfermeiros e médicos) da Estratégia de Saúde da Família. Os dados foram obtidos através de questionário e submetidos a Análise de Conteúdo, utilizando o software Maxqda-2020.

Resultados

Foram evidenciadas três categorias: 1. Um novo saber-fazer precisa ser ensinado a quem ensina, 2. o ensinar e o assistir no processo da preceptoria e 3. abordagem centrada na pessoa: paradigma para o trabalho colaborativo revelam dificuldades e tensões no trabalho do preceptor e de práticas colaborativas.

Conclusão

O estudo identificou a necessidade de qualificar os preceptores com novas abordagens para o desenvolvimento do processo ensino-aprendizagem, para o trabalho em equipe e práticas interprofissionais colaborativas no contexto da Atenção Primária à Saúde.

Palavras-chave
Atenção primária à saúde; Preceptoria; Ensino; Aprendizagem; Relações interprofissionais

INTRODUCTION

In Brazil, with the adoption of the National Curriculum Guidelines for undergraduate courses (DCN), in 2001, Primary Health Care (PHC) assumes a prominent role. Moreover, the importance of preceptors as promoters and facilitators of student learning1 within the scope of the Unified Health System - SUS, is highlighted. Preceptors also provide a link between teaching institutions and the health sector, to ensure a professional training process based on real-life situations2.

Thus, as strategic agents for the promotion of practical learning, preceptors are often supposed to create clinical learning environments, act as models, provide a relationship of trust with students, provide teaching-service integration, adapt different teaching techniques to professional skills and abilities, to facilitate socialization and the development of personal, interprofessional and communication skills that are vital for health education and care. Therefore, preceptorship is a complex process3.

Although Brazil’s Ministry of Health and some Higher Education Institutions (IES) invest in projects aimed at the qualification of preceptors, preceptorship is still fragmented in educational institutions, generating teaching in silos, that is, uniprofessional teaching4, which characterizes the professional identity of students.

Guiding students to learn to work in a team and in a collaborative way is a current challenge in health education. Students must experience a dual identity in professional and interprofessional socialization, given the complexity of health care5.

It has already been proven that two or more professions that work and learn together are more encouraged to share goals, communicate more horizontally, and implement a person-centered care plan. This implies shared decision-making and partnerships in the establishment of responsibilities6.

Filling a gap between didactic learning and practical knowledge, preceptor-based guidance demonstrates that professionals need qualification related to the principles that guide the teaching-learning process. A good professional performance of preceptors does not guarantee a good teaching performance. Thus, these actors must develop educational competence7 in order to understand how students learn, and to stimulate both parties to reflect about learning.

Therefore, the qualification of PHC preceptors must be based on essential attributes of teamwork and collaborative interprofessional practices, which include the use of a shared set of common goals and objectives; communication between professionals to implement shared care; relationships of trust and mutual respect between team members; interdependence and understanding of the role of each team member in the production of care; power and leadership shared for proper development of work in an interprofessional team; person- and family-centered care through active involvement in care planning and shared decision-making, and the participation of all team members in a collaborative process to minimize conflicts8.

The justification for the development of this study, with emphasis on preceptorship and collaborative practices, is the fragmentation of the development of teaching and care practices. This study is relevant because it expands knowledge and contributes to the understanding that the organization of teaching-learning processes is still focused on uniprofessional technical-scientific knowledge. It is expected that the results obtained will contribute to the rupture of the traditional and fragmented biomedical model, enabling changes in health education, health practices, and in qualification of preceptors consistent with user-centered collaborative practices, and also to support further research on the subject.

Given this scenario, we attempted to answer the following investigative questions: How does the preceptor guide the teaching-learning process of students in Primary Health Care? What are the strengths and weaknesses for preceptors to implement collaborative interprofessional practices in Primary Health Care? The study aimed to analyze the perceptions of preceptors about the teaching-learning process, as well as the strengths and weaknesses in the implementation of collaborative practices in Primary Health Care.

METHODS

Quantitative and qualitative research comprising the capital and two municipalities of Rondônia that have undergraduate courses in the health area, totaling 139 preceptors in Porto Velho, Cacoal and Ji-Paraná.

In this article, we chose to present the qualitative results of the study carried out in Porto Velho, capital of Rondônia, a state in Northern Brazil. In a qualitative approach, researchers immerse themselves in a given reality, examining the experiences and situations lived by the respondents, according to a descriptive interpretive approach9.

In Porto Velho, Rondônia, Primary Health Care (PHC) counts on 38 basic health units (UBS): 19 in the urban area, distributed in the Central, North, South and East Geographical Sanitary areas, and 19 in the Rural area (Fluvial and Terrestrial). In the urban area of the municipality, 17 UBS are composed of 76 family health teams (eSF).

Field research was carried out from October to December 2019. The research subjects are professional nurses, dentists and physicians from family health teams (eSF), preceptors of undergraduate courses in Nursing, Medicine and Dentistry developed by different Higher Education Institutions (IES) in the Municipality of Porto Velho and/or Family and Community Medicine Residency and Multiprofessional Residency in Family Health, which attached to the Federal University of Rondônia Foundation (UNIR).

The inclusion criteria for the study were be a nurse, physician or dental surgeon working in the Family Health Strategy (ESF), in the urban area, in complete teams and at least one of the professionals must be a preceptor of undergraduate students/ health residency programs. The exclusion criteria were professionals on vacation, leave and who did not answer all the questions of the instrument.

The total number of professionals eligible to participate in the study was 180. Of these, 30 were on vacation or leave, totaling 150 subjects. At the time of the study, there were 45 complete teams, with at least one preceptor. These were invited to participate in the study.

After accessing the names, professional categories, cell phones, e-mails and workplaces of the possible research subjects, provided by the Department of Primary Care (DAB) of the Municipal Health Department of Porto Velho (SEMUSA), researchers invited the preceptors to participate in the study and made the necessary clarifications about the research, in the Basic Health Units (UBS) in the different geographic urban areas of the municipality.

The individuals who agreed to participate were informed about the research, the objective, the questionnaire and the Free and Informed Consent Term (FICT). These documents were delivered in nominal envelopes to the UBS managers, and seven days later the researchers returned to the UBS to collect the aforementioned documents that were in the possession of the managers. Convenience sampling was used. The final sample included 96 preceptors of Basic Health Units (UBS) of the urban zone of the municipality.

Data were collected through a self-administered questionnaire that contained closed-ended questions about social, educational and work characteristics and three open-ended questions about: 1. What does being a preceptor mean to you? 2. In the preceptorship process, what are the weaknesses for collaborative work? 3. In the preceptorship process, what are the potential for collaborative work? Spaces were allocated for the replies, with up to 15 lines for answer space.

In the analysis, the data necessary for the characterization of the subjects were coded and inserted into a Microsoft Excel platform and then analyzed by absolute and percentage frequencies.

Qualitative analysis was based on Bardin10. The data categorization process was performed with the Maxqda Analytics Pro 2020 software to assist in the qualitative analysis. The interviews were transcribed and imported into Maxqda.in order to constitute the corpus to be submitted to the analytical procedures.

It should be noted that qualitative analysis in Maxqda is not performed instantly or mechanically as in quantitative software. The coding and categorization process is similar to the traditional model of qualitative analysis in which the researcher operationalizes all the steps, from exhaustive floating readings, seeking representativeness, homogeneity and relevance of the material to the final categorization, to obtain the meanings of the statements in the process of analysis.

The main advantage of using this software is the facilitation in the organization of material, in the recording and storage of relevant observations, as well as due to the possibility of a better visualization of the relationships established between respondents and categories.

In the process of pre-analysis with Maxqda, the units of sense/meaning (coding) of each interview were highlighted in color based on the theoretical framework. Codes were created and recreated as interviews were read and reread. In the material exploration phase, context and recording units were extracted, which contributed to the storage of information and facilitated the process of categorization and intersection of the speeches.

The interviews were analyzed in groups (dentists, nurses and physicians) to facilitate the final process of the thematic categories and subcategories. Finally, interpretation was carried out through inferences anchored on the theoretical bases 10, that is, preceptorship and collaborative interprofessional practices, as shown in Figure 1, facilitating the visualization and understanding of the categories and subcategories found.

Figure 1 -
Thematic categories and subcategories extracted from the respondents' speeches. Porto Velho, Rondônia, 2021

The study is part of the matrix project entitled “Interprofessional education and collaborative practice among Primary Health Care professionals in Rondônia” approved by the Research Ethics Committee (CEP) of Universidade Federal de Rondônia, under CAAE 20677519.4.0000.5300 and opinion no. 3,605,943. Given the researchers' commitment to the anonymity of the respondents, their names were replaced by the expression “Interv.”, followed by a number, according to the numerical identification of the respondents (1 to 139). In this study, numbering of the interviews was sequential: “Interv. 1”, “Interv. 2” and so on until interview 15.

RESULTS AND DISCUSSION

Of the 139 health professionals interviewed, 96 preceptors from Porto Velho participated in this study, including 39 nurses, 18 dentists and 39 physicians from the family health teams (eSF).

Most participants (79.20%) were women, with a mean age of 38.43 (SD: 7.09). As for the profession, (40.60%) were nurses, (40.60%) were doctors and (18.80%) were dentists. Regarding the time elapsed since graduation, almost all the respondents (97.90%) had completed graduation more than five years ago.

Of these professionals, (66.70%) had done graduation in private/philanthropic institutions, (67.70%) have general specialization, (21.90%) had specific training in collective health or family health; (37.50%) have been working in PHC for 1 to 4 years and (54.17%) work have been working as preceptors for 1 to 4 years in PHC.

Regarding preceptors, (63.50%) did not have an introductory qualification for the exercise of preceptorship and almost none of the preceptors (90.60%) is aware of the Pedagogical Course Project (PPC) of graduation/residence in which they exercise preceptorship, according to Table 1.

Table 1 -
Some sociodemographic, training and work characteristics of preceptors who work in Primary Health Care. Porto Velho, Rondônia, 2020

Sex	n = 96	%
Male	20	20.80
Female	76	79.20
Profession
Nursing	39	40.60
Dentistry	18	18.80
Medicine	39	40.60
Time elapsed since graduation
< 5 years	2	2.10
> 5 years	94	97.90
Teaching institution
Public	32	33.30
Philantropic/Private	64	66.70
Postgraduate studies
General specialization	65	67.70
Specialization in collective health/family health	21	21.90
Health residency	6	6.24
Master’s degree	3	3.12
Doctorate degree	1	1.04
Has been working in PHC for
< 1 year	33	34.38
1 - 4 years	36	37.50
5 - 9 years	15	15.62
> 10 years	12	12.50
Has been working as a preceptor in PHC for
< 1 year	4	4.20
1 - 4 years	52	54.17
5 - 9 years	27	28.13
> 10 years	13	13.50
Pedagogical training course
Yes	35	36.50
No	61	63.50
Is familiar with the Course's Pedagogical Project
Yes	9	9.40
No	87	90.60e

• Source: Research data, 2021.

A new know how needs to be taught to those who teach

In this category, the lack of specific training of preceptors for the educational activity is evident, as well as the lack of clarity regarding their role, which is consistent with traditional teaching, based on the procedure-centered model, which leads to a fragmentation of health practices.

In this study, PHC preceptors reinforce uniprofessional practices, in silos, whose consequences are reflected in the reproduction of a Cartesian health training for future health professionals, which obviously make it difficult to implement new collaborative practices. The weaknesses of the preceptorship function emerge in the speeches.

It is the professional at UBS who embraces the teaching process, so that students learn to perform the correct dental procedures. The preceptor must know his/her métier and teach students to perform the role of dentists in the FHS (Interv.1).

Fragmented teaching and the biomedical model prevail. Each one is entirely focused only his/her job (Interv. 2).

It is in this context of in service training for work in the SUS that preceptors collaborate to develop the identity of newly graduated professionals. However, this cannot be done in isolation. The speech below explains the emphasis on specific skills.

A medical student or resident must learn to make an accurate diagnosis and explain how he/she will treat the patient. Teach the patient and the family [...]He/she can learn more when he/she becomes a doctor at ESF, if necessary (Interv. 3).

It appears that the professional identity dimension results from a broad process of socialization through constructions and reconstructions, during the different phases of graduation or professional life, being legitimized by social groups as a profession. Encouraging collective work with common goals and maintaining the autonomy and independence of professional categories is a major challenge today11.

'Profession-centrism' is a strong barrier to the dialogue of knowledge and practices, strong division of labor between different health professionals, competitiveness and compliance12, making interprofessional collaboration difficult.

A qualified preceptor in interprofessional health education (EIP) and collaborative interprofessional practices (PIC) can encourage flexible learning for undergraduate and residency students, with shared leadership and decision-making among professionals, in response to users’ needs. Breaking the paradigm of uniprofessional health training and the traditional preceptorship format to encourage teamwork with collaborative interprofessional practices is a challenge. For some professional categories, this change in the health work process may represent a loss of status, reinforcing stereotyped views. This means that performing one’s duties according to the logic of comprehensive care has difficulties.

Many conflicts in the teams are caused by the professional identity factor, which interferes with the quality of the service delivered to users. Therefore, conflict management programs should be developed, so that health professionals can identify and respond to conflicts, strengthening their abilities to deal with this situation13, particularly those who are preceptors in PHC.

It is believed that qualifying preceptors for pedagogical and interprofessional activities is important and necessary. However, most of the preceptors who participated in this study complained about the lack of courses and refresher training for preceptorship, as shown in the he answers below.

Lack of support from management and school for the development of preceptorship, from this perspective. Conduct permanent courses (Interv. 4).

Absence of a preceptorship course to teach us how to work together, because we don't know how to do that! We only know the duties of our dentist job (Interv. 5).

The present study found that the health preceptors were predominantly female, with specialization in the health area. Most of these professionals were trained on the biomedical model, according to a traditional curriculum, having little experience in the role of preceptor and incipient qualification in preceptorship. Such characteristics are similar to the study conducted by Damiance14.

Higher education institutions (IES) and their didactic-pedagogical apparatus can be a constant source of training for health professionals and preceptors, qualifying them based on the Curriculum Guidelines for undergraduate courses (DCN), the principles of the SUS and the attributes of PHC. It is worrying that the responsibilities of guidance, facilitation and student assessment, developed by preceptors, are disregarded by the IES and by the management of health services, which fail to promote training processes or permanent education workshops on the role of the preceptor. Such opportunity would allow special and stimulating training and practice for health professionals and preceptors.

Preceptors must be pedagogically trained for their function. In this regard, continuing education is an important device to provide preceptors with knowledge and pedagogical skills, as well as pedagogical planning, effective communication15 and interprofessional relationships.

Teaching and assisting in the preceptorship process in PHC

This category emerged from the responses of preceptors about the teaching-learning process and monitoring of students in the PHC practice fields associated to the care process.

The preceptor elaborates with the professor a joint plan/strategy for internship... This professional observes the student carefully to see if he/she feels confident to perform his/her tasks. After the assessment, the preceptor gives feedback to the student and supervisor (Interv 6).

The preceptor is someone who knows well what he/she does and has experience in PHC to teach students. He/she is a facilitator and mentor in the training of students (Interv 7).

In their statements, preceptors mention that they are responsible for teaching, guidance and assessment of students, and claim that a preceptor must be a good, reliable professionals, a 'model' as mentioned by some participants, reinforcing the idea that in addition to the didactic-pedagogical aspects, preceptors must be experienced and have mastery of the theoretical and practical knowledge of their area of activity.

These individuals need training assets to optimize student learning, based on scientific evidence. They also need pedagogical qualification in the teaching-learning process, on a permanent basis16^).

However, although students learn during their assistance duties, many preceptors report the difficulty in reconciling educational and care activities, as shown in the statements below.

I think we have to perform both tasks - teaching and assisting. These tasks are often not viewed as separate activities, and it is difficult to identify the moment of being a preceptor and the moment of being a physician in the health service (Interv. 8).

Because it is difficult here. I must at the same time help the residents to manage some specific cases and be a nurse in the health service, perform my daily duties and teach (Interv. 9).

Through teaching, preceptors qualify health care, since the process of teaching and caring are two inseparable fields17. However, this dual function with care overload makes the student-centered teaching process difficult. The reason for this is that care practice is still based on the biomedical model, with fragmentation of care, and with priority of production to the detriment of the integral care model, and with relational and collaborative approaches between professionals, users, families and the community. Preceptorship can be maximized in the context of health education, if this function is recognized by health management and educational institutions as a strategy for the transformation of training processes.

In this regard, teaching-health service-community integration is key for the coordination of a more integrated and collaborative work between higher education institutions and the health service, according to the preceptors' statements.

[...] the link between the health service and teaching to ensure proper training for the residents (Interv 10).

Someone who encourages integration between the team, educational institution and community. A supporter in the learning process (Interv 11).

One of the pillars of health education is the work with the community experienced by health students, which enables them to provoke changes in health practices17 and in community settings. The coordination of knowledge and practices between preceptors, students, professionals and the community aims to improve the quality of health care, through the promotion of a holistic approach and access to health services and professionals, which are the foundations for a practice focused on primary care.

Preceptors perceive themselves as the link between the health service and the training institution, and several studies prove the benefits of this partnership18. Students should be included as early as possible in PHC, in order to become familiar with health care, which can favor changes in training related to care practices, as students are able to recognize the real health needs of the population.

Teaching- health service integration and continuing health education (EPS) can promote changes in health work processes through meaningful learning. Students involved in this process will have a critical, ethical and reflective training, in which health care will be perceived as various shared knowledge and practices to promote comprehensive care for the user, family and community.

Person-centered approach: paradigm for collaborative work

The person-centered approach (PCA) is one of the components of interprofessionality, is essential for teamwork11, and hence, for effective communication between team members and between them and users/family. Based on the responses of the study subjects, it was found that the work performed by some preceptors is now consistent with this approach, as shown in the statements below.

Team case discussions and more horizontal communication are leading to user-centered- action. We are starting this shared process towards collaboration. It's not easy. It's a process. We must work on the potential of each profession to be able to provide comprehensive care to users (Interv 12).

Through active methodologies and permanent education, technical meetings are aimed at discussing cases and collective conduct, with a view to people-centered care. We are learning to agree with users on the actions they can take based on supported self-care. We learn in technical meetings to respect the knowledge of each profession. Residents have accelerated changes in our teamwork conduct. It’s very good (Interv 13).

Primary care units are considered privileged spaces for the implementation of the people-centered approach (PCA). Communication skills are vital to building effective relationships with users and families. In this regard, the family health strategy is the privileged locus to put into practice more horizontal models of communication in the treatment of users, demonstrating to students how to use 'light' relational technologies in the production of care19, enabling users to their decision making.

Preceptors' responses show the importance of communication, teamwork and learning and doing together, as well as the effort to teach students this practice.

I try to prioritize good communication and a user-centered approach, as well as doing together. It's not easy, because they don't learn these concepts in the university (Interv 14).

Learn together and discuss together what is best for users, who are the protagonists of this process. Knowing how to respect their and their family's opinions and discuss with the team and with them the best therapeutic approaches. It is very nice. Deconstruct to reconstruct the students' knowledge, as their view is fragmented. However, there is resistance from professionals who do not think that interprofessional education and collaborative practices are important. Many schools still do not teach this (Interv 15).

The answers clearly show the importance of health education based on new paradigms, with university programs that promote and allow activities anchored in interprofessional education, involving various professions that intentionally learn and work together.

It should be noted that of the 96 preceptors who participated in this study, 46% did not know what collaborative interprofessional practice was, answering “I don't know” or giving unsuitable answers. This is a high and worrying percentage, showing that few professionals are qualified in preceptorship and permanent education activities to work with this topic.

It appears that “I don’t know” answers reveal misunderstanding or little knowledge about collaborative interprofessional practices, which favors the maintenance of the hegemonic care model, with the fragmentation of care, technical and uniprofessional teaching, stereotypes about the roles of different workers in health and fear of losing professional identity20.

Thus, it was found that few preceptors are familiar with collaborative work. This is certainly not easy to achieve, and for its large-scale application teaching-service integration is needed to ensure successful and concrete changes in the health work process.

FINAL CONSIDERATIONS

The thematic categories contributed to the analysis of what was experienced. Obstacles to the teaching-learning process under new paradigms and collaborative practices were identified.

It is necessary to qualify preceptors in the light of new paradigms, as the strategic role played by these actors in the teaching-learning process, expanding their professional assets to ensure teamwork and the adoption of collaborative interprofessional practices in Primary Health Care, is recognized.

More reflection is needed on continuing education programs and refresher/specialization courses for preceptors, aiming at the implementation of new approaches in the teaching-learning process and interprofessional collaboration. The involvement of higher education institutions in this process is essential, as they have a formative role in the teaching-service integration.

The strengths of this study consist in giving visibility to research carried out in Brazil’s North Region, with regard to preceptorship and collaborative practices, whose responses varied in according to the different contexts, but generated consistent qualitative data.

The limitations of the study include the fact that the sample was not randomized, including only preceptors of urban primary care. Thus, it is not representative of preceptors of the Rural Area and other health care points in Porto Velho, Rondônia. Therefore, the results should be considered with caution, as they represent the reality of the context investigated.

It is necessary to qualify preceptors in the light of new paradigms, as these actors play a strategic role in the teaching-learning process, in order to expand their professional assets, ensuring teamwork and collaborative interprofessional practices in the context of Primary Health Care.

Acknowledgments:

To Rondônia Foundation for Support to the Development of Scientific and Technological Actions and Research in the State of Rondônia (FAPERO) for support. This study was approved at PPSUS -CHAMADA FAPERO/MS-DECIT/CNPq/SESAU-RO - No. 001/2018.

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Publication Dates

• Publication in this collection
  01 Aug 2022
• Date of issue
  2022

History

• Received
  05 May 2021
• Accepted
  10 Aug 2021