Perceptions of occupational therapy students about experience of teaching-service-community integration¹

Abstract

The present article tries understand the perceptions of students of the professional internship in occupational therapy on the experience of teaching-service-community integration experienced in a laboratory of daily life activity. It was a qualitative and exploratory study, conducted through semi-structured interviews. Content analysis was used with the thematic category: teaching-service-community integration. The sample consisted of 14 students who were enrolled in the course. The similarities, distinctions between the contents and the central ideas of the narratives about the thematic category were observed. The speeches generated the units of analysis: expectation of integrated practices, reality of teamwork, organizational process, exchange of experiences and suggestions. The results obtained pointed to the distance between students’ expectations and reality. The perceptions of the interviewees revealed that the work dynamics occurs without collective planning of the care actions and without interlocution with the teaching. The students suggested strategies to improve the teaching-service-community integration and to promote the formative process.

Keywords:
Higher Education; Teaching Care Integration Services; Occupational Therapy

Resumo

O presente artigo procura compreender as percepções de discentes do estágio profissionalizante em terapia ocupacional sobre a experiência de integração ensino-serviço-comunidade vivenciada em um laboratório de atividade de vida diária. Tratou-se de um estudo qualitativo e exploratório realizado através de entrevistas semiestruturadas. Foi utilizada a análise de conteúdo com a categoria temática: integração ensino-serviço-comunidade. A amostra foi composta por 14 discentes que estavam matriculados na disciplina. Foram observadas as semelhanças, distinções entre os conteúdos e identificadas as ideias centrais das narrativas sobre a categoria temática. As falas geraram as unidades de análise: expectativa de práticas integradas, realidade do trabalho em equipe, processo organizacional, troca de experiências e sugestões. Os resultados obtidos apontaram distanciamento entre as expectativas dos discentes e a realidade. As percepções dos entrevistados revelaram que a dinâmica de trabalho ocorre sem planejamento coletivo das ações de cuidado e sem interlocução com o ensino. Os discentes sugeriram estratégias para melhoria da integração ensino-serviço-comunidade e para favorecer o processo formativo.

Palavras-chave:
Educação Superior; Integração Docente Assistencial; Terapia Ocupacional

1 Introduction

When the working process in integral health actions are well managed, the sharing of responsibilities with the whole health team is allowed (VIEGAS; PENNA, 2013), and when the work context has the mission of aggregating formative processes, the challenges become even greater and instigating, since they extrapolate the exclusive dimension of health care and teaching in a dichotomized way.

The demands of health of the contemporary world exceed the needs of competent and qualified professionals in the diagnosis, prescriptions, and operation of sophisticated and highly complex equipment (MERHY et al., 2010), requiring new profiles with professional capacity and ability for a teamwork, sharing information and valuing aspects such as listening, welcoming, bonding, and caring in the integrality perspective (MERHY et al., 2010; BRASIL, 2004).

Based on this reasoning, Mello, Almeida Filho and Ribeiro (2009, p. 3) highlight:

Besides competent specialists, it is necessary to train creative, critical, enterprising individuals and, above all, excellent citizens. Yes, because in the new millennium, it is no longer enough to train competent professionals and productive scientists to change the world (who can even reproduce and enlarge, with perverse efficiency, existing inequalities and injustices). It is essential to form, above all, men and women committed to the ethics of the public cause, with the consequences of their own action, with Republican interests.

The learning scenarios should favor students to critically reflect on their action and the reality they are inserted, seeking to problematize their daily life, articulating theory and practice in the process of meaningful learning and teamwork; and the user of the service, it should favor the possibility of quality care and scientific rigor for a comprehensive understanding of the human being and the health-disease process, with humanization of integrated attention and care (CECCIM; FEUERWERKER, 2004; FERNANDES et al., 2005).

In the current context of education and health policies, according to Mello, Almeida Filho and Ribeiro (2009, p. 6-7), the approximation between education and the loco-regional health system favors:

Learning environments that pedagogically promising not only to the more competent grasp of the knowledge already available, with (and above all) propitious to the critical reflection on the national reality and the production of an autonomous knowledge - the differential tool of developed people.

It is considered that health is shown as an interdisciplinary field with high complexity because the health-disease process in its social scope involves social, emotional, affective and biological relationships, as well as socio-historical and cultural reasons of individuals and groups ( GOMES et al., 2011; MINAYO, 2002). Due to these dimensions, it is understood that health work is “[...] a listening work, in which the interaction between health professional and patient is determinant of the quality of care response” (CECCIM; FEUERWERKER, 2004, p. 49).

The understanding of the role of co-responsible person in the training of future professionals has been unveiled and built at the health services, with all the complexity of teaching-service-community integration. Teaching-service-community integration should be understood as a work agreed and integrated among students, teachers, managers, workers of health service teams and patients (CECCIM; FEUERWERKER, 2004).

These same authors in their studies have shown that the teaching-service-community integration is profound conceptual, structural and strategic changes in the curricula of health courses, in the training of professionals with common competence, in work processes and in management, positively affecting in the training of qualified professionals in the context of public policies, in the constant updating of the professionals inserted in the health services and in the improvement of the service offered to the community.

The Physiotherapy and Occupational Therapy Teaching and Assistance Unit (UEAFTO) is a Type II Rehabilitation Center founded in 1997, linked to the Center of Biological Sciences and Health - Campus II of the University of the State of Pará (UEPA). Its mission is providing assistance in the areas of physiotherapy, occupational therapy, speech therapy and psychology. Its patients are exclusively from SUS with the most diverse deficiencies, both physical and intellectual, performing about 65,000 appointments/year in several outpatient clinics, such as outpatient activities of daily living; psychomotricity outpatient clinic; global motor occupational therapy outpatient clinic; child occupational therapy outpatient clinic; hand therapy outpatient clinic; cognitive stimulation outpatient clinic; occupational therapy outpatient clinic in groups and workshops and assistive technology outpatient clinic.

About 50 professionals work in this unit, such as physiotherapists, occupational therapists, speech therapists and psychologists, besides the professors of physiotherapy and occupational therapy courses at the university who use it as a field of training and practical classes, with the mission of bringing the world of teaching closer to the work, aiming to provide the exchange of experience in the curricular, professional and multi-professional residencies.

This study came from observation and daily living experience in the Daily Life Activity Laboratory of the Teaching and Care Unit of Physiotherapy and Occupational Therapy (UEAFTO), which led the authors to realize that the contact and permanent dialogue between professionals, students, teachers and service users have convergences and divergences related to the integration of teaching actions in the context of service practice. The divergences of this process impact on teaching and service, provoking a fragility of appropriation of the practice scenario by the students and a disconnection of the work process of the technicians with the teaching actions.

Thus, this study aimed understanding the perceptions of students of the vocational training in occupational therapy on the experience of teaching-service-community integration in a laboratory of daily life activity.

2 Method

This is a qualitative and exploratory study carried out during the second semester of 2014.

All students enrolled in two sub-courses of the subject “Vocational training in rehabilitation” of the fourth year of the occupational therapy course participated in the study, totaling fourteen students (seven of each sub-shift), with no sample loss.

It was approved by the Research Ethics Committee (CEP) of Campus II of the State University of Pará, under opinion of approval nº 657.258 of 05/02/2014. Participants agreed to participate by signing the Free and Informed Consent Term (TCLE), guaranteeing confidentiality and non-identification, complying with Resolution 466/12 CNS.

Data collection was obtained through semi-structured interviews. The research was held at the Daily Life Activities (ADL) Outpatient Clinic of the Teaching and Assistance Unit in Physiotherapy and Occupational Therapy (UEAFTO) of Campus II of the State University of Pará. The interviews had a pre-established script from June to November 2014, recorded and transcribed as close as possible to the date of performance. The place and time were previously agreed upon with the participants.

For the analysis of the interviews, the technique of content analysis based on Bardin (2011) and Minayo (2014) was used, based on the transcription of the students´ narratives. After a detailed reading of the participants´ speeches, there were three thematic categories - teaching-service-community integration, meaningful learning, and theory-practice relationship -, but for this article, only the category “teaching-service integration -community” was analyzed.

Regarding the chosen category, the interview script had four questions about the student´s perception of the integration between teaching-service-community: I) What is your expectation regarding the service performed in the UEAFTO practice scenario before you know it? II) In which sectors of UEAFTO did you develop your practice? Was there a difference in the services provided in these sectors?; III) What are the main difficulties and facilities found during the attendance at the internship?; IV) How was your experience in the ADL sector? Did it contribute to your training?

Participants´ responses to these questions generated four subcategories: I) Expectation of integrated practices between teaching and care; II) Reality of teamwork; III) Organizational process; IV) Exchange of experiences and production of knowledge.

The similarities, the distinction between the contents were observed as criterion of analysis and the central ideas of the narratives on the thematic categories were identified.

3 Results and Discussion

The participants were 14 students (10 females and 4 males) with a mean age of 21.45 years old who were in the fourth year of the course.

From the answers given by the participants to the four questions, and based on the occurrence frequencies, the following four subcategories were generated.

3.1 Expectation of integrated practices between teaching and care

In the speeches of the fourteen interviewees, implicit references were identified about the expectation of the internship experience in the UEAFTO practice scenario, with recurring key questions being revealed about what the students expected with the approach of the world of teaching to the world of work. In these testimonies, the students revealed their expectations with emphasis on the development of practices permeated by the articulation of the actions of teaching and assistance and, consequently, with knowledge exchange between academics and professionals of the service, and with teamwork, which did not occur in the practice.

[...] I expected something more integrated with the professionals of the unit, [...] because we see a very restricted reality, it is only a short experience [...] because when the internship ends, these patients are passed on to professionals here [...] This exchange is needed so they know what we have been doing [...] After the experience, I saw that there is no such exchange [...] this professional interaction and the academics, as the mission of the unit [...] (Student 1).

[...] That vision of the unit as teaching was actually a bit outdated, because it seems that it is more a unit for assistance, where the student is there to supply the very great demand that the unit is receiving, [...] We are not aware, what kind of planning is done in this division of physiotherapy with occupational therapy, if they are the same patients, if they are articulated [...] after the experience, the expectation was not reciprocated because of this, the idea of teaching was a bit out of date, so the unit only had that same assistance function, and in that case, as students, we would be an “object” to fill some demand for that patient who is arriving, which is quite large (Student 3).

Well, I think it’s really lacking to organize this dynamic because until now, I have not experienced this teaching, assistance and community thing (Student 9).

The work process organization is one of the main issues to be faced in order for the communication and integration dynamics between the team to focus on the user and their needs, given that the characteristic of health service delivery requires an interaction breaking with the division of labor and valuation of workers. This interaction should also be articulated to the learning process of the students (VIEGAS; PENNA, 2013).

3.2 Reality of the teamwork

Twelve interviewees said that the work process emphasizes assistance with meeting goals, with little prioritizing teaching actions. This can be observed in the student´s speech, which indicates the reflex of the significant volume of demand, with repercussion in the internship, which even tries to absorb part of this patients:

[...] I do not know if he [the service professional] has this vision, or sometimes he only assists there to meet goals, that we know that there is a minimum service in the SUS service.

Political-administrative and budgetary aspects are very important, while pedagogical and didactic aspects become increasingly abstract (PERRENOUD, 2000).

Twelve participants noticed the lack of interaction in the physical space and its operational logic was observed, impacting on the student´s understanding of the service routine, work dynamics, assistance flow and, above all, the appropriation of this learning scenario.

[...] There are sectors that the student has never heard or talked about them, he is already close to training and has never even visited some rooms here due to internship practices programmed by the coordinator (Student 8).

The speech of student 8 is representative of most of the respondents, who reported restricted use of the practice context. Thus, they did not experience the specificities of the differentiated service spaces.

The learning context in the Unit is underused by the students. There is concentration of activities predominantly in the classroom used for practical training. This factor leads to a lack of interlocution and integration of teaching-service-community actions.

For the interviewees, there was difficulty in completing the teaching-service-community integration, mainly due to the lack of interaction with the assistant team:

[...] [teaching-service-community integration] is far behind schedule [...] lack of knowledge about the space and what is done in the UEAFTO. There is no contact with other professionals, there is no interdisciplinarity. In the proposal, it exist but in practice, it does not happen (Student 3).

Integration relationships in practice occur routinely and without shared work processes, with little intersection of service activities and predominance of organizational routine.

This reality is different to what is expected in productive work processes. Franco (2007) states that the reality in health unit is produced by the communication among workers, management, and users.

Regarding the facilities manifested, the following aspects were highlighted: the appropriate management and supervision of the teacher - supervisor of the internship in the supervision of care and the diversified demands considered important in the learning process.

[...] We have problems; there is no room for discussion of cases, [...] but the teacher acts as a facilitator in teaching and practice (Student 6).

The easiness of the internship is a diversified demand; it helps to understand that you need to study more (Student 3).

The students emphasized the need for valorization and interlocution of the internship actions with the daily activities of the assistant team. This absence was highlighted as an obstacle, contributing to the mischaracterization of the service mission for the learning situations.

Despite the mentioned problems, all the interviewees mentioned that the stage was significant for the learning. The experience provided contact with the complexity and reality of the world of work and, especially, learning in the relationship with the users of the service:

[...] It contributed, right? More on the community thing, because I realize teaching and assistance is half broken. The assistance is outstanding in teaching. In the UEAFTO, it seems that there is no communication between the teachers and the care team. For me, there is more assistance than teaching environment for the students (Student 10).

Each institution has a current care model. However, the EUAFTO proposal (mission) requires a joint effort by the university and the service towards a political and pedagogical replanning and spaces of intersection between teaching and service.

Sometimes, the authority of knowledge is given to the teachers, while secondary vocations are given to service professionals, leading to a hierarchy of relationships and fragmentation of actions that should be of exchange and integration.

The interviews show convergence regarding the lack of integration between teaching-service in the speeches of the students:

Integration teaching, assistance, community, people see it in the theory, not in practice, I do not understand the community as a whole if I circulated in other sectors and talked with other professionals [...] (Student 3).

There is a critical view of the work in the Unit and discontinuity of the teaching-service-community integration. Thus, the challenge currently assigned to SUS service network professionals is to contribute to the training processes, requiring much more than goodwill in the performance of care.

For twelve interviewees, the team was considered inadequate, with little ability and technical preparation to deal with students, not playing the role of facilitator in training in the context of practice for several reasons: lack of capacity, receptivity, motivation, didactics, and teamwork.

[...] some technicians could have more didactic, to know how to deal with the student... we are here to learn and we know that you have a lot to pass to us [...], there is a lack of communication. [...] In the other places of practice that we go to [...], there is a meeting with the team (Student 11).

Although they recognize the potential of the strategies in the teaching-learning process, they emphasized not having such experiences in the Unit:

[...] I do not know why you do not have these meetings, [...] an integrated therapeutic plan (Student 1).

In the interviews, the relevance and coherence of the interviewees were highlighted, and Merhy et al. (2011, p. 57) emphasize:

[...] producing care through health work depends on the construction of relational processes - between managers and workers, workers and users - that can bear the exposure of the implications that the production of care operates.

The mobilization for the exercise of agreed actions is complex. According to Franco (2007), health services have places of power, practices, and rules of operation.

Collective debate is necessary to problematize and re-signify the practice. The objective is to stimulate new reflections and perceptions of the students, so they are protagonists and mobilizers, provoking confrontation of actions dissonant to the expected and recommended in the project of creation of the service.

3.3 Organizational process

In the interviews, the need for reorganization of the assistance is evident, such as:

I think it is missing to organize the dynamics, so far I have not experienced teaching, assistance, and community (Student 8).

[...] We often find a place of practice that does not have the necessary resources that we need, does not have some materials, we have to bring the material from home (Student 2).

[...] We were linked only in one sector, had there was no interaction with the space, with other sectors, it was exclusive only in one space (Student 13).

The absence of strategies (studies, team discussions, meetings, etc.) favoring the socialization of clinical cases, information about the users and the dynamics of the service was pointed out as a negative aspect in the expected learning process for such a practice scenario.

For Perrenoud (2000, p. 169), “[...] the priorities, content, and procedures should depend on cooperative elaboration, shared discussion on training,” favoring engaged work.

According to Pissinato and Motta (2014), the alienation of the workers from their work process reflects in the worker-user relationships and has the consequence that this is done in a compartmentalized way without the need of a multidisciplinary integration.

Fourteen interviewees indicated little interaction with the technical team and disarticulation of teaching-service in UEAFTO. Thus, it is inferred the discontinuity of the construction of teamwork and interventions with exchange of knowledge and production of knowledge, which can be seen in the most emphatic statements about the theme.

[...] I expected something more integrated with the professionals of the unit, [...] We need this exchange so they know what we have been doing [...] After the experience I saw that there is no such exchange [...] this interaction professional and academic, which was the mission of the unit (Student 1).

[...] That vision of the unit as teaching, it was in fact a bit outdated, because it seems that it is more a unit for assistance, where, in a more crude way the student is there to supply the very large demand that the unit is receiving, [...] We are not aware, what kind of planning is done in this division of physiotherapy with occupational therapy, if they are the same patients, if they are articulated... after the experience, the expectation was not matched precisely because of the idea of teaching being a bit out of phase, then the unit only had that same assistance function, and then in the case, as students, we would be an “object” to fill a little that patient demand that is coming, which is quite large (Student 7).

It was never a professional of the unit that stayed with us in the sector, so I do not know what happens there in that sector, how it is used, I do not know [...] I am unaware of this and also how the flow works, I do not know how is the flow of the sector here, even being in the place of my teaching I do not know (Student 12).

The critical evaluation of the students reflects that the role of contributing to formative processes has been unveiled and built daily with their mistakes and hits. The agreements in the guidelines are not yet materialized in practice and, therefore, do not correspond to the idealized/expected in the learning process.

Franco (2007, p. 3) points out that:

The planner´s point of view walks within, searching for the organizational chart, the structured flows, the functional standard, the norms elaborated for the regulation of life, thus, it is revealed by the optics of the rationally designed world that reflects reality from a certain angle. Changing the focus of the eye can enable to perceive these establishments in other ways, to design them more or less organized, to analyze their operations and to appropriate the quality of the services they provide […].

3.4 Exchange of experiences and production of knowledge

The Federal Constitution and the Organic Health Law establish that it is the responsibility of the SUS to order the training of health professionals so they can be prepared to understand their principles: universality, equity, and integrality of health care.

The interviewees´ perceptions about the profile of the service professional as facilitator of the integration process between teaching and service were antagonistic to what was expected:

[...] I already had this experience of meeting in another place with another professional and it was like this: Ah, here is my territory and you can go only there (Student 1).

Integrity as one of the doctrinal principles of SUS is intended to combine actions in health care. According to Santos et al. (2015), the integrality denies the fragmentation of health problems, in which each professional is responsible for a part of the individual, needing interdisciplinary actions. However, there are difficulties to reach it because each professional marks their territory and in the internship, it is difficult for new professionals to understand the integrality. According to Feuerwerker and Sena apud Capozzolo et al. (2013), there is a need for changes in the training logic of health professionals, so they can understand the main health problems of the population.

According to the interviewees, the internship experience contributed to the understanding/reflection about the SUS and the understanding that the interventions should seek to respond to the health demands of the users.

[...] I think it is important to know the context, not to focus on the pathology, but on the reality of SUS [...]. It brings many experiences to deal with the diversities in the internship; it can happen in the professional life (Student 5).

We notice that because it is a very big demand, a lot of people are waiting [...] The SUS is a good proposal only that sometimes it becomes difficult ... the demand is very great, so there are no vacancies for everyone. I see these obstacles during practice (Student 14).

The curricular guidelines of the health professions highlight the need of training in the SUS units. According to Damiance et al. (2016), health education has to sensitize the student to deal with problems affecting the health of the populations, so he can effectively be prepared to solve their health problems.

Peres et al. (2012) see health services as places of learning and work fostering a transforming role in the professional future, constituting them in environments where, through direct contact, the students can know the difficulties, struggles and life histories of the social subjects present in them.

3.5 Suggestions

The interviewees highlighted strategic planning actions that could contribute to the teaching-service-community integration becoming effective and inducing learning. The suggestions cover critical perceptions about the UEAFTO’s design and mission and the internship management approach.

The planning of the practices should have integration with the UEAFTO, the communication with the professionals, how many times in the week they can demonstrate service for the student. They should sensitize the professionals that it is important to help the students. They are so in training and will be the therapists afterward. [...] The teaching plan should be related to professionals, that is where the break happens, the professional ends up thinking that it is someone else who will stay in the room (Student 4).

Strategies for improvement of the teaching-service-community integration (case study, meeting, therapeutic plan, permanent staff training, etc.) were mentioned and favor the training process, articulation, integration with the team and critical perception of differentiated routines.

At NASF, there is a case study. This integrates the team, it can be seen the point of view of other professionals. These studies are a good tool for integration (Student 6).

The collectively constructed therapeutic design favors health care according to the needs of the user and the available resources and goes beyond the strictly pedagogical dimension (SLOMP JUNIOR; FEUERWERKER; LAND, 2015).

The critical observation below on the “comfort zone” is the under-use of the Unit sectors by the internship; this can negatively impact learning since the student has a partial view of the work processes and institutional dynamics. Thus, the risk of this practice is naturalized and consolidated as a routine of the internship.

It would be nice if the proposal in the curriculum had the student to go through the main sectors of UEAFTO. The Daily Life Activity room should be compulsory [...] when it is free, it is more complicated to join the students because it leaves the comfort zone [...]. It would be very productive, the professional could exchange scientific works (Student 1).

The concerns raised are legitimate since the service management model does not address the demands raised by the students and does little to contribute to the desired changes in the training processes.

This mismatch between academic training and the reality of services is a serious problem for the implementation of SUS; the training of health professionals is a strategic axis for the construction of this system.

There are several disputes and the constitution of policies in the health practices, resulting from the actions of different actors that allude or confront each other according to their interests and capacity for action (MERHY, 2002).

4 Conclusion

They are important demands and strategies critically raised by the students, aiming at the improvement of teaching-assistance, which involves different responsibilities of unit management, course coordination and the work process of technicians.

The results pointed out the distance between the expected and the reality of the work routine, revealing inconsistencies between the expectations of the students and their reality experienced in the unit. The interviewees´ perceptions revealed that the work dynamics occurs without collective planning of the care actions and without interlocution with the teaching.

The students suggested strategic planning actions and strategies that could help make teaching-service-community integration more effective and conducive to learning and favor the formation process, articulation, and integration with the team, experience in the ADL laboratory.

There is a need to listen to the other social actors (workers, managers, and users of the service) so the comprehension of this context is integral, reliably reflecting the divergent and convergent conflicts, intersections and interests.

References

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• Funding Source

  The study was funded through the State Postgraduate Scholarship of the State of Pará.

Notes

• 1
  Approval by the Research Ethics Committee under opinion nº 657.258 of 05/02/2014.

Publication Dates

• Publication in this collection
  July 2018

History

• Received
  30 May 2017
• Reviewed
  28 May 2018
• Accepted
  18 June 2018