Nursing supervised curricular internship in the Covid-19 pandemic: experience in the program Brasil Conta Comigo

Objective: To report the experience of the nursing supervised curricular internship in the program “ O Brasil Conta Comigo ” carried out in the Covid-19 pandemic. Method: Experience report of activities developed in Primary Health Care in a municipality in the southern region of the state of Goiás during the Covid-19 pandemic, from April to November 2020. Results: The inclusion in the government program allowed the strengthening of the student’s active role in the teaching-learning process and teaching-service approximation, with the student as the point of connection, which resulted in the implementation of actions for the fight against the pandemic in the municipality, such as elaboration, implementation, and evaluation of the service flowchart for people with suspected Covid-19. Conclusion: The experience was successful, as it consolidated knowledge regarding leadership and autonomy, integration between theory and practice, critical thinking, and evidence-based problem solving. The participation in the program allowed for contributions to assistance and management in the actions to combat the new coronavirus in the scope of primary care, as well as for the contribution to the training of the student tutored by nurses in the field and supervised by professors from the federal university of origin.


INTRODUCTION
In December 2019, the spread of the SARS-CoV-2 virus began, causing the current Covid-19 pandemic.Since then, there have been many global challenges related to breaking the chain of transmission and to the disease surveillance, such as: maintenance of prevention measures, population testing, clinical management of cases at different levels of severity, and management of beds, especially regarding intensive care, where the demand exceeds the offer (1)(2)(3) .
At the national level, in response to the diligence for health care due to the local spread of the virus, the states have implemented strategies such as field hospitals, hiring of new professionals, and training of the multidisciplinary team, with an important role for Brazilian public universities and reference health services (4)(5) .
To foster new knowledge and help health teams handle the problem, the importance of developing documents such as the Coronavirus Clinical Management Protocol (Covid-19)  in Primary Health Care (PHC) (6) is highlighted, with its updates and other documents that were extensively published by the Ministry of Health (MS) and other competent agencies, based on evidence produced with great agility by the entire world academic community.
A strategy adopted in Brazil and in other countries (7) was calling health care students (5) or anticipating graduation for those with more advanced levels of education (8) , contributing to the availability of more professionals to meet the demand that emerged with Covid- 19.In this context, Call Notice No. 4, of March 31, 2020 (5) is highlighted, with the Strategic Action called " O Brasil  Conta Comigo" (BCC, Brazil counts on me) as a stimulus to final-year students of Nursing, Medicine, Physiotherapy, and Pharmacy courses to integrate the health care frontline.
The participation of students from federal public universities who met the above criteria was organized by the MS itself based on a registry connecting these students with health services which, equally, via a computerized system, signaled the desire to receive them in their facilities (5) .
It should be noted that the notice did not include universities as having a specific role in the program, except for the student's attachment and the curriculum analysis of the use of academic hours or credits, following the Pedagogical Project of the Course (PPC) and having as a guide the National Curriculum Guidelines (DCN) (5) .
The Nursing School to which the student was connected at the time of the BCC call decided to keep monitoring by adapting the institution's regular supervised internship model, naming supervisory professors to follow the performance of activities in the remote modality.This decision was taken based on the analysis of the epidemiological context in the state and city where the program would be carried out, of the curricular matrix, and current regulations.
Thus, this article aimed to report the experience of developing nursing supervised curricular internship in Primary Health Care, in the context of the Covid-19 pandemic, through the program "O Brasil Conta Comigo".

Study type
Experience report on the actions developed in a PHC unit.

LocaL
A Primary Health Care Unit in an inland city of the state of Goiás in the fight against the new coronavirus, during the supervised nursing internship, included in the program "O Brasil Conta Comigo", from April 27 to November 9, 2020.
The internship was carried out in a municipality in the southern region of the state that has 51 health services, 24 of which are public and at the municipal level.Of these, 22 are health units organized by the Family Health Strategy (FHS).
The FHS where the practice took place consists of three neighborhoods in the city with an enrolled population of 4,000 people.It provides care to the population in general throughout the life cycle, from newborns to the elderly, passing through activities common to the FHS Primary Health Units (UBS), in the context of the national health policies and lines of care.

popuLation
The study population consisted of the student who had the experience, as well as the professors who followed the internship, and the professionals from the health unit itself and service users.

data coLLection
With the pandemic, changes in the institution's routine were required, aiming at the inclusion of activities for the management and control of Covid-19.Telemedicine with medical and nursing monitoring to follow suspected and/or confirmed cases, rapid screening of suspected cases in the unit were incorporated, as well as the adherence to the program "O Brasil Conta Comigo" by the nurse, which could be performed via the MS website, with the insertion of the field for nursing supervised internship.
The internship had all the support from the university with monitoring of faculty advisors, through periodic meetings, with discussion of needs, evaluation of the material prepared, as well as clarification of doubts.For the development of the internship activities, the PDSA methodology was used, which is based on planning, doing, studying and acting, aiming to improve the quality of systems (9) .
Together with the preceptor and advising professors, the elaboration of a flow was defined as a priority problem, with its consequent planning for implementation for patients suspected and confirmed for Covid-19 in the health unit.
The evaluation of the elaborated flowchart was carried out constantly by the unit's multidisciplinary team and changed as new evidence guided the updating of the work and care processes.

ethicaL aSpectS
This is a report of professional experience in which all ethical aspects related to the research were respected.

RESULTS
To analyze the student's experience at the BCC in terms of challenges and contributions, the report needs to include the perspective of what the program represented, both for the health unit and for nursing education, from the perspective of the student and the supervising professors.
It should be noted that the routine of care in the health service was not limited to actions to combat the pandemic, which enabled the student to act by promoting nursing consultations for surveillance of child growth and development, prenatal care, puerperium, monitoring and clinical management of patients in different lines of care attended at the Brazilian Public Health system (SUS) network, work in the immunization room, among others.
The activities carried out in partnership with the health team were tutored by a nurse and supervised by professors from the university where she studied, through virtual meetings and study guidelines, in which the learning objectives, the plan of activities during the period, and evaluation of the results obtained with the experience were defined.
In the first month, it was possible to develop a flowchart for the care of patients who presented symptoms and/or signs of flu, or severe acute respiratory syndrome (Figure 1).The flowchart was prepared in conformity with the scientific literature and MS protocols, supporting the scientific evidence-based problem resolution; prior to its implementation in the health unit, it was approved by the advisor, preceptor, and the unit's professionals, reinforcing the teaching-service interaction.
Adaptations to the use of the physical structure of the unit were necessary to implement the flowchart.Aiming to provide an isolation room for suspected or confirmed patients, the unit stopped performing dressings in the period, redirecting them to the municipality's specialty unit.Thus, the room initially designated for this purpose became an isolation, consultation, and management room that followed the protocol, avoiding exposure of other people in the unit.
For agile implementation of the flowchart, given the urgent demands arising from the worsening of the epidemiological situation in Brazil, it was presented and discussed with the team.The intern prepared and conducted an expository and dialogued class, as a strategy for continuing education, explaining the pathophysiology of the disease, modes of contagion by SARS-CoV-2, and protective behaviors (inside and outside the health unit), as well as symptoms and signs suggestive of Covid-19 for rapid isolation, diagnostic confirmation, clinical management, and follow-up.
Therefore, with the team clarified and aligned with regard to the procedures and adjustments to the use of the physical space that were carried out, the flowchart was incorporated into the unit's actions.All stages of patient care were systematically recorded in a paper medical record filed in folders with easy identification so that the organization of the records was maintained, even with the imminent increase in expected care with the upward curve of new cases.As part of the daily routine, all folders and files were cleaned and disinfected, being stored in materials that could undergo these procedures.
The interventions provided more dynamic, safer care and, consequently, with a shorter length of stay for the patient in the unit, directly influencing the transmission chain of the SARS-CoV-2 virus and reducing the risk of contamination within the unit.
All interventions related to fight against Covid-19 were widely disseminated in the city and the unit became a model of flow to other health services.It should be noted that the flowchart was constantly evaluated and adjusted according to new information about the new coronavirus and biosafety measures, reinforcing the patient and the multidisciplinary team's safety.
It is worth mentioning the implementation of telemonitoring in the institution, which was incorporated into the flowchart, being carried out by the student, under the responsibility of the nurse and physician of the FHS unit, as well as the monitoring of the advising professors.
Besides the contributions to the FHS unit, which was empowered with the approximation to the university through the intern and her direct role in the care and administration of prevention and management not only of Covid-19, but of all PHC activities, it is important to discuss the advances noticed in the student's education.
The experience of assistance and management of the PHC unit, conflict and people management, the latter with a focus on the leadership of the PHC team, was provided.The student was able to experience the work dynamics of the multidisciplinary team more intensely and to analyze the direct influence on the quality of patient care and on the comprehensiveness of care when several health professionals contribute, which even brought advances to the perception of the scope of work of each member.
In all activities developed, the intern was responsible for searching for theoretical-scientific elements that would qualify her practice and assist in the interpretation of work processes in the PHC unit, considering health care networks and lines of care, in the interface with policies.She became an important link between the university and health professionals in the inland region of the state; although in different cities, this allowed the strengthening of the theoretical-practical articulation.Thus, the student noticed, in herself, progress in her critical and reflective thinking, resourcefulness for communication to establish a bond with the team and families served, as well as a positive impact in the context of pandemic control based on the study of protocols and scientific materials, elaboration, and evaluation of the flowchart, change in the routine to meet the biosafety objectives, and active role from the beginning to the maintenance of the new work processes and service protocols.This perception was corroborated by the formative assessment carried out by the supervisor professors, consolidating the importance of theoretical-practical integration and scientific evidencebased problem solving.
It is noted that the results were very positive, potentially because, despite not mentioning the role of the university of origin in monitoring the intern during the BCC program, the Nursing School maintained its supervisory role by appointing professors to monitor the student's process of training and contribute to the teaching-service approximation.
The exclusion of the role of the university in this program during its conduction beyond the final assessment of credit utilization provided for in the notice was a weakness recognized in time by the Nursing School, which maintained its practice of regular guidance -periodic meetings (adapted to the virtual model), communication with the preceptorship, review of produced materials and portfolio as a strategy for consolidating learning.Furthermore, in the meetings with the student, themes related to the scope of her performance as a future nurse, but currently as an intern, emerged and demanded reflections and support based on the law of professional practice, nursing ethics, and nursing care protocols in the state.Thus, the close work of the professors, despite the physical distance, was fundamental for nursing education, articulation between theory and practice, and approximation between teaching and service.

DISCUSSION
As described in the PNAB (10) , PHC is the gateway to SUS, a reference for the population when it is not related to urgencies and emergencies, representing the longitudinality of comprehensive care, even if care takes place in the system's multiple health services and levels of attention.
With the pandemic, an increase in the demand for assistance was predicted, both in mild cases of Covid-19 and in the reception of severe cases requiring referrals within the network that was organized in a special way to respond to the epidemiological context.Moreover, a new need emerged, which was the systematic monitoring by telemedicine of patients with suspected or confirmed cases, duly notified in the epidemiological surveillance system (4,6) .
The way to conduct care in a quick and safe way was highly discussed, to promote less exposure time for people in the unit and ensure protection through masks, availability of hand sanitizer and paper towels, resources necessary for the safety of patients and team, aiming to reduce the chance of transmitting SARS-CoV2 (6,(11)(12) .
The differential in Brazil is the guarantee of health as a right through SUS, which is free and organized in a decentralized way, allowing the expansion of access without crowding in large health services facilities (10) .However, difficulties were also experienced, and continue to be, such as the scarcity of resources available in terms of Personal Protection Equipment (PPE) for health professionals, the need for more active health professionals, especially nurses, and few diagnostic tests available for the population.
In the unit in question, there was significant difficulty in operationalizing the biosafety protocols and measures due to the weaknesses in the existing physical structure, as well as few technological devices in the unit and lack of mastery of their use (computers and information systems), reinforcing the need to strengthen digital health throughout SUS (4) , with an emphasis on PHC, which concentrates the majority of care (10) .
In this regard, the application of the flowchart in the unit's routine was essential for the development of actions that, for their full operationalization, had as barriers the difficulty of physical space, lack of technology mastery by the team, lack of knowledge about SARS-Cov2, and untrue information disseminated by social media.However, it met the need for the team to be trained and organized to deal with the demands of the pandemic, supporting the development of problem solving strategies based on scientific evidence (18) and with the use of management tools in nursing and health (19) .
The scarcity of diagnostic tests, as well as the different accuracy -depending on the type of laboratory procedure, quality of collection, and type of sample -were a complicating factor for the control actions not only in the health unit in question, but also in units throughout the country (4,20) .
Despite the obstacles, it is essential to highlight the articulation and organization capacity of health services, public universities, and competent agencies in the face of the adversity presented.The role of Brazilian higher education institutions in the construction of knowledge and its direct application in society was evident, promoting better practices, as well as that of SUS's health professionals, who have adapted to a new reality, reinventing their way of working to serve the population and mitigate pandemic damage.
Universities were involved in various activities, such as the repair of mechanical ventilators, production of PPE, composition of testing teams in a population survey, and also in more complex initiatives of screening, diagnostic testing, consultations, and systematic telemonitoring, preparation and offering of courses with maximum promptness in the areas of biosafety measures, screening, and clinical management of suspicion of Covid-19 in PHC, clinical management in the ICUs, among others (21)(22) .
In these actions, students actively participated along with their professors and experienced learning supported by the aforementioned scientific evidence-based problem solving, mediated by professors, who acted as facilitators, fostering the development of critical thinking and clinical reasoning (21)(22) .Similar to other experiences with nursing internships (23)(24) , the results of this report suggest that the work of professors in the role of facilitators provides theory-practice integration, favoring the transposition of knowledge obtained by students in theoretical classes to their performance in the clinical practice, and problematizing the reality of the health care service for in-depth study.
Through these actions, including the experience reported in this study, it was possible to improve the capacity for critical and reflective thinking, to apply theory into practice, and to seek theory through the needs that are presented in practice, to exercise humanized care, with bonds of trust with the patient, family and team, as well as to value interprofessional work, which are fundamental attributes for health education (25)(26)(27) .
The program "O Brasil Conta Comigo" as a government response to the pandemic resulted in a change in the internship field in relation to the schedule, but through the consolidation of the PPC, which is based on the population's health needs and the context of health services, and the role of professors in supervising and guiding the internship student, despite the geographic distance, allowed the student to have unique experiences in nursing performance in the face of the Covid-19 pandemic.
It is important to emphasize the need that the PPCs of undergraduate Nursing courses, following the DCN, are prepared with a view to training professionals who are going to meet the demands of the population at SUS to be leaders who work with humanization, based on evidence, and with problem-solving skills derived from critical thinking.
Training through the BCC was permeated, during this period, by weaknesses and insecurities, such as access to PPE depending on the resources available in the health units (28) and the risk of overloading preceptors as they had to combine their daily actions, which increased with the pandemic, with direct supervision of students without the presence of the professor on site (28) .This monitoring by the professors during the virtual meetings was essential for both pedagogical and safety support and guidance for the student in the process.
The support from the university is essential throughout the student's education, just as it was done during this student's experience at the BCC, despite the non-inclusion by the MS of the role of the higher education institution in the course of care practices during the program.
In the case reported, the university ensured a health insurance throughout the internship and faculty pedagogical monitoring, an experience that allows reflections on the health and education current situation, in an intrinsic relationship, during the Covid-19 pandemic in Brazil guided by governmental and multi-sectoral actions.

CONCLUSION
The Covid-19 pandemic lead to several adaptations, not only in health services, but in their relationship with universities and also with all institutions in an intersectoral perspective.
As far as the student is concerned, the experience of nursing education when joining the program "O Brasil Conta Comigo" resulted, despite adversities, in the consolidation of knowledge related to leadership and autonomy, integration between theory and practice, critical thinking, and evidencebased problem solving.
For the health unit, there was a contribution with the maintenance of routine protocols, even in a pandemic period, and a quick response based on scientific evidence to address the new challenge, reinforcing the importance of primary care for the community and SUS.
Access to the formulation and execution of the assistance flowchart for suspected and confirmed cases of Covid-19 was essential for preventing SARS-CoV-2 infection, and reinforced the bond between staff and students.Furthermore, with the application of continuing education in health, the team ensured greater security to face the challenges of the pandemic with the support of the university.
It is worth emphasizing the importance of the partnership between MS and Higher Education Institutions, aiming at offering all the necessary support for students and health services, and that it should be regulated, which did not occur in the BCC program call notice.

Figure 1 -
Figure 1 -Flowchart for the care of suspected and/or confirmed patients with FS, SARS, and/or Covid-19.Source: the authors.