Nurse’s training centred on professional practice: perception of students and professors

ABSTRACT

Objective

To analyse the perception of students and nurses regarding the insertion of students in the professional nursing practice.

Method

Exploratory research with a qualitative approach based on the analysis of evaluation documents completed by students and professors of the nursing course. In this study, all the documents completed by the professors and students were used and analysed using thematic content analysis.

Results

The identified nuclei of meaning led to the following themes: “Learning from the professional context” and “The teaching and learning process: strategies used”.

Conclusion

The study revealed the importance of integrating students in the hospital context to enhance learning and allow greater approximation with the reality of the nursing profession. The partnership between education and service was also highlighted, which stresses the need for permanent education that serves as a tool of reflection for professors and nursing professionals, and enhances curricular reorganisation.

Professional practice; Education, nursing; Nursing care; Students, nursing

RESUMO

Objetivo

Analisar a percepção de estudantes e professores sobre o processo de inserção do estudante na prática profissional de enfermagem.

Método

Pesquisa com abordagem qualitativa exploratória, por meio da análise de documentos de avaliação, preenchidos por estudantes e professores do Curso de Enfermagem. Nesse estudo, todos os documentos preenchidos por professores e estudantes foram utilizados e analisados por meio da análise de conteúdo, modalidade temática.

Resultados

Foram identificados núcleos de sentido que deram origem às seguintes temáticas: “Aprendizagem a partir do contexto profissional” e “Processo de ensino e aprendizagem: estratégias utilizadas”.

Conclusão

O estudo demonstrou a importância da inserção dos estudantes no contexto hospitalar para o desenvolvimento da aprendizagem, permitindo maior aproximação com a realidade da profissão. Também foi valorizada a parceria entre o ensino e o serviço, destacando a necessidade da Educação Permanente, como ferramenta de reflexão para os professores e os profissionais do serviço, potencializando também a reorganização curricular.

Prática profissional; Educação em enfermagem; Cuidados de enfermagem; Estudantes de enfermagem

RESUMEN

Objetivo

analizar la percepción de los estudiantes y profesores en el proceso de inserción del estudiante en la práctica profesional de enfermería.

Método

la investigación exploratoria con enfoque cualitativo, a través del análisis de documentos de evaluación cumplimentados por estudiantes y profesores del Curso de Enfermería. En este estudio, todos los documentos completados por los profesores y estudiantes fueron utilizados y analizados mediante análisis de contenido temático.

Resultados

se identificaron unidades de significados que originaron los siguientes temas: “Aprendizaje a partir de un contexto profesional” y “El proceso de enseñanza y aprendizaje: estrategias utilizadas”.

Conclusión

este estudio demostró la importancia de la inserción de los estudiantes en el contexto hospitalario para el desarrollo del aprendizaje, permitiendo así una mayor aproximación con la realidad de la profesión. Y también se valoró la asociación entre la enseñanza y servicio prestado, poniendo en relieve la necesidad de la Educación Continuada como herramienta de reflexión para los profesores y demás profesionales del servicio, y que también mejoran la reorganización curricular.

Práctica profesional; Educación en enfermería; Atención de enfermería; Estudiantes de enfermería

INTRODUCTION

The role of higher education institutions (HEI) is to qualify healthcare workers with a critical and reflexive vision that enables them to transform the practice in various scenarios of the unified health system (SUS). To achieve this goal, the HEI must redefine student qualification and organise the curriculum to include educational projects that allow the newly qualified professionals to make changes and strengthen the SUS.

For the SUS to be strengthened in a gradual and continuous manner, students must be inserted in the different levels of healthcare. This initiative will allow students to experience the public health model in the national context and subsequently use the acquired knowledge to reflect on how they can effectively contribute to transform the system in the future(¹).

The SUS is chiefly responsible for attracting health professionals in Brazil, so the integration of the students in this system can help replace a reductionist, disease-oriented, hospital-centred, and speciality-centred model for a more humanistic, health-oriented model that focuses on prevention(²).

The partnership between education and services also depends on investments in the work process of nursing professors and professionals who are immersed in care activities. The approximation of these professionals should be mutually beneficial since it can take educational qualification and scientific knowledge to the service and bring the health services into academia(¹). Furthermore, students can represent the vector of this dialogue between service and education.

The insertion of students in the various professional practice scenarios can be operationalised at the end of the course; a process commonly known as “supervised internship”. In this model of inserting students into the professional practice, they are afforded the possibility of consolidating their work performance throughout the graduation programme and consistently integrating theory and practice. Thus, these students can act in professional practice settings as agents who trigger social change in healthcare and consequently strengthen the SUS. However, supervised internships at the end of the course have been deemed insufficient by nursing graduates since their education focuses more on theoretical and technical aspects that make it impossible for them to understand the real difficulties in the world of work(¹).

Currently, several curricular models allow students to participate in professional practice scenarios from the beginning of the course. In these models, students generally conduct nursing care actions of growing complexity to track their progress throughout the course. Students who gradually gain autonomy can also assume more responsibilities. However, professors must monitor each student and ensure students work together with the professional service.

Some national nursing courses use several practice scenarios for supervised internships at the end of the programme and offer theoretical and practical activities from the first years of the course, thus allowing students to develop their professional skills throughout the training process(¹,³).

The national curriculum guidelines of the course of nursing also reinforce the importance of a training model that works together with the professional practice to enable reflection (action-reflection-action) that transforms reality, allows practical and theoretical integrations, and helps organise cognitive, affective, and psychomotor domains into action. In addition, these guidelines reveal the need to use active methods of teaching and learning so students can become the protagonists of the dialogue between the world of work and academia(⁴).

Moreover, in academic activities that involve professional practice scenarios care must be taken to prevent students from becoming mere objects for the development of attributes. It is therefore important to establish relationships based on solid ties and accountability toward people and the health team.

Inserting students into the professional practice scenario from the beginning of their education allows them to break away from the paradigm that theoretical learning must precede practice. Given the wide range of professional experiences professional practice scenarios can provide, it is important to understand how professors and students perceive this nursing education model.

Consequently, the aim of this paper was to analyse the perceptions of students and professors regarding student’s insertion in the professional practice of nursing.

METHODOLOGY

Research was conducted with the exploratory qualitative approach based on the analysis of evaluation documents that are used in the institution in which the study was conducted, known as format 5 (F5). These documents were filled out by students and professors of the third year of the nursing course of the Faculdade de Medicina de Marília (Famema) in the first half of 2015. Famema is a public institution in the state of São Paulo that offers medicine and nursing courses based on a curriculum that targets dialogic professional competence and uses active methods of teaching and learning.

The curriculum at Famema is divided into educational units. One of these units is the Professional Practice Unit (“UPP”) and it focuses on the professional practice of the nurse. The UPP is composed of an educational cycle that initially offers experience-based confrontation and preparation of a first synthesis through reflection on practice and learning issues. Sequentially, the students must identify bibliographic sources and search for and analyse information. At the end of the cycle, the students prepare a new synthesis based on conceptual, methodological, and scientific research that they can apply to the professional practice(³).

In the first and second years of the UPP, students are inserted into the primary care setting, and in the third year they practice in the hospital setting.

The evaluation process includes assessing the Famema educational units where the students study. There are specific assessment formats for each teaching and learning scenario. These institutional formats or forms are filled in systematically and anonymously by the professor and students involved in the process. The Fanema Assessment Unit examines the forms or format to support any changes to the curriculum. In addition, these documents can also be used to analyse the information with more detail and share experiences with the scientific community, as is the case of this study that verifies the process of inserting nursing students in professional practice.

Data were collected in August 2015 by organising the statements of students and professors who filled out the evaluation form. This format contains closed-ended fields for a quantitative assessment of the educational unit and open-ended fields for subjective evaluations. This study excluded the analysis of quantitative fields. The fields in the documents that were analysed to record the perception of students and professors were “proposal of the educational unit”, “teaching-learning process”, “organisation of the educational unit”, and “comments/suggestions/recommendations”.

The methodology used to analyse the F5-UPP was based on thematic content analysis with emphasis on qualitative social research. The steps of content analysis were exploration of the material, pre-analysis, treatment of results, and interpretation(⁵). All the statements were skim read to identify the main ideas and form the nuclei of meaning, which in turn composed the themes.

Of the 11 professors, six completed the evaluation format, and of the 28 students, 19 completed the form. All the documents/formats filled out by professors and students were used in this study.

Since this is a documentary analysis that includes professor and student statements, the subjects were identified using the letters “S” for student and “P” for professor, followed by number.

The Research Ethics Committee of Famema approved this study under opinion 1.210.110 of September 1, 2015. Since this is a document analysis, informed consent was not required. However, the persons responsible for the documents approved the use of these documents by signing a cover sheet generated by Plataforma Brasil.

RESULTS

Learning from the professional context

In general, the reviews showed that the students were satisfied with the professional practice activities. The change from the primary care setting to the hospital setting and the consequent transmission of a continued concept of care were positively assessed. In this new scenario, the students mentioned the possibility of having real nursing practice experiences and of identifying the strengths and weaknesses of the profession.

Being close to the practice of nurses and seeing the good and bad of the profession (S92752).

[...] it is the first time we get close to the [patients] hospitalised and it was very beneficial (S92611).

In the third year, our UPP scenario changes, and now we’re at the hospital [...] my assessment is that we practice what was studied in the first and second year (S540).

According to the students, the hospital setting provided direct contact with routine nursing care and patients, which was not as frequent in primary care, as in the case of newborn infants, and greater insight into the health needs of this population. They mentioned the association between theoretical learning in the UPP and the Laboratory of Professional Practice (LPP) where they can practice in the women’s health setting. In addition, the students valued the daily monitoring of patients. Thus, they were able to correlate the adaptation process of newborn infants and of pregnant women with nursing care. The following statements illustrate these perceptions:

Associate the theoretical learning acquired at the UPP cycles and LPP with the practice in women’s health, with the physiological changes of pregnant women and women who have recently given birth, nursing care for pregnant women and women who have recently given birth [newborn infants], physiological adaptations of the newborn babies, and the nursing diagnosis (S92506).

The UPP allows us to get in touch with everyday reality and show us how to prepare for the future. Being in daily contact with patients is unique and irreplaceable (S92741).

Paediatrics is very relevant, because in the first and second-year UPP not everyone has contact children, and there we are in the hospital, so we learn to take care of infants in a hospital environment, which is very different to caring for an adult (S92480).

Some students perceived the importance of having prior knowledge to construct additional knowledge, and reinforced the possibility of improving nursing consultations and gaining the autonomy to complete procedures, as shown in the statements below:

This activity is really important for our training as nurses because we can continue from the previous year in a hospital environment, which was previously impossible (S92300).

With adult healthcare, I acquired a lot of new knowledge and improved the knowledge I already had. I improved my physical examination technique, anamnesis, my patient care plan (because I observed and appreciated the whole context of the admitted patients) and even gained a lot of autonomy in several nursing procedures (S92579).

One of the professors also mentioned the benefits of the hospital setting and how students appreciate the context of the hospitalised person. These aspects are related to the performance students constructed in previous years.

[...] the insertion of students [in the UPP3] stimulates their critical thinking and clinical reasoning, and allows them to directly care for hospital patients, and consider their families and communities (P6).

However, another student also mentioned the weaknesses of this setting.

It is essential for the construction of theoretical knowledge, but [he] recognises the difficulties of the health system to which we operate, and identifies weaknesses and potential, and the things that can be changed by our work in the future based on a theoretical knowledge (S92667).

The students appreciate learning from professional practice combined with scientific knowledge, which can be reverted to change their future practice.

The teaching and learning that is developed in professional practice scenarios by students, teachers, and professionals of the service can help transform the health care model in the future. The contact that students have with nursing assistants and technicians and the professional team brings other learning opportunities of individual care and work management(⁶).

For this partnership between education and service to be successful, investments must also be made in the work process of teacher nurses and nursing professionals who are immersed in care activities. The approximation of these professionals should be mutually beneficial since it can take educational qualification and scientific knowledge to the service and bring the health service into academia(¹). Furthermore, students can represent the vector of this dialogue between service and education.

The professors also mentioned the absence of permanent education (PE) as a weakness of this process:

We haven’t had PE to date, and it’s important for the advancement/reflection of our practice as professors (P1).

This semester there was no PE for the third and fourth years of nursing, which had been offered for some years, along with the service staff, and I consider this a loss for the year and for the service professors (P6).

Given the need to bridge the gap between teaching and service, PE should be restored as a viable and powerful strategy that allows room for reflection and helps workers rethink their practice, understand the work process in which they are inserted, and seek further ways to overcome work-related difficulties(⁷).

The students mentioned the introduction of the nursing diagnosis of NANDA International (North American Nursing Diagnosis Association) and the Systematisation of Nursing Care (“SAE”). The students probably appreciate these two processes because they feel closer to their profession and are more involved with specific professional practice activities at this stage of their education.

I improved my technique of physical examination, anamnesis, my patient care plan [...] and even gained lots of autonomy in many nursing procedures [...]. All the knowledge I acquired at this stage that I had not yet come into contact with the was nursing process, where I was first introduced to the NANDA diagnoses (S92579).

At first we had lots of difficulties with the SAE, but we’re organising it now [...] (S92540).

The Federal Council of Nursing, through Resolution 358 of 2009, establishes that the aim of the SAE is to organise care based on a systematic method that guides nursing care and professional practice documentation, thus strengthening the visibility and recognition of this professional category(⁸-⁹).

The students feel closer to their professional practice and are able to add these learning experiences to their performance, together with the classification of NANDA International(¹⁰). However, the SAE and the NANDA classification system used to organise nursing care can promote care automation. Consequently, professors must provide room for listening and reflection on the practice to prevent this from happening.

In additional to patient care, the students mentioned the importance of the healthcare team:

It’s not just the contact with patients, but also the way the team works that helps us learn how that environment is managed and learn about the competencies of each professional in there (S92579).

This statement is in line with the national guidelines for graduation in nursing in relation to managing and organising the work process and collective care(¹¹).

However, in the opinion of one professor, this work and management process has become weaker in relation to teamwork and overworked staff.

[...] the lack of a real interdisciplinary teamwork and the overload/dissatisfaction of nursing professionals directly reflect on the quality of care (P6).

These performances are related to identifying the organisation of teamwork and defining how the team can meet the healthcare needs of people and make decisions regarding the tasks that workers can do or delegate to the other members of the nursing team(¹²).

The students stressed their appreciation of the changes in attitude in this practice scenario; some were generic and did not mention the actual attitude, while others mentioned dealing with personal difficulties to improve contact with patients.

It has provided some special moments and [it is] helping me improve my contact with others, to be less shy (S92741).

Another aspect of the learning process was the fundamental role of the professor in group work:

The strong point is going through this scenario with these really dedicated professors who show just how involved they are with the group and with one another [...] and the educational process has been effective in that unit, because I always have the professor`s encouragement regarding these steps [educational cycle] (S92300).

The most common complaint of the students was the short time spent in the hospital setting, although they also claimed to understand this limitation and recognised that this organisation allows the performance of activities in the different nursing care scenarios.

The weakness may be the time spent in each setting (S92300).

[...] When we are getting used to and familiar with the setting, we have to leave, but it is necessary and important to go through all the areas (S92685).

The proposal of combining teaching with professional practice involves care, ties and accountability regarding the hospitalised person, rather than merely an object of learning(¹²).

Students in this year remain in each scenario for around ten weeks. In each week, the student have three periods to accompany the professional practice in the hospital environment, one period to complete the education cycle, and one period to participate in a simulated professional activity. Every fifteen days, they attend a conference related to the professional practice experiences. This model allows students to observe how the team organises the work process. Some of the students mentioned they would have liked to remain in this scenario for longer, as mentioned above. The wish to remain in the hospital setting for longer may be related to the ties they build and their identification with the area, or to their inability to perceive that there are other expected goals to achieve in the year, in the next setting they will encounter.

Teaching and learning process: strategies used

In relation to the organisation of the education units, the students mentioned that their immersion in the hospital setting strengthens their learning. They also mentioned that the simulated LPP setting provides a basis for their future work.

The real scenario, which is where we have constant contact with the patient, is very valid because it prepares us for the daily routine in the hospital. - The simulation scenario gives us the basis to develop our work in the hospital and it clarifies many queries we have there (S92741).

Curricular models that involve integration between scenarios must also ensure that there is effective communication between these scenarios. Professionals who work in all the scenarios can facilitate this integration. The professors stressed the combination of the LPP and the hospital setting, and appreciated the fact that the members of the organising team act as facilitators in the various scenarios. Although there was no direct relationship between these two aspects, the fact that the organisers of the educational unit also act as facilitators with the groups of students also favours integration between the scenarios, as mentioned previously.

One of the benefits of professors who act in both scenarios is the communication established between these scenarios. Models of curriculum organisation that involve the passage of students through different teaching and learning scenarios require effective communication between the faculty members of these scenarios. Thus, the presence of the same faculty members in the different scenarios fosters communication with the other professors and students involved. In addition, the pedagogical proposal operationalised by the creators minimises the subjectivity of any interpretation of the planned activities. When this organisational configuration is impossible to maintain, an effective education proposal will depend on the appropriate communication between professors and students.

Strengths: involvement of professors from the construction of the educational unit and with all the teaching and learning strategies, and assessment (P1).

One criticism mentioned by a student was that “it’s horrible to examine dummies” (S92480). The reason the students mention this situation in the simulated scenario is that they learn a lot more from examining children than examining dummies. However, from a legal standpoint, the participation of underage patients in training is not permitted(¹³).

In paediatric simulation units, the University of São Paulo (USP) also uses alternatives such as mannequins, photographs, films, and complementary testing to assess simulated practice called OSCE (Objective Structured Clinical Examination)(¹⁴).

In other countries such as Canada and Chile, paediatric OSCE units invite children with their parents for possible assessments. However, there is some controversy regarding the use of children since they are exposed several times to a situation does not support or improve their development. Another ethical issue is that they are paid for their participation, which requires the parent’s permission. The use of children is considered a possibility and it is supported by the parents and children, who claimed they would participate again(¹⁴).

In view of this limitation in Brazil, it is important for professors to work with students regarding the use of dummies as learning resources, even with the obvious limitations. Professors can also enforce the chance of combining these experiences with the experiences of students in the paediatrics scenario to enhance performance.

The adaptation of students to the activities of the UPP is not restricted to care; it also covers the teaching and learning process. Some differences were observed in relation to completing the portfolio in comparison to previous years.

[...] I started the cycle of children’s healthcare with difficulties in constructing a good portfolio, but over time, with the practice and help of the facilitator, I believe there was a significant evolution (S92741).

This year was complicated because each year a facilitator pushes a different way, so this year was more complete; I had lots of doubts when I followed these steps (S92480).

Educational proposals that involve active methods of teaching and learning have a more individualised approach that differentiate them from traditional teaching. Institutions that use active methods of teaching and learning tend to use a wider range of assessment instruments(¹⁵). The student statements focused on one of these assessment tools - the portfolio - and the different conducts in the completion guidelines of this instrument. Although the evaluation process will inevitably depend on the evaluator’s subjectivity, curriculum managers must closely oversee evaluative activities and ensure that assessment instruments are uniformly understood.

More importantly, the reflective portfolio is widely used in nursing courses for students to report their experiences and expose their values, skills, and knowledge that can be confronted with the proposal of the course(¹⁶). The self-reflection that this instrument provides helps students rethink the practice and the educational conduct that involves the professors, rather than merely issue a judgment or a student classification, which means it also helps to qualify students(¹⁷). Consequently, the portfolio is an instrument of dialogue between professors and students(¹⁵).

One aspect highlighted by students is the importance of carefully completing this assessment tool. According to the statements, the students felt that the steps of the educational cycle were developed and described in the portfolio:

All the stages of the educational cycle are made and transcribed for the portfolio. We have the reflective narrative readings, discussion of the questions, preparation of the questions, searches with diversified sources, and sharing studies through discussion to create a new synthesis (S92579).

This record in the portfolio clearly identifies that, in the opinion of the student, the educational cycle is completed in the group in which it is inserted and serves to continuously support the strategies used by the facilitator in teaching and learning activities. This feedback is important for the professor and managers.

In the area of healthcare, all reflection on professional practice is critical for the provision of comprehensive care, that is, a more humanised care that does not merely consider technical aspects.

Similarly, the process of qualifying health professionals deserves reflection and demands constant approximation with the teaching and learning scenarios and the adopted educational practices. Students and professors occupy a prominent position in this process since they represent the distal elements of the system and are directly involved in the materialisation of the curricular proposal.

The results of this study, which originated from the perception of these two segments, can support reflection on the education of nurses in the professional practice and in the praxis that exists in the health services. In the latter case, the representative of academia, be they professors or students, have rights and duties.

CONCLUSIONS

In general, the students and professors evaluated the UPP as satisfactory, which highlights the importance of including students in the hospital context to enhance learning. This immersion provides greater proximity of students with the reality of the profession and gives them the chance to use concepts covered in previous years and build new nursing-specific knowledge.

The partnership between teaching and learning emerged in various moments of this assessment. This partnership can be consolidated by restoring permanent education as a tool of reflection for professors and service professionals, which later rolls back into the qualification of care and learning of students.

The portfolio, considered one of the objects of student evaluation, and the systematisation of care should be worked through in teacher training to enable greater realisation of the educational project of the courses.

This study reaffirms the importance of including students in professional practice from the first year to help them become critical and reflective qualified nurses with prior nursing knowledge when they enter the hospital setting. However, the limitation of this study is that it was based on the perception of a group of students and professors. New studies would therefore be necessary.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  06 Apr 2016
• Accepted
  06 Oct 2016