Preceptorship in the perspective of comprehensive care: conversations with nurses

Preceptoría en la perspectiva de la integridad: hablando con enfermeros

Abstracts

The aim of this study was to understand preceptorship in nursing practice fields and its association with comprehensive care. This study was based on qualitative field research conducted in Fortaleza, Ceará, Brazil, from April to June 2012. A total of 20 preceptors were interviewed in the practice fields of three higher education institutions at three public state hospitals and one basic health unit. Thematic analysis enabled apprehension of the theme 'preceptorship in the perspective of comprehensive care', and the empirical categories: (dis)articulation in teaching-service: distancing from academic institutions; welcoming students in the practice field. On the field, routine teaches: articulation in teaching-service from the preceptor's perspective. Results showed that teaching-service integration is at risk in light of biologicism and the gap between teaching institutions and health services, but that it is a way of constructing the necessary changes to consolidate the National Health Service.

Nursing; Preceptorship; Unified Health System

El objetivo fue comprender la preceptoría en Enfermería y en campos de prácticas y su articulación con la integralidad de la atención. Investigación de campo cualitativa llevada a cabo en Fortaleza-Ceará, Brasil, de abril a junio de 2012. Fueron entrevistados 20 preceptores en campos de práctica de tres Instituciones de Enseñanza Superior en tres hospitales públicos y una unidad básica de Salud. El análisis temático aprendió el tema Preceptoría en la perspectiva de la integralidad, y las categorías empíricas: (des)integración de la enseñanza-servicio: el distanciamiento de la academia; acogimiento del estudiante en campo de prácticas; en el campo, la rutina enseña; integración enseñanza-servicio bajo la perspectiva del preceptor. Los resultados señalaron la integración enseñanza-servicio en situación de riesgo delante del biologicismo y brecha entre las instituciones de enseñanza y los servicios de salud, pero una manera de construir cambios necesarios para consolidación del Sistema Único de Salud.

Enfermería; Preceptoría; Sistema Único de Salud

Objetivou-se compreender a preceptoria em Enfermagem nos campos de práticas e sua articulação com a integralidade do cuidado. Pesquisa de campo qualitativa, realizada em Fortaleza, Ceará, Brasil, de abril a junho de 2012. Foram entrevistados 20 preceptores nos campos de prática de três Instituições de Ensino Superior em três hospitais da rede pública estadual e uma unidade básica de saúde. A análise temática permitiu a apreensão do tema Preceptoria, na perspectiva da integralidade, e as categorias empíricas: (des)integração do ensino serviço: o distanciamento da academia; o acolhimento do estudante no campo de práticas; no campo, a rotina ensina; a integração ensino-serviço sob a ótica do preceptor. Os resultados apresentaram a integração ensino-serviço em situações de risco mediante o biologicismo e a lacuna entre instituições de ensino e os serviços de saúde, porém como, caminho de construção para as transformações necessárias, a consolidação do Sistema Único de Saúde.

Enfermagem; Preceptoria; Sistema Único de Saúde

INTRODUCTION

Professional nursing education in the perspective of comprehensive care contemplates teaching-service integration between institutions of higher education and the healthcare services. Supervised internships support practice learning and preparation of the student by providing contact with the dynamics of healthcare services, and helps students define their role in the multi-professional team. They are carried out in hospital units and basic healthcare units and should correspond to 20% of total programme classroom hours, in conformity with National Curriculum Guidelines of the Undergraduate Nursing Programme (DCN/ENF)^{( 1 )}.

Supervised internships occur during the last two semesters of the programme with the aim of allowing students to solidify knowledge acquired at the institution by means of planning and implementation of the healthcare practice. They allow the insertion and practice of students in the social context as change-provokers in social healthcare production areas, and the consequent consolidation of the Unified Health System (SUS)^{( 2 )}.

Preceptors must present theoretical, educational and political knowledge in order to supply students with an understanding of the objectives and purpose of nursing. Their experience and discernment are essential to interconnect undergraduate studies with the work market. The healthcare services provide a fertile environment sought by higher education institutions for professional practice, the acquisition of specific skills and for humanization and ethics.

Since the mid 1970s, by means of historical and conceptual milestones brought by the Sanitary Reform and the Unified Health System (SUS), there have been changes in healthcare programmes that target a new professional profile with practices that must adapt teaching and service provision to a new healthcare system and include innovation and implications of social policy^{( 3 )}. Work in this area is essentially relational although care is still, in many cases, limited to the realization of procedures^{( 4 )}; a model that is seriously debated in relation to the paths that lead to the construction of humanized healthcare.

Applicability of the SUS depends on factors such as financing and management, in addition to human resources. Decentralization, one of the great accomplishments of the SUS, for example, was one of its deflections due to the lack of professionalization of its leaders, the persistent political cronyism, high team turnover and bureaucratic "stiffening"^{( 5 )}.

The lack of preparation of professionals in the perspective of a healthcare promotion model triggered the need to transform healthcare education, currently detached from the reality of the service, structured by an individualistic practice and distant from debates on social problems. The focus of a nursing programme is to provide care, even during the learning stages of care provision processes ⁽⁶⁾.

Teaching-service integration emerges with the intention of involving the school and healthcare-related work. In terms of social determinants of the health-sickness process, it connects education to the technical and political dimension and the construction of a new ethical and political commitment of healthcare workers based on the democratic issue, on the supportive relationship with the population, and on the defence of public services and human dignity ⁽⁷⁾.

The preceptor in nursing must signal the profile of new graduates and must also be prepared for this task. Changes raised by the Sanitary Reform have been demanded of healthcare professionals, whose nursing practice tries to adequately correspond to services and teaching. This is still an arduous path that, during its development, requires supervision and assessment.

Preceptorship has been scarcely addressed in literature^{( 8 )}, which generates concern for the current moment and leads to continuous movement towards improvements in the provision of public healthcare. Accordingly, this study was based on the following guiding question: How is preceptorship occurring in nursing practice fields and what is its articulation with comprehensive care?

Questioning the teaching-service in the scenarios of healthcare practices refers to collective thought on nursing education and its correlation with the SUS. Consequently, the aim of this study was to understand preceptorship in nursing and its articulation with the education of nurses for comprehensive care.

METHOD

The method consisted of qualitative field research in the municipality of Fortaleza, capital city of the State of Ceará, Brazil, from April to June 2012. A total of 20 registered nurses who also worked as preceptors at three - two public and one private - higher education institutions were interviewed for the study. Research locations were three public state hospitals and a basic health unit, all of which are practice fields of the referred nursing programmes.

As inclusion criteria, minimal experience of one year as preceptor was considered. Criteria for exclusion were nurses that worked in units that did not include the practice fields of supervised internship of the higher education institutions and nurses who were absent from service during the data collection period, whether due to leave or holidays.

The sampling process was intentional and initially consisted of two nurses per field. Participants were two primary care nurses, two nurses from a neonatal intensive care unit (ICU), one from rooming-in, one from a paediatric nursing unit, eight from an adult nursing unit and six from an adult ICU. Criterion adopted for data collection close-out was further theoretical and empirical analysis of data and relevance to the objective of this study.

The semi-structured interview was a fundamental technique for the obtainment of data. These interviews are based on conversations between two individuals or between several speakers conducted by an interviewer in order to obtain pertinent information according to the object of the study on equally pertinent topics, within the scope of this objective ⁽⁹⁾.

The following guiding questions were created for preceptors to be immersed in the theme: address the preceptorship process; how do you achieve the articulation between theory and practice in the internship fields of the nursing programmes? What are the teaching-learning strategies that you use in the educational process of nursing students on duty?

Data underwent thematic analysis, which consists of discovering the core meanings that compose communication and their presence or frequency and relevance to the chosen analytic object ⁽¹⁰⁾.

Analysis comprised four stages: pre-analysis, exploration of material, treatment of obtained results and interpretation^{( 10 )}. Empirical material was subsequently subject to skimming and vertical reading. Record and context units were identified by forming the research focus that, once categorized, provided an outline of preceptorship in the practice field from the viewpoint of the investigated nurses. Horizontal reading of composite material allowed further interpretation of statements and more extensive analysis.

The scope of understanding the core meaning provided four categories, after a process of coding, interpreting and inference on manifested latent content. Statements transmitted and apprehended by the preceptor were analysed according to pertinent literature on the subject. The study is based on the research "Processo de formação em saúde como estratégia de melhoria do cuidado interdisciplinar e integral do SUS" ("The healthcare education process as an improvement strategy of interdisciplinary and comprehensive care of the SUS") approved by the Research Ethics Committee of the State University of Ceará, process number 14061052-2, and financed by the National Council for Scientific and Technological Development (CNPq). The terms of Resolution 466/2012 that governs research with humans were observed^{( 11 )}. To protect the identities of the nurses, they were classified with the letter "E" followed by a point, Arabic numeral, point and care level (H-hospital and AB-primary care).

RESULTS AND DISCUSSION

Thematic analysis allowed an understanding of the topic Preceptorship in the perspective of comprehensive care, composed by the following empirical categories: (dis)articulation in the teaching-service: distancing from academic institutions; welcoming students in the practice field. On the field, routine teaches: articulation in teaching-service from the preceptor's perspective.

Teacher-institution-user relations in teaching-service integration revealed aspects on how healthcare education occurs and an understanding of the articulated context according to proposals presented by the SUS.

(Dis)integration of the teaching-service: distancing from academic institutions

Relationships established between the actors of the practice fields, students, professionals and community, support integration ⁽¹²⁾, and when positive, they intensify critical and reflexive growth of the student and target comprehensiveness of healthcare actions and services ⁽¹³⁾. However, the preceptors did not clearly understand the processes that legitimize the stages, such as objectives and educational content:

[...] I don't know how it is done [...]I think it is previously established (E.19.H).

[...] the hospital, has an agreement with the universities. (E.5.H)

To understand the objectives of the SUS, the preceptor must appropriate the processes that precede teaching-service integration, which surpasses the more passive position of higher education institutions. For supervised internship to effectively be a professional practice within the context of education, it needs interaction that can lead to transformations in the arenas of education and work, narrowing the gap between educational institutions and healthcare services ⁽⁸⁾.

Understanding the SUS is a historical tangle of several viewpoints that originate from the social classes, as the sanitary reform is an active movement of vindications for care in health^{( 14 )}. In the perspective of extended clinical care, teaching-service integration carries forward proposals of the SUS, reinforcing and enabling critical awareness on the right to healthcare. However, preceptors encountered problems in understanding the proposal of nursing education in this context:

[...] we don't even know what the professor wants us to cover with the student [...] because she does not tell us. (E.5. H)

[...] I don't know how the student should be educated or which is the profile that the SUS professes for this professional that will be launched into the market, nor do I know the main objective of the university in relation to the student. (E.4.H)

Nurses must take possession of the content established in the laws of the SUS from a critical and transforming standpoint, considering that the democratization of healthcare is a collective interest. Restricted by the know-how and demands of the services, professionals focus on care and remain at the margins of discussions on comprehensiveness. In order to involve them in the aspects of teaching-service integration, the aims of education must be transparent. Schools must more extensively seek the participation of actors of several healthcare and education sectors for their programmes ⁽⁸⁾.

The articulation between education and healthcare is a challenge, consisting in creating and providing interfaces between the different fields of knowledge and powers and generating opportunities for increased disciplinary dialogue, methodological alternatives that target the renewal of healthcare knowledge and practice^{( 6 )}.

The Educational Programme for Healthcare Work (PET-Saúde) provides scholarships for tutors, preceptors (service professionals) and undergraduate students in the fields of healthcare as one of the intersectoral work actions for education ⁽¹⁵⁾. Although this was only detected in primary education, these measures suggest a transposition of formalities that limit relations between service and academic institutions.

Welcoming students in the practice field

The preceptorship experience revealed ambivalence. In general, preceptors did not feel responsible for students and did not know that their participation in the educational process was ensured by the National Curriculum Guidelines of the Nursing Undergraduate Programme:

[...] I really supervise them [...] as if it were courtesy. (E.3.H)

[...] that's how it is, it's like I already had that obligation, because we are nurses, of teaching! Because the hospital is a hospital school! (E.10.H)

For preceptors, nursing education on the field accumulates the commitment and responsibility of constructing knowledge when delegating, under their supervision, specialized care paired with humanization. Healthcare services demand from the preceptor attention, readiness, resoluteness and the capacity to solve problems. Preceptors exposed their feelings in the context of these adversities, which corroborates another study ⁽¹⁶⁾.

Teaching-service integration is based on the partnership between the university, local healthcare services and the community, and it is founded on the transformation processes of professional education and healthcare systems, given that actors of this scenario establish bilateral relationships among themselves that are expressed by teaching-healthcare integration (university-service), by university outreach (university-community) and by primary care (services-community)^{( 17 )}.

On the other hand, all students were well-received on the field. Anchored by their own experiences, good or bad, preceptors sought to welcome all students. Previously experienced negative feelings promote thought on their attitudes in order to avoid reliving moments that caused suffering:

[...] everyone goes through this period [...]no one refuses to help students, we are always very eager to teach. (E.7.H)

[...] I try to use my past experiences, I have to use what I did not get when I was also a student here [...]the attention that I would have liked to receive, the openness that I would have liked, but did not get, I try to receive them differently to how I was received, something that I thought was very important at the time, I was apprehensive, I was afraid of a lot of things and today, when I see a student in the same situation, it's like I'm seeing myself [...] (E.19.H)

Welcoming is defined as the act or effect of welcoming and approaching, a "being with" and a "being near", that is, the attitude of inclusion that entails relating to something or someone ⁽¹⁸⁾. By welcoming students with readiness and attention, nurses help students feel part of the care process.

Routine teaches

The provision of care supports intellectual and cognitive competency for the work market. The dynamics of service invites students to participate in the context and teaches them how to proceed in situations experienced by nurses:

[...] as I am not the official teacher, they have to adapt to the service of the day, to the daily agenda. (E.1.AB)

[...] I try to show them the service routine (E.4.H)

Although the role of facilitator seems clear to nurses, preceptors are faced with assignments that were not previously part of their daily work and for which they do not feel prepared^{( 8 )}. The preceptors reported an absence of training for teaching and the gap between service objectives, that target care based on know-how, and the objectives of the academic institutions, namely the provision of care. In light of the difficulties found, professionals act in the manner in which they experienced their teaching-learning process^{( 6 )}.

Activities conducted by the nurses shows the reality of an educational process, in which approximation with the promotion of healthcare has been sought. The know-how based on the handling and dexterity of situations and techniques are fundamental qualities of the healthcare professional. However, their articulation with human subjectivity helps to overcome biologicism and cure-oriented care. Some preceptors mentioned comprehensiveness and humanization in their decision-making process and the provision of care:

[...] We have that first contact with patients [...]that first thought of talking to them, of asking them how they slept, what they felt, if they are feeling alright, and we realize when patients are anxious, when they are this or that, if you know what I mean. They reveal all this to us. [...] we already see each patient as a whole. (E.7.H)

[...] As we work with paediatrics, it is impossible not to deal with patients as a whole. [...] We have to deal with the psychology of the mother, who is emotionally shaken [...]so we end up dealing with everything. [...] (E.9.H)

Statements showed that care is the objective of the nurses' work, represented by attitudes, such as listening and observation, both of which are fundamental to direct systematized nursing actions. Consequently, nursing actions approach comprehensiveness, which provides an important role to professionals in the context of the Sanitary Reform that is still in progress, as being close to users can change the way in which healthcare is provided.

Teaching-service integration from the preceptor's perspective

Preceptors considered the field as an extension of the classroom to form a critical and reflexive subject. Availability of students to absorb the manifestations of the subjectivities of daily work indicated a richness of teaching-service integration:

[...] You change your viewpoint just by leaving the campus, by leaving the classroom, to come to a hospital unit, to see the reality of it all. (E.6.H)

[...] The dissociation of theory and practice. [...] they get a chance to see the difference. (E.2.AB)

In general, the practice fields suffered with the precariousness and revealed to students the work situation they will have to face when they graduate. The development of unique techniques due to the scarcity of supplies or observed inadequate conduct of other professionals in situations that result from professional disqualification can influence students ⁽¹⁹⁾.

The exercise of creativity and the capacity to tackle non-conformities, forging solutions that are distant from the theoretical method, may be experienced by actors of the field. These new ways of acting can compromise the educational process, create losses for users and break the required rigidness for the provision of care.

Discontinued content between academic institutions and the practice scenario were also mentioned by preceptors as a cause for concern, which complements the previous discussion, considering that would cause a disagreement between discipline proposals and field possibilities:

[...] when I was a student [...]we would see one thing in theory that did not always exist in practice! [...]It was something different, theory was not associated to practice. (E.3.H)

In the perspective of nurses, to work based on the philosophy of the SUS is still far removed from reality. The demands of their professional practice stimulates proceduralist efforts to meet needs and distances them from providing comprehensive care. Statements showed that the principle of comprehensiveness has been neglected and that education that focuses on the new system would not be possible, which means that education and teaching-service integration have become discredited, leading to hegemonic ways of providing healthcare.

[...]We don't see comprehensive care, many times the nurse does not care, doesn't even know what comprehensive care is, inside the healthcare system. (E.4.H)

[...] I don't think professionals are qualified to work in the SUS, [...] I think the university does not prepare us, it offers a path for you to follow, and you choose how you will follow it after that. (E.14.H)

The preceptors considered that humanization is inherent to personality, either from the school, teacher or preceptor, and nursing care was associated to the responsibility of the professional. The statements illustrated their perception on humanization:

[...]the issue of humanization yes, and that depends, also, on the professional that will accompany that student. (E.14.H)

[...] I think that a university [...] Is very responsible for the education of professionals, but I truly believe that the part of humanization, that part... It's like... Personal, depending on the character of each person, do you know what I mean? (E.19)

The meaning of being a committed professional implies taking a stand that involves a decision of the subject/social actor and occurs at the level of actions⁽²⁰⁾. In fact, nursing education is governed by moral and ethical principles on which the action of nurses should be based. Consequently, in academic institutions and services, during undergraduate studies, the first concepts of care require some discussion so that these values can remain in the profile of the professional.

The internship environment allows students to be part of the SUS project and helps them to experience real situations and interact with the environment. The modern proposal of care established in the promotion of healthcare and comprehensiveness should be fomented at undergraduate level so that knowledge in healthcare can emerge from the needs of users as a way of transforming care. Considering the participation of nurses and teachers as educators, their worlds must draw close in the context of teaching-service integration for education and the application of SUS among healthcare professionals.

FINAL CONSIDERATIONS

Discussions on professional education are extensive and always current. This study revealed a part of the way in which education occurs in the perspective of comprehensive care. It showed the fragility of the relationship between that which is professed at the higher education institutions and that which is effectively experienced in practice.

Given the scarcity of integration between preceptors, the professional profile coveted by higher education institutions no longer prevails due to empiricism or even vices of the practice. The presence of students on the field represents a living link between service and academic institutions, a guarantee of the re-signification of knowledge and (re)construction of conducts that comply with the demands of users.

Study limitations were the non-inclusion of other national states, which has repercussions on the context of healthcare services. This suggests the conduction of further research on the topic and collective debates, involving professors, educational institutions and preceptors, that target nursing education in the perspective of comprehensive care.

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Publication Dates

• Publication in this collection
  June 2014

History

• Received
  01 Dec 2013
• Accepted
  02 Apr 2014