Nursing preceptorship: challenges and strategies to strengthen teaching-management-care-social control integration

Abstract

Objective  to characterize the teaching-learning challenges of undergraduate students in the Supervised Curricular Nursing Internship and the strategies proposed for the integration of teaching-management-care-social control in the perception of preceptors and supervising professors.

Method  qualitative study through Appreciative Inquiry, carried out in 2023, in a nursing course. Twelve preceptors and two supervising professors participated. Data were collected in two meetings and audio-recorded. The phases of the 4D cycle were used as a strategy: Discovery, Dream, Design, and Destiny. The material was analyzed from the perspective of teaching-management-care-social control integration and competencies required in nursing education.

Results  the main challenges lie in monitoring interns, practices that are more assistance-oriented rather than focused on prevention/promotion, little pedagogical support, and distancing from the skills profile. In terms of contributory aspects, there are reports of interprofessional work, but with limitations. Participants developed nine improvement strategies to guide the development of the required competencies, which require changes in the educational institution and the preceptor’s practice.

Conclusion and implications for practice  the study’s findings reveal the need for a significant review of supervision methods and pedagogical support, a balance between immediate care and preventive actions, and alignment of the competencies expected in supervised practice. The proposed improvement strategies aim to qualify preceptorship to strengthen nursing education.

Keywords:
Nursing Education; Nursing; Higher Education Policy; Preceptorship; Unified Health System

Resumo

Objetivo  caracterizar os desafios de ensino-aprendizagem de graduandos no Estágio Curricular Supervisionado de enfermagem e as estratégias propostas para a integração ensino-gestão-atenção-controle social na percepção de preceptores e professores supervisores.

Método  estudo qualitativo por meio da Pesquisa Apreciativa, realizado em 2023, em um curso de enfermagem. Participaram doze preceptores e dois professores supervisores. Dados coletados em dois encontros audiogravados; foram utilizadas como estratégia as fases do ciclo 4D: Descoberta, Sonho, Planejamento e Destino. Material analisado na perspectiva da integração ensino-gestão-atenção-controle social e competências requeridas na formação de enfermeiros.

Resultados  os principais desafios estão no acompanhamento do estagiário, na prática mais assistencialista do que prevenção/promoção, pouco apoio pedagógico e distanciamento do perfil de competências. Nos aspectos contributivos existe relato de trabalho interprofissional, porém com limitações. Participantes elaboraram nove estratégias de melhoria para orientar o desenvolvimento das competências requeridas, mas que exigem transformações na instituição de ensino e na prática do preceptor.

Conclusão e implicações para prática  revelam necessidade de revisão significativa nos métodos de supervisão e apoio pedagógico, do equilíbrio entre cuidados imediatos e ações preventivas e alinhamento das competências esperadas na prática supervisionada. As estratégias de melhoria propostas visam qualificar a preceptoria com vistas ao fortalecimento da formação em enfermagem.

Palavras-chave:
Educação em Enfermagem; Enfermagem; Política de Educação Superior; Preceptoria; Sistema Único de Saúde

Resumen

Objetivo  caracterizar los desafíos de enseñanza-aprendizaje enfrentados por los estudiantes universitarios en la Pasantía Curricular Supervisada de Enfermería y las estrategias propuestas para integrar la enseñanza-gestión-cuidado-control social en la percepción de los preceptores y profesores supervisores.

Método  Estudio cualitativo utilizando la Indagación Apreciativa, realizado en 2023 en un curso de enfermería. Participaron doce preceptores y dos profesores supervisores. Los datos se recogieron en dos reuniones grabadas en audio. Se utilizaron como estrategia las fases del ciclo 4D: Descubrimiento, Sueño, Diseño y Destino. El material fue analizado desde la perspectiva de la integración de la enseñanza-gestión-cuidados-control social y las competencias requeridas en la formación de enfermería.

Resultados  los principales retos están en el seguimiento de los pasantes, en ejercer más un papel asistencial que de prevención/promoción, con poco apoyo pedagógico y lejos del perfil de competencias. En cuanto a los aspectos contributivos, hay informes de trabajo interprofesional, pero con limitaciones. Los participantes propusieron nueve estrategias de mejora para orientar el desarrollo de las competencias requeridas, pero éstas requieren cambios en la institución docente y en la práctica del preceptor.

Conclusión e implicaciones para la práctica  los resultados del estudio revelan la necesidad de una revisión significativa de los métodos de supervisión y del apoyo pedagógico, un equilibrio entre los cuidados inmediatos y las acciones preventivas, y la adecuación de las competencias esperadas en la práctica supervisada. Las estrategias de mejora propuestas tienen como objetivo cualificar la preceptoría con vistas a reforzar la formación en enfermería.

Palabras clave:
Educación en Enfermería; Enfermería; Política de Educación Superior; Preceptoría; Sistema Único de Salud

INTRODUCTION

In Brazil, services for integrating teaching and care have been considered the space for sharing the work process between professionals, users, and managers of the health system, and professors and students of higher education institutions (HEIs). These services strengthen the actions of the Brazilian Unified Health System (SUS), in terms of integrating teaching, care, management, and social control, and constitute a higher education policy.¹ The proposal to think based on this integration has become a conceptual framework called the “four-way approach to training in the health field,” with the aim of directing and proposing the organization of educational processes in training environments while supporting a particularly Brazilian composition, through the proposal of meaningful learning of pedagogical components that activate and control the training process.²

The guidelines of nursing education policy in Brazilian HEIs have sparked reflections that have signaled challenges in achieving the guidelines of the National Curriculum Guidelines (DCNs), especially with regard to the alignment of curricula, the inclusion of students in the practice scenario, and the problematization of the profession's social action in different practical learning scenarios.³-⁵

The training of professional nurses is expected to significantly contribute to the SUS, since its services occupy a central place as a field of practice and internships during training.⁶,⁷ Given the above, it is understood that the approach from the perspective of teaching-care-management-social control integration at the SUS enhances the experience of its principles and guidelines and relates factors that are intrinsic to the health-disease process through the development of teamwork skills,⁸ thus creating a purposeful environment of social contribution in professional training, while at the same time raising responsibility for this teaching environment.

The moment of practice that brings students closest to reality, given the completion of the teaching course load in the health service, is the Supervised Curricular Internship (ECS, as per its acronym in Portuguese), which is responsible for effectively providing professional practice. The ECS requires intense interaction between the training institution and the health services, to align teaching-learning strategies and the skills to be provided during ECS.⁵ In this learning space, the figure of the preceptor has been considered strategic in the training process, in terms of integration and qualification through teaching-learning methods that collaborate with ongoing education processes.¹

Preceptorship, an essential movement in the learning process that can coordinate this strategy that strengthens training and the development of student autonomy, can be understood as an attempt to overcome the difficulties in correlating theoretical content with practical applicability.⁹,¹⁰

There is a need to invest in education and training programs for nursing preceptors, especially to develop their skills in the teaching-learning process.¹¹ It is worth emphasizing that training processes with preceptors are an opportunity to take advantage of the strengths of their professional experiences and improve skills by aligning learning objectives to integrate essential attributes in the training of nurses, in terms of management and health care, in addition to being a space for exchanging experiences and bringing the teaching institution closer together.¹²,¹³

In view of the above, in the absence of a participatory analysis by the actors involved in preceptorship of this scenario, and indicators for monitoring and evaluating the strategy with its impact on investment as a teaching-learning proposal, the following questions arose: What are the challenges of teaching-learning in the ECS, according to the preceptors and supervising professors? What strategies contribute to guiding the integration of teaching-care-management-social control, as perceived by the preceptors and supervising professors? Thus, the aim of this study was to characterize the teaching-learning challenges faced by undergraduates in the Supervised Nursing Curricular Internship and the strategies proposed for integrating teaching-management-care-social control in the perception of preceptors and supervising professors. The study’s contributions aim to qualify preceptorship to strengthen nursing education.

METHOD

This is a qualitative, descriptive-exploratory study, using the Consolidated Criteria for Reporting Qualitative Research (COREQ) instrument to guide the methodology. It was carried out in a nursing course at a public HEI in the state of Mato Grosso, which has a biannual offer for new students, being the only health course at a public institution in the region and, since 2019, has used preceptorship to ensure greater teaching-service integration and carry out the ECS. The municipality where the course operates has stood out for its teaching-care-management coordination,¹⁴ in addition to the expansion of primary care and reorganization of the healthcare network with institutional support from the teaching field.¹⁵

The study sample was intentional, and the participants were preceptors of undergraduate nursing students and supervising professors who were linked to the ECS subjects. The following inclusion criteria were adopted: being a nurse preceptor or supervisor and having supervised undergraduate nursing interns for at least one year. Based on the criteria adopted, seventeen possible participants were listed, with those who were away during the period of the meetings being disregarded.

The study was developed based on Appreciative Inquiry (AI).¹⁶ This methodology is based on action research, organizational change, and innovation to capture the practices employed by the actors through action guided by respect and dialogue, in an analysis of their engagement and participation in the process, with the opportunity to critically reflect on the aspects involved, and possible suggestions for improvement.¹⁶ The four phases of the 4D cycle were followed: Discovery, Dream, Design, and Destiny.¹⁷

The research took place in the second half of 2023, organized in two meetings, conducted by two researchers with expertise in the type of collection and an auxiliary researcher responsible for the recording equipment, time control, and recording summaries of each stage of the dialogue. The researchers were linked to the HEI under study and held doctoral degrees. Each meeting lasted approximately four hours and was held on the premises of the HEI.

The 4D cycle was used to guide data collection, and it was chosen because of the strategy that encourages the participation of those involved. In addition to engagement,¹⁷ it offers a field for critical analysis that allows for the proposition of improvements.¹⁶ The methodology is based on action research, organizational change, and innovation to capture the practices employed by the actors through action guided by respect and dialogue, in an analysis of their engagement and participation in the process, with the opportunity to critically reflect on the aspects involved, and the possibility of suggesting improvements.

In the first meeting, guided by the Discovery phase, a diagnostic assessment was carried out, led by two triggering questions asking people to report on the aspects that needed to be improved in the relationship between the HEI and the preceptor in the context of preceptorship. Afterward, a brainstorming session was held to trigger reflection on the Discovery and Dream phases. In the second meeting, the Dream phase was resumed, using the method's participatory strategy, and the Design and Destiny phases were conducted. At this meeting, the participants were given cards and pens to record their proposals on a wall. At the end of each moment, the researcher read out the proposals, which were debated and organized into converging nuclei. The group then reached a consensus on the proposal through a single wording encompassing all the opinions, thus finalizing a set of actions. At the end of the second meeting, the document containing the Dream, Design, and Destiny phases was presented to the participants so that they could express their agreement.

The material was separated into two folders, one containing the structure of the cycle and the other the audio-recorded material from the two meetings. The audio-recorded material was transcribed in full by two research advisors and checked by the researcher in charge and an assistant. This material records the contributions of each participant in the meetings during the 4D cycle phases, which made it possible to analyze the participants’ perceptions. Data were interpreted using thematic analysis, which identifies, analyzes, and reports on the patterns (themes) within the data, organizes and describes its data set in detail - which, through its theoretical freedom, provides a useful and flexible research tool that can potentially provide a rich, detailed, and complex account.¹⁸

The theoretical framework for analyzing the data was the teaching-care-management-social control integration, and the four dimensions of the four-way approach led the analysis and immersion for each category and subcategories.² The data collection strategy, based on the 4D cycle, made it possible to analyze the different fronts on which preceptors and professors work in the health system, with an emphasis on the Discovery, Dream, and Design phases.

The categories were previously divided into the dimensions of the four-way approach. Within each dimension, subcategories were sought, thus resulting in the presentation with the following subcategories for Teaching: Little pedagogical support, Devaluation of planning, and Low feeling of belonging to the teaching staff. For Care, the subcategories were Work overload, Focus on the amount of care produced, Little use of interprofessional work, and Inadequate physical space for learning processes. For Management, the subcategories were: Little discussion of health system management and Emergency care to the detriment of management. For Social Control, the category was Introspective movement in participation and social control.

After submitting the material, the four-way analysis used the competencies listed in the National Curriculum Guidelines¹⁹ to identify possible inferences from the study that indicate aspects that weaken their achievement in order to guide further research into the teaching-preceptorship relationship.

The study respected the ethical aspects regulated by the National Health Council, which integrates the results of the research approved by the Research Ethics Committee under CAAE: 70179523.8.0000.5166. The participants were ensured information, the possibility of participating/leaving the research, anonymity in the processing of the data obtained, and all ethical aspects were respected, including the signing of an informed consent form.

RESULTS

Of the 17 possible participants, 14 nurses took part in the research, 12 of whom were preceptors and two professors who supervised the ECS. The absence of three nurses was justified by their non-attendance at meetings. Most preceptors were female, 10 (83.4%), and 8 (66.7%) had more than three years of experience in preceptorship. They worked in primary health care, 7 (58.4%), health surveillance, 1 (8.3%), and hospital care, 4 (33.3%).

Chart 1 presents a diagnostic evaluation, which was drawn up through the meetings guided by the phases of the 4D cycle with the participants and analyzed using the framework of Ceccim and Feuerwerker.²

Chart 1
Categories and subcategories with the main strata that highlight the analysis of the key aspects that need to be improved in the teaching-service integration environment, Mato Grosso, 2023.

CATEGORY: TEACHING
Subcategory: Little pedagogical support
Main speech strata of key informants
“I don't know the pedagogical project of the course”.
“The courses are very specific and there's no follow-up to present the teaching pedagogy.”
“I do my routine directly with them, but I don't know how to problematize my work and think about whether I'm following what they should be learning.”
“I feel very insecure about making that assessment, because I can't offer everything there, or it's not a priority during the time they're going to be there.”
“For the assessment tool, we needed to review it, let people participate in drawing it up, have a reality that is closer to what we offer and what we do.”
“Our communication takes place mostly in two meetings we have, one at the beginning of the semester and one at the end, then it's with the supervisor, but I don't feel this attitude of having to be together with them.”
“There are things I learn more about from the students than from the institution.”
“There's no guide, no document that says what I, as the preceptor, need to do as this student's professor, there's the teaching plan, but it doesn't detail my role and what method I can use.”
Subcategory: Devaluation of planning
Main speech strata of key informants
“They do the planning to start the internship, but it's more theirs than ours, because it's their responsibility to hand it in to the professor.”
“I think there needs to be more focus on planning, every semester it's something different, it's not integrated, it's done and not continued.”
”The interns sometimes focus on problems they're not going to solve. It becomes more about fulfilling what the subject asked for.”
“They [the interns] don't just work on the planning, and then when the due date comes, they say they need to stop doing some activity to fulfill the planning.”
“The interns come in with difficulty in doing the SNC [Systematization of Nursing Care] and we also have this difficulty, in the services it is not yet a guideline for nurses' work.”
“Not all services have a nursing process, some buy into the idea, others don't.”
Subcategory: Low feeling of belonging to the teaching staff
Main speech strata of key informants
“We participate more among ourselves in meetings, I don't remember ever having a meeting with all the professors.”
“Our schedules are different, we don't have protected time to be here at the university, but we signed an agreement that our bosses have to give us time off for pedagogical activities, but I don't see this as the focus. It's more to train for something or to align the activity at the start of the semester.”
“I've been asked to come during nursing week to teach a mini-course, or a class, but there's no integration with us. There could be, but there isn't”.
“At no time have I participated in a joint meeting with the course teachers since I've been here, and I'm from the first class that started with preceptorship.”
“It seems to me that the internship is separate from the practical classes, sometimes I can even receive practical classes in my unit, but there's no interaction with the service, and I have an intern from the university there.”
CATEGORY: CARE
Subcategory: Work overload
Main speech strata of key informants
“During the pandemic and after it, it seems that our job has been to do and do, always with lots of problems and the focus is on providing care, providing care, and providing care, for other things it hasn't been a priority.”
“The service has grown in the hospital, there's a lot of opportunity, but as there are only a few of us, we have to deal more with direct care to cope with the demand.”
“We don't always have time to hold meetings, sit down, and analyze a case, reflect on what happened and interact in the proposal to check the literature on the subject, because the service is full of patients to attend to.”
“I have a busy schedule, I don't have time to teach, there are so many people to look after with immense vulnerability.”
“Sometimes I don't give as much attention as I'd like, the agenda is full and you can't do it, plus the interns need more time to make an appointment, a procedure, this is a challenge so as not to generate too much delay, sometimes I go ahead with an emergency.”
“There had to be a way to include preceptorship in our workload, to recognize this time, even to protect these moments with the students and also to qualify ourselves.”
Subcategory: Focus on the amount of care produced
Main speech strata of key informants
“Management has prioritized numbers, so we've been working on indicators.”
“The focus is on the indicator, you have to meet the indicator, so as not to hinder the transfer.”
“There's the fact of prioritizing some kind of indicator, but you also have to see that the basic health unit has become more of an assistance service, an emergency service, than what was really proposed for it.”
“The interns end up taking on this routine of working to the numbers and often what they planned to do doesn't succeed”.
“In fact, the unit that has a preceptorship doesn't follow an agenda geared towards it, the demands are the same, so they help with the quantity of things we have to do.”
Subcategory: Inadequate physical space for learning processes
Main speech strata of key informants
“The unit doesn't have room for many interns, I get three and I think that's too many.”
“It's important to bear in mind that none of the municipality's services were thought of as a school space, not even in the renovations. There are a lot of educational institutions that use these services, and when you add several of them together, the space gets bad and even compromises teaching.”
“We don't have space to discuss cases with the teams, in the basic unit they have a meeting room, but not in our case [hospital]. We improvise in the clinic, or somewhere else that's available.”
“In some, there's an auditorium, but it's not even a space for students to stay and study, they even find it difficult to keep their belongings, because there's no space for interns.”
Subcategory: Little use of interprofessional work
Main speech strata of key informants
“They arrive and haven't been taught how to work as a team, and I see that we don't have this teaching focus either.”
“There are opportunities that can be worked on from an interprofessional perspective, but the opportunities aren't always taken, it's more limited to our action than theirs.”
“Some professionals comment that they are my interns, so I have to teach them, and they don't involve them in joint care.”
“They should have a moment before their internship that makes them think about interprofessional care, this experience, so that when they arrive, they recognize it and know how they can help.”
CATEGORY: MANAGEMENT
Subcategory: Little discussion of health system management
Main speech strata of key informants
“There isn't that moment when we sit down and reflect like a case analysis, studying the path the user has taken and their problems, pointing out how the regulation of that case happens and how public policy should be provided, they learn if they want to do this on a daily basis, some are willing, others don't even recognize this possibility.”
“I don't focus on management, because their internship is in the unit to experience my routine, and it's really been more care-oriented.”
Subcategoria: Emergency care to the detriment of management
Main speech strata of key informants
“They come in wanting to do the procedure, since it's their last year, so they focus on that.”
“Many don't like management, they say they don't want to do it, so we leave it more to their planning.”
“There's a lot of demand for the services, so it ends up being more about providing care, especially as there aren't enough professionals to do just that, so between doing both things, the priority is the user who has arrived.”
CATEGORY: SOCIAL CONTROL
Subcategory: Introspective movement in participation and social control
Main speech strata of key informants
“They participate in municipal conferences”.
“I don't see a strong commitment on the part of the course to the SUS, to defending the SUS. I don't see it, I don't feel it strongly, one professor or another, but the course doesn't have this position and, consequently, these students, they criticize this system that doesn't recognize what they do.”

In the Teaching category: Little pedagogical support - aspects of monitoring and offering training or specialization courses in the area were related to the low level of support for pedagogical issues. Devaluation of planning - especially with regard to the continuity of actions when changing classes from one semester to the next, which were cited as limiting factors for the performance of the preceptorship. A low feeling of belonging to the teaching staff - aggravates the integration relationship, given the verbalized position of these preceptors that they do not feel part of the training process, even though they participate in an essential moment in the development of future nursing professionals.

In the Care category: Work overload - the dynamics of the nursing work process in health services, with considerable overload in the care, management, and preceptor functions. Focus on the amount of care produced - motivated by the focus of care on the healthcare dimension and duplication of functions in management, measured more by the quantitative action of the work. Little use of interprofessional work - this has an influence on the spaces that could be used by the preceptor to reflect with the student, which ends up being a more care-oriented action than a reflective one. Interprofessional work is not strengthened due to the routine of the services and the very culture of reducing these spaces, given the expansion of the more care-oriented response, especially in primary health care. Inadequate physical space for learning processes - participants highlighted that the physical structures of the services, for the most part, are not adapted to the reality of teaching environments, becoming a limiting factor for sharing moments of direct action in care, case discussion meetings, and feedback.

In the Management category: Little discussion of health system management - the spaces that could be used to reflect on management tools and their role in the health system are reduced, since the focus has been on practices aimed at providing care. Emergency care to the detriment of management - the framework of care management was not mentioned, and the systematization of nursing care was not uniformly established in the health services or in the practice of preceptor nurses, which has repercussions on the training process of future nursing professionals.

In the Social Control category: Introspective movement in participation and social control - very limited mention was made of meeting spaces and participation in conferences, but there was no evidence of an expanded, leading role in working in the territory and with the community, with a view to the social responsibility of training in defense of the SUS. The participants did not discuss or mention the understanding and experience of the health council.

The set of aspects not covered in the preceptors’ and supervising professors’ statements, shown in Chart 2, supports the need for investigation on the part of the actors who think about the training process, especially in aspects considered elementary for professional practice in nursing. It should be noted that planning, which is essential for aligning teaching-care-management-social control integration, will need to be concerned with a coordinated proposal for the short, medium, and long term, in order to translate responses that qualify the work process, while inserting students into a plan that makes sense in the integration agreement process.

Chart 2
Analytical aspects not mentioned that may interfere with the achievement of the competencies required in the training of nurses during the ECS, Mato Grosso, 2023.

Competencies	Main analytical aspects from the material collected
Health care	- There is no strong evidence in the speeches of action for prevention and promotion.
	- Students’ difficulties in taking a comprehensive approach, in consultations, and in planning actions.
	- There was no evidence of making interns understand the regulation of care in the health system, through experience in analyzing access problems and possible solutions.
	- There was no evidence of discussion or use of high-quality standards to support practice.
	- There was no mention of discussion in the work process about the principles of ethics/bioethics.
Decision-making	- There was no mention of a discussion on efficacy and cost-effectiveness.
	- Although the workforce is mentioned in the preceptors' analysis more in terms of overload, there is no evidence of interns practicing sizing in order to manage care.
	- It cannot be said that there is a discussion on resources, from the perspective of understanding logistics.
Communication	- It is difficult for both preceptors and students to search for evidence in foreign language material.
Leadership	- It is not clear how preceptors work on leadership and prepare interns to lead the nursing and multi-professional teams.
	- There is no evidence in the strata of the speeches that interns are capable of assuming leadership positions.
Administration and management	- It can be seen that the actions of the preceptors exemplify the management and administration of the workforce, physical and material resources, and information, but it is not possible to say that the interns are able to carry out this function in all the internship fields.
Permanent education	- There are reports of more specific training for a particular subject, rather than a systematic plan that supports the continuing education project. Permanent education is not even a strategy applied in the course, as far as the training of these preceptors is concerned.

Chart 3 shows the actions drawn up during the two meetings with the participants using the phases of the 4D cycle. As observed and based on the dream, the group established a design that guides the destiny of actions for teaching management. Thus, it is hoped that it will be possible to make the projection of change feasible, given that all the actions are under the governance of the actors involved in the process.

Chart 3
Actions designed by preceptors and supervisors to strengthen the preceptorship activity in a municipality in the mid-northern region of Mato Grosso state.

DREAM	DESIGN	DESTINY
Expanding cooperation between service and university through the design tool.	- Drawing up a cooperation agreement to expand teaching, research, and extension activities with the Municipal Health Department, private hospitals with SUS agreements and other services within the course's field of practice and internship.	- Signing a cooperation agreement with the institutions.
		- Drawing up a teaching, research, and extension demand form for each institution participating in the preceptorship.
		- Holding a meeting through a forum to validate the lines of teaching, research, and extension.
		- Opening calls for proposals every six months in partnership with health services.
	- Designing lines of research and extension to develop thematic projects.
		- Agreeing at the beginning of the semester on the work agenda in conjunction with the lines of research and extension, which should be included in the duration of the preceptorship grant.
	- Encouraging non-compulsory extracurricular internships during vacation periods.
		- Holding discussion circles with health service leaders/managers to share their experiences in health service management.
Quantifying the benefits of preceptorship in relation to users and health services.	- Promoting exchanges of experiences between academics and health services and users.	- Every six months, holding the Teaching-Service Integration Meeting open to the academic community, ensuring that the 8th phase is part of the event’s program.
	- Aligning spaces for researching the impact of preceptorship and defining indicators.
		- Holding an annual showcase with the submission of a report at a Teaching-Service-Management-Community Integration Meeting.
	- Integration of preceptors in meetings to evaluate and monitor teaching and learning and the profile of graduates.
		- Integrating the preceptors in the closing and integration meeting of the phase to which the ECS will go.
		- Ensuring that the work plan is a prerequisite for completing the grade and that it gives rise to a summary of the experience.
	- Suggesting that each student, or pair, write a summary as an experience report, together with the professor and preceptor, on the activity carried out during the period.
		- Creating a research project to analyze preceptorship and teaching-service-management-community integration.
		- Integrate the preceptor into research and extension groups.
		- Jointly defining parameters for creating a list of monitoring and evaluation indicators.
Enhancing students’ commitment to clinical reasoning capable of thinking of solutions to evidence-based problems.	- Investing in implementing the stages of the Nursing Process in health services.	- Developing an integrated project between the higher education institution and the service to strengthen the nursing process and the systematization of nursing care in health services.
	- Strengthening nursing consultations.
		- Choosing groups at a greater risk to implement nursing process actions.
	- Developing case studies during the preceptorship that monitor the student's scientific search in the presentation of the case.
		- Applying at least one individual case study during the preceptorship, assessed as part of the procedural grade.
		- Providing periodic guidance on the cases experienced in the service, focusing on clinical reasoning.
	- Mentoring by the professor responsible for the preceptorship and the preceptor in the discussion of clinical reasoning.
	- Providing students with the opportunity to experience the Systematization of Nursing Care.
Students as protagonists of their teaching-learning process.	- Ensuring spaces for students to work and be welcomed into the role of nurses in the health service.	- Establishing visits prior to entering the internship with guidance on the expected competencies for performance.
Preceptorship specialization	- Ensuring that the course is offered by the educational institution.	- Offering the course.
Development of the assessment tool in conjunction with preceptors, so that they are more involved in planning the activities and assessing students.	- Establishing an agenda for meetings and a working group to list competencies that can be assessed in the health service and that include the instrument.	- Mapping the competencies that each service can offer in preceptorship using a form.
		- Drawing up scripts and instruments together with the preceptors.
		- Validation meetings during the semester with the preceptors present.
	- Ensuring that the preceptor is involved in the construction process.
Training to conduct the student teaching-learning assessment process.	- Training preceptors in the skills and competencies to develop students’ teaching-learning assessment.	- Offering an annual course/training with an external speaker (higher education institution and service), which can be done remotely.
		- Explaining the role of nurse preceptors to students.
Ensuring a permanent staff of preceptors.	- Expanding institutional discussion to ensure teaching-service-management-community integration with preceptors linked to teaching, research, and extension projects.	- Opening five-year calls for proposals, in accordance with the rules for hiring professors.
		- In the event of the scholarship being terminated, due to a reduction in the number of students in the subject, ensuring that they remain in another semester linked to the call for proposals.

The dreams reflect an expanded vision of a strategy for improving nursing education, which highlights the construction that strengthens the proposal for teaching and care integration services so that it results in preceptorship benefits for students, both for users and health services. In addition, the dreams emphasize the improvement of students’ clinical reasoning, promoting critical thinking based on evidence to solve problems.

DISCUSSION

Regarding the training of nurses for the SUS, aligned with nursing education policies and strategies used to strengthen this guideline, the results of this study highlight relevant aspects in the local scenario, which reflects the efforts of public policies to support the defense of this health system. The results presented were strategically directed from the point of view of points for improvement in the integration of teaching, care, management, and social control, with a reduction in the social control dimension, as it was not a solid manifestation of the ECS space.

It is worth noting that the lack of focus on social control is distant from the recommendations of training for the defense of the health system, in a space of knowledge about legitimate decision-making actions through representation in a collegiate space. It is worth returning to what Ceccim and Feuerwerker² say: “Training has always been very different from informing, but it seems that we easily fall into this trap.” At the same time, they ask: “How can we train without analyzing the order of realities? How can we educate without activating vectors of power contrary to those that preserve a given reality that we want to change?

The answers need to be reflected in the local dimension of the teaching-care-management-social control integration projects, given the specificities of each territory and the structure of the institutions’ links with local health services and management. Using preceptorship as an undergraduate method makes sense in terms of rescuing strong bonds, while at the same time corroborating the call for responsibility from the players involved in the training process and the integration of the four-way approach. In this study, a group of preceptors with a long history of ties to the teaching institution participated and, therefore, their considerations provide a relevant analysis for the teaching management scenario.

There is no doubt that the presence of preceptors in the process of training human resources in health is important, given their involvement in the dynamics of the service and working relationships.²⁰ Preceptors are recognized for their technical competence, given their length of professional experience in the health service, but not recognizing or diminishing their didactic-pedagogical competence in the training process can replicate traditional models of professional performance in the health system, without problematizing the changes in the work process and in the concept of thinking about the responsibility of the profession in a health system.²¹,²²

It can be seen that preceptors, in the act of teaching, devise their own means of teaching and use their experienced knowledge to create and define the teaching-learning process.¹⁰ It is worth mentioning that these preceptors are linked to the ECS, a moment considered important for exercising social commitment, mastery of practice, and the skills required for professional practice.²³ Given this statement, the use of meaningful learning, which favors problematization and values the insertion of the actors in the teaching process, needs to expand the dialogical process of problematizing education as a teaching method to achieve the expected guidelines for professional practice.²⁴

The support provided by HEIs to preceptors with regard to pedagogical issues has been weak in the analyses carried out.²⁵-²⁷ The demand from preceptors in different professions for specialized training in the area is an important pedagogical support and has been a request to qualify their praxis.²⁸,²⁹ Continuously training preceptors to conduct the evaluation process and ensuring a permanent staff of preceptors are fundamental measures for maintaining quality and consistency in nursing education.

Since 2001, with a strong orientation towards training for the SUS, HEIs with courses in the health field have carried out strategies to comply with this guideline.¹⁹ However, the expansion of courses with the devaluation of practice spaces and experience in health services contributes to fragmenting the system, reducing the scope of preparation for professional practice under the dimension of professional competencies,³⁰ which ensure psychomotor, cognitive, emotional, and social skills, essential to develop decision-making and problem-solving skills.³¹

It is expected that, in the ECS, students will be able to develop their autonomy, given the course workload,³² while at the same time being positioned as the actors responsible for their own learning, since the experience of the professional functions of their practice, ensured by getting closer to the health services, becomes decisive for the qualification of future nurses.³³ It is also in this space that the focus on ethical and comprehensive care should be problematized.²⁴

Graduates of the nursing course stated the need to expand early insertion into health services to encourage autonomy, as well as training in the perspective of interprofessional work and strategies for applying the systematization of nursing care in services.³⁴,³⁵ Promoting students as protagonists of their own teaching-learning process is essential for training autonomous and competent professionals.

The results presented in this study express important challenges contextualized at the curriculum's interfaces, the work process in practice settings, and the logic of thinking about “doing health” in health services. The practice of preceptors is characterized by work overload, the accumulation of duties, and the lack of incentives for preceptorship,²⁷ in addition to aspects that reduce the effectiveness of the field of preceptorship in training and the time spent monitoring the workload allocated to this activity.²¹,³⁶ The lack of physical structure in health services as a space for training professionals also contributes to these aspects.²³,³⁷

Design is considered a cornerstone in the health field for managing the system, services, and programs in nurses’ management and care practice,³⁸ as well as program content in health training curricula, to bring teaching and service actors closer together and strengthen the development of communication, leadership, and decision-making skills.³⁹ However, has been little valued as a management strategy and for teaching management tools from the perspective of the framework of teaching and care integration services.⁴⁰

The use of indicators, envisioned as a possibility for designing and evaluating health actions in teaching and care integration services, is an important management tool that still requires mastery of its investigation to ensure quality in the execution of processes.⁴⁰-⁴² However, the prevailing discourse should not be that the quality of care provided is based on the fragmented production of procedures that systematize the production of care.⁴² Therefore, revisiting the field of training based on comprehensiveness is an invitation to re-examine the curriculum and how learning spaces are built within it from a meaningful integrative perspective.

It is worth noting that the essential activities considered to be exclusive to the professional practice of nurses in Brazil are designing, organizing, coordinating, executing, and evaluating nursing services.⁴³ The low value given to design in training and the difficulties faced by preceptors and supervising professors in mastering the method contribute to disqualifying it as a powerful pedagogical strategy in the management practice of nursing services, programs, and teams.⁴⁴

The Systematization of Nursing Care (SNC) includes a theoretical framework design for organizational aspects, which requires nurses to have expertise in management to develop the design stages. However, its implementation faces resistance from professionals who justify their overload and lack of interest in the method, as well as the difficulty of implementing and using these tools in the work process.⁴⁵,⁴⁶ In the case studied, it is worth pointing out that the university, as a training center, needs to assume its social role in collaborative projects from the perspective of teaching and care integration services to strengthen the SNC and the nursing process in practice scenarios.

The results of this study show that there is a gap in practice settings for teaching based on the SNC and the nursing process, and that clinical reasoning is challenging to teach. Regarding the latter, there is evidence that its teaching comes against theoretical perspectives, methodologies, methods, and procedures.⁴⁷ Thus, it requires concomitant training environments between the actors who promote the teaching-learning process in order to qualify nursing care and broaden the debate on management tools in teaching.

The results showed the need to reflect on the role and social commitment of HEIs to their territory. From this perspective, in addition to preceptorship training, their work should be based on participation in projects that strengthen the permanent education of the service network and qualify the services provided by the institution. A low feeling of belonging to the HEI’s teaching staff has been noted by preceptors,⁴⁸-⁵⁰ which makes it necessary for teaching management to create strategies to bring preceptors closer together and train them to deliver teaching based on the competencies that guide the curriculum proposed by the course. It helps to remember that the training of preceptors and professors was mostly based on traditional teaching models with a strong biomedical model. Changes in the way professionals think about health and their actions are the result of investment in educational processes.⁵¹,⁵²

The preceptors presented the students' difficulties in taking a comprehensive approach during consultations, intervention plans, and action planning. Despite a strong movement towards a broader conception of health and the incorporation of comprehensiveness into curricula, the hegemony of the biomedical model still prevails, which disregards the multidimensionality of human beings, focuses on the individual in order to intervene in the affected part, places little emphasis on analyzing the determinants of the health-disease process, and distances itself from cultural and ethical aspects.⁵³

In view of the above, it is necessary to reflect on the curriculum and its alignment with the principles of the SUS in order to guide care practices, not only in the physical description of the course’s pedagogical project, but also in the day-to-day teaching-learning approach of the classroom and practice scenarios.

Traditionally, the development of training projects at the university follows the logic of a group of professors in the course, which does not incorporate analysis of the practice scenario and the voice of the different actors in the training process. In this sense, the experience of promoting forums that stimulate collective debate among the academic community, students, professors, and representatives of the rectory and the training services, together with social control, supports ways of building a training profile and reduces the daily isolation of courses.⁵⁴,⁵⁵

The challenges of broadening the concept of multidimensionality in health have come up against the fragmented multiprofessional work process in health services, which has not incorporated the interprofessional and interdisciplinary extension into practices.⁵³,⁵⁶ Practices in diagnosis, treatment of pathologies, and medicalization prevail in a hierarchical and centralized manner,⁵⁷ while combining with the heterogeneous dynamism of the teams' work configuration, which is shaped by social and regional contexts.⁵⁸

Once again, it is advisable to review the HEI social commitment to permanent education processes, through its university tripod of teaching, research, and extension, capable of offering a set of arrangements that bring about significant changes in the organization and work process through teaching-service integration, by incorporating learning to teach into everyday practice.⁵⁹

The replication of practice scenarios that make no progress in improving the quality of care ends up producing a picture of training processes that are not committed to reality. In this logic, the expression “knowledge that does not know”, by Barros,⁶⁰ problematizes fragmented teaching by disciplines that specify a certain objective, but do not train for teamwork and comprehensiveness and, therefore, have little to offer in transforming the scenario.⁶⁰

Change makes the most sense when it comes to connecting with actors, including students who, by participating, critically reflect on professional practice and their responsibility towards training and the health system.⁶¹ The introspective record of the social participation movement and the understanding of social control is a weakness in teaching based on the four-way approach, in addition to the reduction in the discussion about training for SUS management, and thus the actors who think about the training process in the course need to reflect on students’ political-pedagogical performance for training that guides them towards an active position in society.

The construction of citizenship and solidarity, symbolic materials in the SUS, calls for an interface between education and health work, with spaces for action and reflection that value cooperation in the practice of care units in order to achieve resolvability in the health system. Thus, students are fundamental components in this coordination, as they are future professionals, but mainly because they are under construction as social subjects. Hence, they expose spaces for co-management, as an organizational model that involves and places action in an agreed design process between the collective actors.

The development of actions by preceptors and supervisors to strengthen the preceptorship activity, in the context presented, can be referred to the ability to use engagement to affect the relationship of the different actors.⁶¹,⁶² In view of the above, and the frameworks of analysis,²,¹⁹ the results subsidize a debate on this in which only the quality of training will be a decisive factor for the complete incorporation of competencies and the consolidation of a professional practice more aligned with the commitment of the profession in health systems, especially in the SUS.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

There is still a real need to expand the commitment of HEIs to the practice setting, in terms of their participation in offering training processes based on the method of permanent education. In addition to pedagogical support, there are work fronts that support the university tripod and can achieve greater integration between teaching, care, management, and social control. It is pertinent to reflect on the student movement's conception of training and its contribution to practice scenarios, without neglecting the profession's social commitment and the ethical values that support professional practice and belonging to the largest professional category in the health system.

Taking competencies as an analytical strategy for the graduates and the actions that are being carried out in the practice scenarios to develop them will be convenient in terms of examining the field of training, given the aspects not covered in the participants' statements. Based on the strategies developed to expand teaching-care-management-social control integration through preceptorship, it is possible to recognize elements that subsidize tactical action for the work, all of which are possible given the actors' governability over resources.

The synthesis of the dialogues evoked by the authors confirms the scenario already described as a challenge for health training and the urgent need for dialogue between the health services, which are training spaces, and the training centers in order to align agreed activities that will bring about transformation and help reduce territorial inequalities. In this sense, this study contributes as possible material for designing parameters to monitor and evaluate what has been projected as an improvement.

A limitation of this study is that it was carried out in only one reality and that students did not participate. However, another study is being carried out in which the comments of students who have experienced preceptorship are analyzed, as an attempt to validate the aspects presented in this study. The study offers support to qualify preceptorship in Nursing and presents paths for teaching management as a link between training processes. It is also possible to replicate the method in other scenarios.

ACKNOWLEDGMENTS

Fundação de Amparo à Pesquisa de Mato Grosso.

• FINANCIAL SUPPORT
  The present study was carried out with the support of the Scientific Initiation Scholarship of Pedro Henrique de Oliveira Marques Vidal.
• DATA AVAILABILITY RESEARCH
  The contents underlying the research text are included in the article.

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Edited by

• ASSOCIATED EDITOR
  Sabrina da Costa Machado Duarte https://orcid.org/0000-0001-5967-6337

• SCIENTIFIC EDITOR
  Marcelle Miranda da Silva https://orcid.org/0000-0003-4872-7252

Data availability

The contents underlying the research text are included in the article.

Publication Dates

• Publication in this collection
  03 Feb 2025
• Date of issue
  2024

History

• Received
  11 July 2024
• Accepted
  17 Dec 2024