ORIGINAL RESEARCH

Basic care nursing internship: challenges for it to be effective

Heluana Cavalcante Rodrigues^I; Maria Socorro de Araújo Dias^II; Antônia Eliana Araújo Aragão^III; Maria Adelane Monteiro da Silva^IV; Diógenes Farias Gomes^V; Maria da Conceição Coelho Brito^VI

^I Nurse. Master in Family Health from the Federal University of Ceará (UFC). Tutor of the Sobral School Health System (Sistema Saúde Escola de Sobral). Visconde de Sabóia Family Health Training School (Escola de Formação em Saúde da Família Visconde de Sabóia). Ceará, Brazil. E-mail: heluanacavalcante@yahoo.com.br
^II Nurse. Post-doctoral in Clinical Care at the State University of Ceará (UECE). Teacher of the Nursing Course. State University Vale do Acaraú (UVA).Ceará, Brazil. E-mail: socorroad@gmail.com
^III Nurse. PhD in Nursing from the UFC. Coordinator of the Nursing Course. Higher Institute of Applied Theology (Instituto Superior de Teologia Aplicada). Ceará, Brazil. E-mail: antoniaelianearaujo@gmail.com (in memorian)
^IV Nurse. PhD in Nursing from the UFC. Coordinator of the Nursing Course. State University Vale do Acaraú. Ceará, Brazil. E-mail: adelanemonteiro@hotmail.com
^V Nurse. Master's Degree in Family Health by the UFC. CAPES social demand Scholarship. Federal University of Ceará. Ceará, Brazil. Ceará, Brazil. E-mail: diogenesfgo@gmail.com
^VI Nurse. Master in Family Health from the UFC. Research Assistant of the Teaching and Research Center. Visconde de Sabóia Family Health Training School. Ceará, Brazil. E-mail: marycey@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2018.26979

ABSTRACT

Objective: to examine the challenges for nursing education in Basic Care to be effective, based on the collective discourses of the actors involved. Method: this exploratory, descriptive study of Basic Care nursing internships took place between March, 2013, and January, 2015, at two universities in northeast Brazil. Participants were seven students, three teachers and six preceptors, selected on pre-established criteria. Collective Subject Discourse was used with the support of Quantiqualisoft© software. Results: the main challenges for an internship to be effective were identified as being the interconnection between theory and practice, and integration between education and work. These were understood as challenges of an education and structural order, denoting necessary participation by the public health system. Conclusion: there was shown to be a need to restructure internships, particularly to construct an agenda of commitment and duties between university and municipal administration.

Descriptors: Nursing internship; Primary health care; Education, nursing; Education, higher.

INTRODUCTION

The Federal Constitution (FC) of 1988, article 200, clarifies the need for training of human resources for the Unified Health System (SUS). Thus, doctrinal principles instituted in this system (fairness, universality and integrality) influenced the constitution of new educational arrangements, in order to develop professionals capable of a new model of health care.^1,2

Through the proposal, the challenge of (re)constructing health education was added, seeking to refute the model of biomedical education, to intensify the significant formation and the development of competences.² With this idea, the movements of health education reform began, promoting the articulation between the SUS and educational institutions.

In the 1990s, normative elements intensified the teaching in Health. Of particular note is the Law on the Guidelines and Bases of National Education (LDB), which establishes a reorientation of the concept of education, stating that: "covers the formative processes that develop in family life, in human coexistence, at work, in educational and research institutions, social movements and civil society organizations and cultural manifestations".³ These aspects have been influenced by provisional measures, such as the No. 746 of September 22, 2016, which changes the content of LDB with emphasis on technical education and exclusion of disciplines such as Philosophy and Sociology.³ In this perspective, the education intensifies the adoption of new curricular models, which triggers the formation of guidelines for each course, allowing to interpret the conceptions of field and core.⁴

In this path, also in the 1990s, the National Curricular Guidelines (NCG) of the Health courses were consolidated, which emerged in an attempt to incorporate humanistic practice, the SUS principles and sensitivity to problems arising from the social context. It stands out for this study, that the NCGs of the Nursing Course aim at the formation of a generalist professional, oriented towards the health care of the population, strengthening professional relations and lifelong education.⁵

The goals of Nursing training also establish a reflective aspect about professional work for SUS. From this perspective, the nursing internship is a fundamental step for the development of skills and attitudes necessary for the exercise of the profession. The experiences provided in this stage of graduation enable the contact with the reality of the health system, generating meaning, from the practice assisted by a preceptor.^6,7

Therefore, it is important to carry out an investigation that includes nursing internship as part of the training of nurses to work in the National Health System (SUS), intending reflections that permeate the challenges imbued for the effectiveness of this strategy.

From the above, this study outlines the objective of analyzing the challenges for the effectiveness of training of the nursing internship in Nursing in Primary Care, based on the collective speeches of the actors involved.

METHODOLOGY

Study of qualitative, exploratory-descriptive epistemology, carried out from March 2013 to January 2015, in two Higher Education Institutions (HEI) - one public and one private - in the municipality of Sobral, Ceará, in the Brazilian Northeast. These institutions were selected based on the following criteria: attend the northern region of the state, offer the bachelor's degree in nursing, and be inserted in the practice field of basic health care of the municipality.

Participants were professionals and students involved in the nursing internship of the second semester of 2014, with seven students, three teachers and six preceptors. The delimitation of the number of participants respected the information saturation technique.⁸ These participants were distributed in the territories of the Family Health Strategy of Alto do Cristo, Coelce, Padre Palhano and Sumaré.

The eligibility criteria of the participants were: student, having attended at least 75% of the total hours of internship; teacher, to be collaborating with the Internship in Primary Care; preceptor, have previous experience in this function, be a professional in the primary care service and be accompanying one of the students of HEI enrolled in boarding school.

The information was collected through a semi-structured interview, with questions about the nursing internship in Primary Care, the articulation of theory and practice, teaching-service integration and the skills learned by the students as a reflection of a curriculum instituted for competency training in SUS.

The content of the interviews was organized in the Quantiqualisoft© and analyzed using the Collective Subject Discourse (CSD) analysis technique. These methodological aspects were adequate for this study to the extent that a discourse-synthesis of the participants was possible, representing an interesting choice for qualitative studies.⁹

Study approved by a Committee of Ethics in Research, under Opinion No. 842.449/2014. The identification of the speeches is thus represented: DSCdoc, for teachers; DSCprec, for preceptors; e DSCdisc, for students.

RESULTS AND DISCUSSION

The results of the study point out two challenges to the effectiveness of AB training: the relation between theory and practice and teaching-service integration. The first takes on an educational connotation (relation with teaching-learning) and the second, as structural, involving aspects that transcend Nursing training and include university, health services and management in Health.

The close relation of students, teachers and preceptors with the phenomenon investigated allowed a homogeneous interpretation. With this, the speeches are presented in the following categories: "Theory and practice at the nursing internship of Primary Care: basis for discussion of the challenges"; and "The teaching-service integration: exchange for the effectiveness of Nursing internship".

Theory and practice at the nursing internship of Primary Care: basis for discussion of the challenges

When considering all the trajectory permeated by advances, potentialities and fragilities in Brazilian education and Health, it was intended, with this analysis, to understand how close or distant the training of nurses, for the SUS reality, is presented in these two HEIs, being prospective the reality of other Brazilian institutions.

The DSCdoc allows the reflection of the formative itineraries adopted in the HEI Nursing courses. The analyzed courses show a regional historical construction linked to the current social and health needs, contributing to a dynamic curricular path. This characteristic connotes a socio-historical relationship of the construction of these courses with the regional health needs Historically, Nursing presents a vast trajectory that reveals the adoption of essentially technical training strategies for a long time, guided by the needs of the current public health system.¹⁰ For this study, it was verified that the curricular model used is highlighted as an updated and important tool for the alignment between theory and practice, fundamental for the teaching-learning process of Nursing students. In this way, the necessary relation between theory and practice was presented as an essential aspect to link nursing education to the needs of Primary Care.

The curriculum is, if not, a longing for the effective relationship between theory and practice. In one of its concepts, enables the knowledge of the extremes of theory and practice, which highlights a continuum which deserves to be explored in educational contexts.¹¹

Consonant, it is important that the relation between theory and practice is an element presented in the curricular proposal of the Courses as an essential aspect for the effectiveness of the training. Thus, the Nursing internship provides a meaningful learning, based on the experience of the students in devices and services of Primary Care. In this way, it could be viewed as a coping strategy for the constant dilemma inserted in the theory and practice relation.

To achieve this relation, it has been triggered initiatives to strengthen the bond of universities with the health services and even among other courses, as the proposal in an earlier study follows, by provoking an innovative training in Occupational Therapy, from an integrated and interdisciplinary curriculum.¹²

The curriculum model adopted in the courses has enabled the quality of education of students, taking, as an indicator, the theoretical knowledge and its effects in practice. Therefore, it is mentioned that this learning process is initiated in the previous semesters, being matured during the internship:

The student from the first semester simultaneously experiences theory and practice (DSCdoc).

The DSCdoc shows that the praxis of teaching theory and practice has manifested itself since the early periods of the course. However, it is emphasized that, in the initial moments of Nursing graduation, the disciplines/modules are essentially theoretical and structuring for the later moments of the course. However, two pedagogical perspectives were identified for the courses, banking in the private HEI and humanistic in the public, which can be attributed to the differences also adopted by other institutions located in the national territory.

The NCGs of the Degree in Nursing are clear to elicit the formation of a generalist, humanist, critical and reflective professional, to do so, needs to acquire knowledge about health care, decision making, communication, leadership, administration and management and lifelong education, which allows us to infer the need for basic theoretical knowledge that underlies a safe practice.¹³

Sustained in the discussions of Paulo Freire, it is highlighted that there will still be an effective technique that allows the relation between theory and practice.¹⁴ This reveals the constant challenges that are found in this relation and, also justifies the fragilities found in the internships analyzed, as traces of the dichotomous model between theory and practice.

Based on DSCdoc, it should be pointed out that the processes of knowledge acquisition, based on undergraduate experience, are necessary steps for the understanding of professional bursing practice. This is revealed as a necessary move for the maturation of the student as a future professional.

In addition, it is possible to identify that the Nursing internship reveals to the students, situations for which they were not prepared in the graduation. This experience is necessary to trigger a meaningful learning, catalyzing the desire for the investigation of new situations to be experienced in the daily routine of the Basic Care professional.

The above corroborates with the DSCdisc, which presents that these situations awaken skills that will be necessary for their performance in the health system guided by SUS:

The DSCdisc presents a mismatch in the theory and practice relations. The same point out, in addition to the difficulty with some everyday situations, unrelated facts with the reality of the practice learned in the university. There are, however, two interpretative hypotheses for this relation of challenge: the first is the lack of necessary inputs for the accomplishment of the procedures in the health services that corroborate with a quality and effective attention; and the second is based on the disproportionality between the graduation teaching and the reality of the professional in the service.

The foregoing is based on the reality that the Primary Care services have faced structural challenges for resolutive attention, and point out differences in nursing training in public and private institutions. This challenge could be overcome, If the Primary Care was a priority for managers and it was seen as a strategy that orders the care in the SUS. In addition, the construction of the training itineraries presents a certain dissonance in relation to the services arranged in the SUS, an aspect that opposes article 200 of the FC of 1988.¹⁵

The hypotheses presented show that the organizational aspects of the Health and Teaching System are points that deserve to be discussed as a priority for qualified training, as shown below:

Thus, the student perceives that the practice environment consolidates the theoretical knowledge and approaches the discussion of cases, from the reality of the health services. However, they rescue the difficult interconnection between theory and practice.

The DSCs made it possible to reflect the internship as a space that allows the development of competencies for expanded care in Primary Care, fostering a formation guided by ethics, professional posture and co-responsibility.

The teaching-service integration: exchange for the effectiveness of Nursing internship

In order for the training to meet the health needs of the population, a closer approximation between these two historically disconnected contexts is necessary so that the actors involved can understand the aspects related to real life and to spaces for the provision of health care. The speech, below, shows weaknesses in this articulation.

The DSCprec indicates aspects that make the teaching-service integration a process management challenge. This short, but complex, binomial propels reflections that involve the management of education in Health and the teaching role. Formerly, it allows to scale the affectation of professionals-preceptors in the face of this difficulty and the coping strategies that have been developed

In addition to the need for alignment between theory and practice, the CSD of the participants revealed the challenge of teaching-service integration, pointing in particular to the lack of communication between HEI professionals and service-providers.

It is explained that, in this study, the term "professional-preceptor" was adopted, aligned with the municipality's policy that defends the Health System as a health-school system In this, the professionals collaborate in the training of Health professional.¹⁶

The CSD of the preceptors reinforces the indicated difficulty in pointing out that there is a need to intensify the presence of supervising teachers that facilitate certain moments of learning on which they have difficulties to choose the best methodological and theoretical approach that can supply the need of training of students in Primary Care.

The speech points to a dialogue that needs to be rethought in order to strengthen the links between teaching and service. In this premise, the dialogue and reflection become opportune for the effective development of the students, which points to the considerations on complementarity that must permeate the entire teaching-learning process, minimizing the formation of educational gaps.¹⁷

This reality is softened when one observes in DSCprec how the relation is established when it presents a representation of the HEI in the health services.

The representative, pointed out in the speech as "teacher advisor", assumes the role of preceptor of the course, that acts in the monitoring of the students in the services, in partnership with professionals-preceptors who work in AB. This characteristic, available only in one of the HEIs, was pointed out as a potential for the relation between teaching and service, which allows for the best follow-up of the student.

In the same speech, the professional indicates that the difficulty that marks this process is the deficiency of teachers that make the internship effective. To this extent, it is verified that the teaching-service relation also involves the realization of a teaching staff that ensures equitable distribution for the monitoring of the teaching-learning process carried out in the field.

The teaching-service integration was always mentioned in the preceptors' discourses and faced with the challenging perspective of effectively connecting the higher education institutions with the services and professionals of the public health system. Therefore, it is possible to consolidate communicative channels, which seem relatively easy to formulate and institute, when considering the achievements made in the Sobral School Health System (Sistema Saúde Escola de Sobral).

The evident desire for better integration between teaching and service are also peculiar perspectives of studies available in the scientific literature that, similar to this, treat the Nursing internship as the focus of discussion. Thus, it should be emphasized that this integration must influence the organization of spaces that enable qualification for attendance, promoting an exchange of knowledge among students, teachers and service professionals in the construction of a professional profile committed to quality in Health.¹⁸

As indicated in the preceptors' speech, the teachers of one of the HEIs also indicate a difficulty in monitoring and evaluating the activities of the internship in Primary Care, when they show that the evaluation counts on the (effective) participation of teachers in conducting of portfolios and case studies, and of the preceptors-professionals, in the final evaluation of the student, but separately. This difficulty is seen as an operational challenge, apparently surpassed by the other HEI, as it has preceptor professionals hired and available for the follow-up of the students in the field.

A device that has been used to facilitate and qualify the teaching-service integration, observed in this study, was the presence of a school for the training of health workers linked to the municipality that has enabled the organization and allocation of students in the local system Health and enabling a channel of communication between the university and the health services. This feature is part of the internship planning process. The CSD of the teachers affirms this initiative:

Still, the same speech shows that the competencies are formulated from university initiatives, configuring as a pertinent practice to the teachers, without provoking the participation of the professionals-preceptors. It is worth highlighting the openness to changes in the evaluation processes, which suggests a democratic perspective of student participation.

At some points in the teachers' speech, it is possible to identify that the cause for the non-inclusion of the preceptors-professionals in the organizational processes of the internship is due to their lack of availability in relation to a schedule of meetings with the teachers, as evidenced by:

The speeches of the two institutions make possible a reflection about the health-school system, namely: the unavailability of the agenda (time) and the involvement of the preceptors with the process of learning of the inmates in the health services, when the moments of planning and evaluation occur extra-time and working space, should raise new strategies.

It is also stressed the need to establish a responsible for the occurrence of this mismatch in moments that involve students, professionals-preceptors and teachers. Therefore, human and structural resources must be available to confirm their potential for the effectiveness of the internship. The integral relation of the Health System includes, in addition to the teachers, students and preceptors, teaching managers and Health System. ¹⁹ Therefore, it is essential to involve them in a unique relationship, in order to provide a qualified education for health professionals.

In this perspective, the teaching-service integration was one of the challenges for the implementation of Nursing internship in Primary Care as a training strategy for SUS that, together with the challenges of the theory-practice relation, shows the necessary formation of initiatives/coping strategies for these problems.

CONCLUSION

This study, focusing on a step in the graduation course in Nursing, allows for reflection through the applied teaching model and the structural challenges in the formative itineraries.

By ascribing the reality of a municipality in the Brazilian Northeast, it becomes a relevant evidence for the scientific community, in the possibility of fostering a possible comparative analysis between the challenges encountered with the reality of other courses.

The results identified from the use of CSD are clear to point out that the opinion among the subjects is homogeneous. To that end, it is understood that the previously mentioned challenges are unique through the role of students, teachers and preceptors, being affected by their singularities of insertion in teaching and learning.

It is evident the need for restructuring in the internship analyzed. As for theory and practice, it is important to understand and approximate university education with the challenges of health services, with the care not to intensify a practice dissociated from science. In the teaching-service integration, professional resources that allow the improvement in the relation between university and service are necessary, even if strategies have already been implemented. Thus, it is necessary to build an agenda that composes commitments and duties between Universities and the health system.

It is recommended to conduct studies in support of the Nursing training in Primary Care taking into account the whole formative process of Graduation counting, as problematization, the teaching-service integration and the theory-practice relations.

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