CASE STUDY

Social and pedagogical practice of the nurse-preceptor: a case study

Verônica Caé da Silva¹, Ligia de Oliveira Vian², Claudia Regina Gonçalves Couto dos Santos²

¹Ministry of Health, Rio de Janeiro Federal University
²Rio de Janeiro Federal University

ABSTRACT
Aim: To describe the pedagogical practice used by the nurse-preceptor with graduate nurse students.
Method: Case study conducted in 2011, at São Francisco de Assis Hospital-School, with 14 nurse-preceptors who mentored students from the Anna Nery School of Nursing. We used official documents and interviews to collect qualitative, descriptive data and analyzed the thematic categories. EEAN/HESFA protocol CEP number 114/2010.
Results: The teaching actions occurred mainly in nursing consultation and the nurse-preceptor hardly took part in the planning and evaluation of student activities. There was concern regarding the service organization and distribution of the number of students per sector.
Discussion: The power relationship, the political dimension, and the dichotomy between theory and practice.
Conclusion: The nurse-preceptor did not participate in all the constituent steps of pedagogical practice, but conducted activities requiring such participation.
Descriptors: Preceptorship, Nursing Education, Teaching.

INTRODUCTION

In Brazil, they organize formal education into basic education with kindergarten, elementary and secondary, and higher education. Each government entity is responsible for granting the right of the population to school and to systematized knowledge. As Law No. 9.394/1996 states, establishing the guidelines and basis for national education for all citizens, the design of education in schools should be tied to the world of work and social practice⁽¹⁾.

Educational institutions that offer Nursing Degrees must train nurses in the area of health knowledge, so they are capable of performing their practice in different work areas, as Brazilian citizens committed to the development of society.

During the Nursing Undergraduate Program, student’s experience fieldwork on internships, as knowledge of the relationship between theoretical and practical knowledge is required in order to complete the program. This professional construction involves different social actors, such as teachers, students, the users of health services, their families and service professionals, and especially the other nurses, their future colleagues.

The nurse-preceptor is the professional employed in the health service who participates in the supervision and guidance of trainees for the construction of their knowledge using their own knowledge and experience. We consider the nurse-preceptor an agent of pedagogical practice. This practice is recognized as part of a social process that embraces the sphere of education, not only in schools, but also in the dynamics of the social relations that produce learning⁽²⁾.

Both teacher and nurse-preceptor are concerned with what, whom, and how to teach, in order to produce educational work that transforms nursing students into competent and capable workers. In short, they should consider how to conduct effective pedagogical practice, which involves teaching a particular content⁽³⁾.

Teaching practice, as a social event in the whole world, does not remain restricted to areas of theoretical discussion, it includes the experience of everyday life. It is worth noting that the “interrelationship between subjects may favor the continued construction of interdisciplinary knowledge that promotes a more critical and supportive social formation”^(4:8).

Some components are essential to prevent the teaching practice from becoming reproductivist, and for it to fulfil its role in the transformation of reality, such as planning, goals, content, strategies, didactic resources and assessment. These are not static, or compartmentalized or unilaterally designed; on the contrary, they should ensure participation from everyone.

To reflect on the possibility of teaching practice of nurses from the health service and their students during the execution of activities such as fieldwork or internships, we formulated the following research question: How does the nurse-preceptor develop and perform practice nurse undergraduate traineeships? To this end, we formulated the following objective: Describe the pedagogical practice of the nurse-preceptor with the nurse student from the fourth to eighth internship period.

METHOD

This is an exploratory, descriptive and qualitative study using a methodological approach, which allowed the investigation of the research object “on a contemporary phenomenon in real-life context”^{(5: 22)}.

In this, the phenomenon studied was characterized as unique, representative or typical of an institution. We conducted the case study on students from the Anna Nery School of Nursing (EEAN), the first School of Modern Nursing built in Brazil using the Florence Nightingale template, the first study of its kind in a university where they use new methodologies and where they integrate curriculum guidance in three forms:  

• Integration of theory and practice - to encourage the student to relate everyday situations at work with theoretical study, to integrate and associate it in the cognitive field;

• Integration of work and study - the integration of the student with practice fields, to aid understanding of the problems of practice, its representation and inclusion in the social field;

• Disciplinary integration - the interrelationship between significant content, the articulation, analysis and synthesis of thinking into knowledge⁽⁶⁾.

The research scenario was the São Francisco de Assis Hospital-School (HESFA), of Rio de Janeiro Federal University (UFRJ) and the subjects were 14 nurses who acted as nurse-preceptors of EEAN undergraduate students from the fourth to the eighth curricular period. We called respondents "key informants" and guaranteed anonymity using aliases.

We considered using more than one data source, as advocated for case studies, and which provided the “development of converging lines of research and a chain of evidence”^(5:123).

We used 19 official documents as the primary source of data including graduation course material from EEAN, HESFA, Ministry of Health, Ministry of Education, Ministry of Labor, the Federal Council of Nursing and the Brazilian Association of Nursing, all important institutions that guide the pedagogical practice of the nurse-preceptor.

We used semi-structured interviews, which we conducted from February to June 2011, to collect descriptive data, as a secondary source. For the 14 interviews, we asked the key-informants to read and sign an Individual Informed Free Consent Form.

For the analysis, we used an approach that occurred within the data collection, to “demonstrate the flexible nature of qualitative methods”^(6:53). We categorized from a conceptual basis - Historical-Critical Pedagogy (PHC) - theoretical references to pedagogical practice and preceptorship in nursing education, and the different nuclei found.

This article is part of the Master’s thesis "Preceptory - Links with Saviani’s Historical-Critical Pedagogy: the Case of Anna Nery Nursing School", approved by the EEAN/HESFA Ethics Committee and Research, registered under the Protocol 114 / 2010, according to the precepts of Resolution 196/1996⁽⁷⁾.

RESULTS

The organization of teaching practice and the relationships created by and among the social agents
The main teaching and learning activity carried out with students from EEAN HESFA is nursing consultation. The nurse-preceptors describe the teaching of consultation on an outpatient basis as recommended by Law No. 7.498/1986⁽⁸⁾, and meet the Nursing Assistance System (SAE) standards, in explaining some of its stages: history, physical examination, prescription and nursing assessment.

Thus, they respond to Article 4 of the National Curriculum Guidelines of the Nursing Graduation Course⁽⁹⁾, which establishes the desired skills for nursing education about health care and decision-making.

I carry out the nursing consultation, the entire physical exam, all the data collection, the anamnesis. We read the patient’s records, forward it [...] I show them the service. (Faith)

Nurse-preceptors, concerned about the value of nursing in everyday work, are keen to establish their presence and make students understand what being a nurse means today, distinguishing it from other areas of health professions.

It's a way to provide assistance that is not medical. But it meets the individual's needs, and this is very important. In a nursing consultation, you can do all this survey. [...] The student follows everything. (Loyalty)

I made it very clear that [...] “the nurse of Y sector,” she works with people, she works with the concept of subjectivity [...] the student begins to see what it meant to be a “nurse of Y” and why he was important in the institution. (Joy)

When Joy, the key-respondent states that the nurse is important in the institution, it is a statement of defense of the occupational category, the place they occupy at work, and the importance of informing others of commitments and responsibilities.

EEAN undergraduates have little time on practical activities in the sector and being with the nurse-preceptor, which hinders interaction, the establishment of trust and the possibility of further discussion about the world of nursing work. The interviews confirm that this led to disappointment, in both nurse-preceptors and students, since they cannot make new appointments with the same patient, to evaluate the implementation of care and/or a prescription. For example:

I think they go too fast. We see it very well when they come and stay with us: "Oh, will you come back?", "No, I won’t come back." So sometimes, they get a little upset. So sometimes, in the shift, there are some who only come once. (Goodness)

Key-respondents support the short time students stay with patients, and explain why they only allow close observation of nursing care, but their comments are contradictory:

So actually, they [students] do more observation of our work. They do not stay long enough to enable them to develop any kind of activity. (Goodness)

We don’t let the student do, but they always watch, are always close by and we are always explaining something. (Wisdom)

This pedagogical practice clouds the perception of the educator regarding the student's process of teaching and learning, of moving from abstract to concrete, from common-sense knowledge to elaborated know-how, which should be provided in university. We see an indication of how to solve this impasse in the next statement:

But when I have an undergraduate student, it is either educational activity or they watch. If they are in 4th period they can only watch the nursing gynecological consultation, if they’re in the last, I let them perform, the nursing consultation under supervision. (Affability)

From this perspective, the student (in the fourth to eighth course period) left the social practice (which is common to him and the preceptor), passed the stage of questioning and is already exploited to perform the expected action. We recognize these as steps in the Theory of PHC Saviani⁽¹⁰⁾ method, which we present in the discussion section of this article.

It appears from the interviews that a quantitative organization of students in the sector is inevitable, so that the nurse-preceptor can provide a quality service to the user and make the teaching and learning easier for those under his supervision.

In the training field, we have about six or seven students. They come at the same time, but we usually divide these students in two rooms, three or four stay and then the others come back. (Faith)

Regarding the presence of the teacher in the work area, we emphasize that it should not be a reason for the distancing of the nurse-preceptor, but a moment of additional opportunity for the student, from which they may benefit from the experience of two nurses: one whom they already recognize from the classroom and another they are about to know. Unfortunately, this partnership in teaching and learning sometimes does not happen because,
Normally he [the teacher] is the one who stays. I'm just present when he can’t be. When he can’t be present the student works with us. (Loyalty)

A remarkable fact, present in some testimonials is the valuation of the “one that does”, who might be called the nurse assistant - the nurse-preceptor, different from the “one who teaches how to do”, the teacher-nurse.

And sometimes, this teacher, he is not in, is not inserted in the practice anymore, he’s that teacher who is only in the college, a little further away. And then, well, we're in a hands-on, front-line practice. So it makes a huge difference. Thus it is that dichotomy of theory and practice. So when it comes here, in the practice, that’s when we have to really show it, to teach it. (Science)

Often when a nurse takes a position as a 40 hours per week teacher at EEAN, he can no longer have other professional relationships, because he is legally required to be exclusively dedicated to academic activity. If he teaches a theoretical discipline for a semester, he will be away from the customer, which may compromise his future performance, and the return of the surveillance of students assisting in the field. In fact, the teacher does not hide in the college classroom, he responds to an established standard.

Some social workers can articulate the necessary pedagogical practice to the student because whether we like it or not, the relationship between theory and practice is present.

And the practice, it brings great flexibility, where you have to have theoretical knowledge, and the idea of where I'll enter what I'm thinking or what I have identified as a diagnosis, how to get him to want to do that or at least have the interest to think about it. (Loyalty)

It is relevant to stress a positive response about the permanence of the Professor in the sector from a key respondent:

The presence of teachers is essential [...] we're always discussing, exchanging information. We try to know the courses ongoing so we can participate. So, there’s a major exchange for me as a nurse with the teachers from Anna Nery. (Gentleness)

Therefore, the presence of the nurse-preceptor with the teacher will improve the quality of training, and the presence of the teacher in the practice space can be a catalyst for change.

Planning and evaluation of teaching practice: the expression of nurse-preceptors
During the interviews, we identified agreement among the preceptors and teachers regarding the organization of the numbers of students in the sector. However, this does not happen in a period previously set between the two, which shows lack of planning of practical pedagogical activities.

The teachers, before sending the students, perform an ambience period in the unit, they go with them, they present the sector and say, “hey, you're going to be here” and notify me “X, I will send them for you.” Of course, we have a deal, since I cannot take care of too many students, I get at most two students. (Healing)

When asked about their participation in the process of planning the practical activities the students undertake in the sector, their responses were almost unanimous in that they do not take part in this.

No. No, not with those who organize. [...] When they come, they already say what they are going to do [...] they explain, send the spreadsheet, but we don’t participate. (Charity)

But, in this way, the planning is basically an implementation of the teacher. It only becomes a planning of the unit, in the absence of the teacher. (Loyalty)

One of the key-respondents sees the nursing student as an individual in a personal development and professional construction process. He mentions their need for participation in the planning of practical activities to learn more and contribute to the objectives of the training, as happened at other times, during his 15 years working in HESFA with students from EEAN.

Something I think is bad, in terms of not having such participation. From the moment that “X” came out, I started to not have such participation. The idea of the new person was different, as they say, “look, if you don’t have a master's degree, I am the teacher, you're the nurse.” I’m not saying these were their exact words, but I clearly understood. (Joy)

The logic of this reproduction is also well expressed, in the speech of a nurse-preceptor:

No. They [the teachers] have it already, they previously come with a structure and I can opine, change something, but generally, we are already somewhat accustomed to receive it and work that way. So I see no need to be interfering. (Gentleness)

It appeared from the testimony of Gentleness, that a pedagogical practice that does not complain about periodic review and analysis, which settles for and sometimes fears change, is disturbing. After all, it is difficult to remove barriers to build a dynamic curriculum in daily health care with the client, family, community and even with other service professionals.

The reports also show that the nurse-preceptors of the EEAN students remain distant from the evaluation process.

Written assessment by my part, no. The teacher always asks “so, is everything okay?” and how the student is doing, just as a conversation. I explain what is happening, but the one who makes this assessment is the teacher. (Wisdom)

The question that arises is: how to assess, if they do not know what standard the student is expected to reach or what skills they need to develop. When the nurse-preceptors do not take part in the planning, they cannot really know what to ask of the student, and are excluded from the educational practice evaluation process.

DISCUSSION

Based on the results, we found that the nurses in the study describe the nursing consultation as the main activity performed in preceptorship. They considered the steps of SAE and the relevance of the human being, demonstrated devotion in teaching the students actions related to the subjective aspects of patients, such as hospitality and listening.

They put aside the care model based on the solution of physical health problems (biomedical or hospital-called) from the health surveillance model focused on understanding, equity, humanity and the right to information. They followed the path described in the hospital mission, public health policies and national education.

The objectives of preceptorship nursing, in one of the HESFA services, includes the introduction, guidance and monitoring of students in the process of working in the sector, in order “…to build a critical view of the different care models”⁽¹¹⁾.

This is evidence of one of the steps of the Dermeval Saviani⁽¹⁰⁾ PHC; instrumentalization, the interest of nurse-preceptors in conducting the students to take a critical look at the reality in which they live. They need also to think critically about the models of health care in Brazil.

In this study, it is possible to identify the power relationships and political dimensions of the social practice of the nurse in an institutionalized space for the collective construction of care.

Struggles in the area of health sciences are a feature of the nursing profession.  In Brazil, the government discusses a 30-hour working week, working conditions, the fragility of the labor relationship without tender and temporary hires, and the profession is exposed and visible to others through television. Because of this, during practice, the student must meet professionals who can reveal the reality of the working world “inhabited by political and technology disputes”^(12:108), often mentioned by teachers in the classroom.

The nurse-preceptor who discusses the political, social and class issues with students, meets what Saviani⁽¹⁰⁾ proposes: to help students reflect on issues of their practice, with no reservations, with transparency, bringing the real facts of the everyday professional.

The short time some students remain in the sector leads to disruption in the educational process that the nurse-preceptor sometimes establishes with them. This can complicate the development of student learning and act as a barrier to reaching the Saviani PHC⁽¹⁰⁾ catharsis, where the “effective incorporation of cultural instruments, modified as active elements of social transformation”^(13:231) is expected.

In an attempt to minimize such issues (training only one morning in a given sector, for example), during the organization of the calendar and the number of days for the students in practice areas, it’s important the school keeps activities going, so they are performed in time to reach goals. They need to allow the student to proceed from being an observer to a performer of actions.

Regarding the redistribution of the numbers of students in the sector, from the analysis of Law No. 11.788/08⁽¹⁴⁾, we observe that HESFA preceptors, considered the transferor part of the internship program, act properly. A maximum of ten students should be directed and supervised in outpatient nursing care.

It is clear from their cordial relationships with teachers, that nurse-preceptors welcome students without imposing major obstacles. They understand that the two institutions are part of UFRJ, and recognize and respect HESFA and its direction, composed by teachers of EEAN, as a renowned educational institution.

However, despite good will, we can see the challenge the work and academy professionals face when they encounter each other in relation to value. The preceptor craves recognition for his actions, he is not a passive agent, an illustrative figure in the health unit. Saviani teaches that value is a relationship of non-indifference between man and the elements he faces, and that we cannot treat people as objects, as they are able to make decisions, assess and be committed, in a collaborative bond.

The fact of not being indifferent to the other person, the fact of recognizing the value of the other, their freedom, indicates that man is able to transcend his situation and his personal options to put himself in the perspective of the other, to communicate with him, to act in common with him⁽¹⁵⁾.

From the feedback of key respondents, we can see the complexity of relationships in the practice areas and the clash between those in the classroom and those in nursing care. This can be mitigated by creating communication spaces where “service professionals should feel co-responsible for the training of future professionals and teachers should consider themselves part of the health services.”^(16:359).

In the study, we identified that the nurse-preceptor intends to provide the student with a link between content learned in theory and actual practice. However, they need to meet and plan with the university professionals for work that leads to a complete teaching and learning process for the EEAN student. When they do not do this, they ignore the proposals in COFEN Resolution No. 371/2010⁽¹⁷⁾, which aims to ensure the nurse in service participates in the formalizing and planning of the internship program.

Effective pedagogical practice developed by the nurse-preceptor should be re-thought based on existing legal documents, even if they lead to adjustments. Some scholars claim that, still “there are few courses where the preceptor participates differently from planning to evaluation”^(18:243) of the activities of students, whether in clinical training, fieldwork or internship.

Understanding the different pedagogical roles within the teaching and learning process can only facilitate the link between theory and practice and this behavior must emanate from the subjects who are part of this reality. Indeed, the attitudes and approach of both teacher and preceptor can help the student in the process of training, and in the development of critical and transformative thinking.

CONCLUSION

We concluded that the nurse-preceptor does not participate in all the constituent steps of teaching practice; this absence was explicit in the planning and formal evaluation of the students’ performance.

However, we saw that they conduct activities that require such participation.

The country expects transformation in the public health services, including in working conditions and the enhancement of the nurse professional. This will only occur when there is effective contact and dialogue between all the social agents - preceptors, students, teachers and others – who are interested in improving the system.

There must be a place for planning, organization, development and evaluation of the activities that nursing students’ conduct that allows everyone to participate and express their desires, criticize, make suggestions, and offer directions.

The nurse-preceptor plays an important role in training nursing students, and we should respect this as an essential part of the pedagogical practice that happens every day in health care units designed to prevent, promote and aid the recovery and rehabilitation of the Brazilian population.

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Authors Participation:
All the authors took part in all the stages of the project, elaboration and finalization of this article.

Received:11/12/2012
Revised:10/21/2013
Approved:02/25/2014