ORIGINAL ARTICLES

Nursing preceptorship in multi-professional residency in oncology: a descriptive study

Myllena Cândida de Melo¹, Gisella de Carvalho Queluci², Mônica Villela Gouvêa²

¹National Cancer Institute
²Fluminense Federal University

ABSTRACT
Aim: To analyze the perception of resident nurses in terms of the potentiating and limiting factors related to preceptorship in a multidisciplinary residency program in oncology.
Method: This is a descriptive study that uses a qualitative approach. The methodology of problematization and content analysis was applied in this study.
Results: Participation was intense, and preceptorship was reaffirmed as a priority for the group, by means of a multi-dimensional discussion.
Discussion: Preceptorship plays a fundamental role in the meaningful knowledge building process in terms of the human and professional training of resident nurses, requiring of its actors a different perspective to perceive the dynamics of the process.
Conclusion: The perception of residents in terms of preceptorship reveals the need for teaching qualifications for the professionals involved in this activity. Despite the criticism related to the application of the problematization methodology, in the view of the participants, the learning resulting from the residency program is positive.
Descriptors: Preceptorship; Problem-Based Learning; Nursing.

INTRODUCTION

Historically, health education has been based on the use of traditional methods based on mechanistic, Cartesian and Flexnerian standards. Thus, in such a conservative teaching and learning model, the teacher is placed at the center of the educational process, as a content transmitter, while the student is a mere recipient of such content⁽¹⁾.

There is international recognition in terms of the need for change in health professional education regarding the inadequacy of educational institutions in their response to social demands. Currently, taking into account the advances in the health education field worldwide, and a growing concern in terms of the quality of the training provided, several teacher training programs are contemplated and have been developed, in addition to renewed consideration of the professional competence and methodological aspects, given that these are major requirements in the field of professional ethics and the personal requirements for all professions in the contemporary world⁽²⁾.

It is understood that, in terms of the process of preceptor formation, such individuals need to conceive what a dialectical process of teaching and learning means in educational and pedagogical perspective models that go beyond the mere transmission of knowledge,  in such a way as to allow professionals to apply knowledge gained from the complex and contradictory situations considered, to their daily professional lives, and provide them with the ability to overcome obstacles and build alternative solutions. To ensure a non-fragmented training approach and to contribute to a systematic and well-founded reflection on the healthcare model aimed at preceptor development, an educational strategy that encourages an emancipatory perspective is needed⁽³⁾.

A preceptor must also have the ability to integrate the concepts and values of education and work in such a way as to serve as a model and source of reference.  In such a way they will inspire students to develop clinical skills, and embrace the inherent value of nursing practice, respecting them as members of the nursing team, working on their inexperience and lack of confidence, and encouraging them to develop as future ethical and committed professionals⁽⁴⁾.

In this sense, active methods in the development of the teaching-learning process, intentionally working with problems and valuing the learning to learn process, such as found in the Problematization Methodology (PM) have long been recognized. In this methodology, the reflection process triggers a search for explanatory factors in terms of solutions or amendments to the problem(s). The contents are reconstructed by the student who needs to reorganize the material and adapt it to its previous cognitive structure, in order to discover relationships, laws or concepts that s/he will need to assimilate. Consequently, problematizing means the ability to resolve the conflict inherent in the problem⁽⁵⁾.

This study aimed to investigate the perceptions of resident nurses on the potentiating and limiting factors of the preceptorship role in a multidisciplinary residency program in oncology (MRPO) based on the application of PM.

METHOD

This is a descriptive study using a qualitative approach. The research is theoretically grounded in the historical critical pedagogy of Saviani, and the research questions have been addressed and further developed by through the use of PM, following the steps of the Arch de Maguerez.

The Arch of Maguerez is based on the lived reality, which seeks to work in a real life context, that is, taking reality as a starting point as shown below in the five stages of the study process: observation of reality → key points → theorization → solution hypotheses → application to reality (Figure 1), returning to the same reality, intending to transform it at some level⁽⁶⁾.

Figure 1 - Arch of Maguerez as used by Berbel from Bordenave and Pereira.

Source: Berbel and Gamboa, 2012(6).

The research was carried out in 2012 and 2013, and the data were collected in November 2012 in a public teaching hospital of the in the state of Rio de Janeiro, which offers MRPO.

The study involved 1st year MRPO nursing residents who entered the selection process in 2012.  The participants were intentionally selected for greater feasibility and operability in terms of data collection. They were then approached individually and in advance by the main research and presented with the research plan and the consent form. The main researcher had had a previous relationship with the participants, since she is an oncology nurse and preceptress of the afore-mentioned hospital.

The research population was composed of nine of the fifteen nursing residents who agreed to participate.  This made up a relatively young group (23-29 years of age) with a maximum of two years’ experience following graduation. Consequently, most of them were single women from other states of Brazil.

Discussions with the participating residents occurred in three meetings, based on the data collection scheme outlined below (Figure 2). The meetings were held in a classroom in their dormitory, 15 days apart. The meetings were mediated by the principal investigator. The research team included 2 doctors who were teachers from a higher education public institution, neither with a prior relationship with the research participants. These were included so that there was no loss of speech and subjective data, allowing the main researcher to stay focused and to maintain the steady rhythm of the discussion.

Figure 2 – Scheme for data collection.

Source: Scheme prepared by the researchers, Rio de Janeiro, 2012.

During each meeting, the researcher mediated the group discussion by typing and projecting data showing the summaries simultaneously to ensure visualization and collective analysis. Data were collected through participating observation and recording in a field diary by the research team, in addition to individual analyses of the participants. The individual syntheses were entered, and participants were identified by means of the letters A through I.

To process the data, the content analysis technique proposed by Laurence Bardin, was adopted.  This incorporated the following three stages: 1) pre-analysis; 2) material exploration; and 3) result processing and interpretation. Thus, the research data was gathered and organized from the initial reading. Secondly, they were coded from the registration units and, as a result, categorization was made possible. The elements were classified according to their similarities and differences, with subsequent reunification, based on common characteristics⁽⁷⁾, generating delimited thematic categories according to significant units. In light of the objectives of the research, two categories were identified: potentiating and limiting factors.

It should be noted that the project was approved by the Research Ethics Committee, under record number CAAE/03454912.0.0000.5243, fulfilling the ethical principles of Resolution 466/2012⁽⁸⁾.

RESULTS

The application of PM with the subjects participating in the research, led to the discussion of private and common issues, general and specific, regarding the role of the preceptorship in MRPO. It is worth noting that participation was intense, and that the topic generated discussion and controversy that reiterated the role of the preceptorship as a priority issue for the group.

The institution where the research was conducted offers Medical and Multidisciplinary Residences, and the latter include professional nursing categories, pharmacy, physical therapy, nursing, dentistry, psychology and social work. The teachers, tutors and mentors of the program are professionals linked to and/or belonging to the institution.  They are clinical staff with experience in oncological care in activities such as care, research, teaching, management, and cancer prevention/control and who have academic qualifications ranging from Specialists and Master’s degrees through to Doctorates. In the year 2013, the MRPO made use of 63 expert preceptors who were responsible for the supervision of residents in service. There were 69 counselors (65 with Master’s degree and four with Doctorates) who, when they were needed, also worked as preceptors.

The National Commission for Multi-professional Residences (NCMR) defines a preceptor a a professional who belongs to the teaching staff of an educational institution or service, being a staff member who is ethically and technically qualified to supervise the activities of residents in every stage of training⁽⁹⁾.

During the discussions facilitated by the application of PM, the participants identified potentiating and limiting factors with regard to preceptorship in MRPO.

Potentializing factors
Among the identified potential factors, we note that the group primarily elected points favorable to the preceptorship, linked to the dimension infrastructure, such as the fact that the institution receives injections of advanced technological resources, material resources and equipment suitable for teaching, research and support activities. For the group, these qualities contribute to the learning of advanced techniques and the improvement of scientific and technological knowledge related to healthcare.

The guarantee in terms of benefits provided by the institution such as scholarship, accommodation and food, was also recognized by participants as a factor that favors the teaching-learning process in MRPO, taking into account that there are few public institutions of repute offering residency programs in Oncology and these are concentrated in the Southeast region of Brazil. A study involving medical residents found a relationship between low academic and professional performance, and experience of a stressful process.  This was triggered by a lack of determination and organization on the part of the students, as well as by socioeconomic and family problems.  These led to one anxiogenic and/or depressive process, and disrupted student achievement during their specialization⁽¹⁰⁾.

Limiting factors
The research group also pointed out limiting factors with regard to the practice of preceptorship in the MRPO studied, associated with the didactic and pedagogical dimensions. Among them we may include a weakness in understanding their educational role on the part of the preceptors; difficulty in performing activities that integrate theory and practice; and a deficiency in the supervision and evaluation of the residents’ activities that were consistent with the program objectives.
Below are some of the statements by the residents that highlight the limiting factors:

... The roles are poorly defined or defined wrongly, which ultimately interferes with the development of activities in the field of practice – Resid. F.

There is a widespread institutional "confusion" regarding the roles of tutor and preceptor - Source: Speech registered in a field diary during debate at the 1st meeting.

... Residents are learning, but they are treated as professionals, (...) it is not interesting (for the resident) to know how to do something and not know why. - Source: Speech registered in a field diary during debate at the 1st meeting.

Learning at work means to study, discuss cases... not only work or be supervised, (but) to be corrected and receive help. Unfortunately they find that education means (only) work (and) that what you need is to work ... learn procedures! - Source: Speech registered in a field diary during debate at the 1st meeting.

Aggravations (...) occur due to lack of training on the part of the professionals to allow them to perform a guided assistance in technical procedures with the trainees, but which at the same time enhances the theoretical and scientific importance in the care provided to cancer patients - Resid. E.

In a piece of self-criticism, the group of residents considered the unwillingness not only of the preceptors, but also of the residents themselves, to be involved in the development of discussions and activities in addition to assistance in everyday practice. This can be understood by the fact that the institution has a good reputation for assistance, and where professionals add the supervisory function of the activities performed by residents in their working day, but with no financial benefit or reduction in in their workload. In the view of the resident nurses, this scenario is compounded by what are considered to be excessive working hours, although it respects the template of 60 hours of work/study per week, as recommended by regulatory agencies⁽¹¹⁾.

It should be remembered that, despite the fact that MRPO guidelines represent a problematizing pedagogy in which the actors are considered subjects in the learning and social processes, one can perceive a training mode that is much closer to the logic of training at work, of the "doing"; thus reducing and restricting the real and broad concept of education.

A problem to be faced is that the preceptors' awareness of the residents’ learning needs, do not always coincide with the residents’ vision about what he needs to learn, resulting in motivation problems. The recognition by the preceptor, in terms of the perception of the residents regarding their learning preferences and the relevance assigned to each subject, makes the process more effective⁽¹²⁾.

To play a significant role, didactics cannot be reduced and/or engaged only in the teaching of the means and mechanisms by which teaching-learning processes are developed. In reality, it should be a critical way of developing an emancipatory educational practice that is different from the traditional process and will not be done solely by the educator alone, but by him jointly with the student and other members of society⁽¹³⁾, thus developing motivational and creative teaching and learning strategies and sharpening the curiosity of those involved.

Intellectual curiosity is important, especially in a profession in which basic knowledge is constantly expanded as students/professionals come into contact with the reality of care aimed at another person⁽¹⁴⁾.

DISCUSSION

The data obtained from the meetings and discussions regarding preceptorship in the MRPO allowed the researchers to identify the lack of preparation of the preceptors as a theme/issue. The researchers then started to contemplate the dimensions of this issue/problem, considering from the point of view of multiple perspectives in order to understand possible reasons for the existence and maintenance of the issues raised by the participants.

Gasparin points out that a recognized problem involves, in reality, a range of perspectives, or a set of interdependent aspects, and their analysis should be considered in terms of multiple interfaces⁽¹⁵⁾.

The conceptual dimension was one of the dimensions identified. It could be perceived in the discussions that preceptors and residents were unaware of their roles and responsibilities in the MRPO. Resolution No. 2 of the National Multidisciplinary Residency in Health Commission⁽⁹⁾ defines the preceptor as a professional linked to the forming or executing institution, with a minimum amount of specialist training, who must be in the same professional area as the resident under his supervision. The resolution also points out that the preceptor’s function is characterized by the direct supervision of the practical activities performed by residents in the health services with regard to which the program is developed; therefore, the preceptor is the "…reference advisor for residents in carrying out practical activities experienced in daily care and health management"^(9:25).

The figure of the tutor was unknown to the residents, who only discovered it during the studies undertaken in the dispersion phase of the PM.

In this context, the group pointed out a degree of ignorance on the part of both residents and preceptors regarding the legislation that governs a multidisciplinary residency program. This legislation indicates that the residence is a teaching modality that aims at learning at work, and has not only the preceptor but also the tutor as subjects in the teaching-learning process. The tutor has the important task of promoting the academic orientation of the preceptors and residents, and "implement(ing) teaching strategies that integrate knowledge and practices, thus promoting the teaching-work integration, in order to provide the acquisition of skills in the pedagogical project of the program"^{(9: 25)}.

Thus, the tutor would be a key agent for the control of one of the main factors affecting  the residents’ perception of the preceptorship: the lack of integration between practice and theoretical discussion.

In the teaching of nursing, the preparation for clinical practice is undoubtedly a vital component for the construction of knowledge, and association strategies of the integration of theory and professional practice have been encouraged⁽¹⁶⁾.

For the participating residents, such detachment is due in part to the fact that practice is the responsibility of the preceptors, while theory is conducted by teachers.

The link between theory and practice in nursing education, as in any health course, must presuppose pedagogical actions that exceed the confines of the academic discipline, inserting the subject in the process of formation, in the production of care, thus linking the world of education to the world of work⁽¹⁷⁾.

The polarity between the criteria of the residential experience and the reality of dissociation between theory and practice, is an everyday paradox for residency programs. Such a context refers to the serious problems faced by these workers with regard to staff policies, to the precarious conditions experienced in the workplace and the limited number of opportunities for teacher training and continuing education. This translates into a daily exercise of problematizing the collective labor issues and pedagogical purposes related to this work⁽³⁾.

In a residency program, such educational provision only survives if it overlaps with the dialogic process of teaching and learning, based on an educational model aimed at overcoming the mere transmission of knowledge, enabling professionals to extract from the complex and contradictory situations of everyday life the possibility of overcoming obstacles and building alternative interdisciplinary solutions.

Missaka points out that the preceptor has the potential to do more than apply theory to practice, and can incorporate clinical practice that raises issues and motivates the search for explanations or solutions⁽¹⁸⁾.

Deep learning is associated with the perception of choice and a sense of independence, and requires a receptive work environment. However, the ability to compare the degree of supervision with the degree of independence of action must be carefully considered. If, on the one hand, an excess of freedom in professional practice might lead the resident to feel abandoned, very close supervision might interfere with the sense of freedom and hinder the development of skills that should last a lifetime⁽¹²⁾.

The preceptor term is designated as the one that provides precepts or instructions as a trainer or educator. In research performed by Missaka⁽¹⁸⁾, the use of this term in published articles and in Brazilian laws and regulations, refers to the professional who often does not belong to academia but who has an important role to play in the integration and socialization of new graduates in the workplace. It should be noticed that in the MRPO study, preceptors have care competency, but fail in the educational role of encouraging residents to develop skills to perform such procedures. They are not able to bridge the gap between theory and practice. Instead, they seem to increase it.

In this scenario, during the dispersion phase, the participants identified that the lack of financial assistance for the supervision of resident nurses, works as a demotivating factor for preceptors. Ordinance No. 754/GM sets standards for the implementation and execution of the scholarship program for education through work experience, establishing scholarship opportunities for preceptors, tutors and advisors in terms of the services related to multidisciplinary residencies⁽¹⁹⁾.

However the participating residents found that, since it is a teaching hospital, serving as a preceptor or facilitator in the learning process of resident nurses, is included in the server statute received by professionals on their admission to the institution, without any mention of financial support. Such a fact shows that the institution recognizes its role in the Unified Health System (UHS) as the authorizing body in terms of human resources, and the importance of enabling the in-service training of health professionals. However, not all professionals are engaged in this challenge, considering that the entry of students leads to the lack of accommodation and requires openness to a new focus on teaching and assistance for which they are unprepared.

Reflection on what should be done to solve the issue of the lack of preparedness on the part of the preceptors has revealed an operational and political dimension related to the apparent lack of pedagogical training with regard to preceptors.

Most preceptors are chosen for their professional merits, which are not always reflected in the ability to teach. Many of them do not have - or have very little - proper pedagogical preparation, which may impair the improvement of the residence experience⁽¹²⁾.

Even today the vast majority of professionals have been trained as the result of the traditional model of education. In this context, we must remember that the troubled bureaucratic routines and care chores of nurses, in addition to an excessive workload and a frequent insufficient institutional quantity of personal ends up favoring the static transmission of knowledge.

Consequently, when preceptors find themselves in this professional situation, they often reproduce their experience of education in their relationship with resident nurses. This raises the need for the institution to consider the development of the preceptor, discussing with him, for example, teaching strategies in terms of health, didactics, organizational concepts, active learning pedagogies, assessment methods and use of information and communication technologies⁽¹⁸⁾.

Finally, preceptory has been described as a key activity for the process of promoting the construction of meaningful knowledge and the training of human resident nurses. However, the residents pointed out that the application of PM seems to be a methodological way that is unknown to both teachers and preceptors as they are used to the mere transmission of knowledge, requiring of its actors a different understanding of the dynamics of this process.  This requires listening, flexibility, wisdom, availability and proactivity, in the search for greater efficacy and in order to achieve its ultimate goal, which is the qualified training and excellence in the assistance provided by the professionals involved.

CONCLUSION

The research confirms the importance of the problematization of residency as a destabilization strategy with regard to the crystallized practices of professionals and staff, and the need for openness to the pedagogical qualifications of the professionals involved in the preceptorship.

According to the understanding of the participants, the preceptors' group perceives itself, at times, without the qualifications required for the research activities related to residency, given that most of these consist of experts with extensive experience in healthcare, but little experience in teaching and research activities.

An attempt to address this shortcoming would be the promotion of teaching method and research courses for preceptors, and enabling vacancies on graduate courses, especially at the professional Master's and doctoral levels.

It is noteworthy that, despite the fact that the scientific and educational domains are essential for the development of preceptors' work during the research process, at no time the residents have inquired or have shown related skills concerning the care provided to cancer patients and their families.  The appropriate reflection on the suffering, pain and hopelessness that are often presented in this scenario, can add significant value to learning about specialized assistance in all its aspects.

During the dynamic situation proposed by the researchers, we noticed a group of participative residents who were interested in PM and willing to discuss problems encountered in their daily lives. The discussions were enriching and exciting for everyone, since they could break the unilateral addiction to knowledge transfer that shapes traditional teaching.

Therefore, the results of this study allow the conclusion that, once they are incorporated into daily work, involved in activities at the institution for several hours a day, residents become aware of the structure and the dynamics of services, as well as the relationship between the key players as part of their learning process. Thus, the need to consider the perception of residents regarding the development of the course was revealed, once they had developed the ability to point out the relevant aspects, the difficulties encountered, and had suggested changes to improve the quality of services and the on-going improvement of the program.

However, despite the criticisms made, it was noted that, in the opinion of the participants, the results of learning within the residency program was positive. The facts that the residents had an opportunity to engage in differentiated clinical practice, and that the knowledge acquired with regard to oncology were unquestionably valuable, were recognized. The fact that residents experience all sectors of the healthcare institution, represents one of the reasons for the perceived quality of the professional experience provided by the program.

We emphasize that this article is not intended to end or exhaust the discussion regarding the problems experienced in the residency program, nor with regard to preceptorship. What we expect is that it will motivate a debate in other residency programs that suffer from the same problems, and will encourage such providors to propose and implement pedagogical training programs for their preceptors.

We also would hope that the potentialities and facilities highlighted by the problematization methodology as a pedagogical strategy that proposes contact with reality, revisits previous experiences and presupposes reflective thinking on the part of the people involved, encourages its use in other graduate education programs. This is because, in education in general, such an approach excels not only for the formation of a critical professional, but also for the education of dialogic and emancipated citizens, aware of their rights and duties and, above that, in terms of subjects that are active and transformers of their real scenarios.

REFERENCES

1. Melo MC, Queluci GC. Problematization methodology in nursing of oncologic education: a descriptive study. Online Braz J Nurs (Online) [ internet ]. 2012 Oct 23 [ Cited 2012 Nov 10 ] 11 (2) Suppl. 1. Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/3965. Doi: http://dx.doi.org/10.5935/1676-4285.2012S020.

2. Mourão LC, L'Abbate S. Teaching implications in curricular transformations in the field of Health: a socio-historical analysis. Online Braz J Nurs (Online) [ internet ]. 2011 set-dez. [ Acesso em 10 nov 2013 ] 10(3). Disponível em: http://www.objnursing.uff.br/index.php/nursing/article/view/3423/1136

3. Jesus JCM, Ribeiro VMB. Uma avaliação do processo de formação pedagógica de preceptores do internato médico. Rev Bras Educ Méd, 2012; 36(2): 153-161.

4. Brathwaite AC, Lemonde M. Team Preceptorship Model: A Solution for Students' Clinical Experience. ISRN Nursing (Online) [ internet ]. 2011 May 4. [ Cited 2014 Jan 13 ] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169842/pdf/NURSING2011-530357.pdf. doi:10.5402/2011/530357

5. Marin MJS, Gomes R, Marvulo MML, Primo EM, Barbosa PMK, Druzian S. Pós-graduação multiprofissional em saúde: resultados de experiências utilizando metodologias ativas. Interface (Botucatu) (Online) [ internet ]. 2010 abr-jun [ Acesso em 2 Ago 2011 ] 14(33). Disponível em: http://www.scielo.br/pdf/icse/v14n33/a08v14n33.pdf.http://dx.doi.org/10.1590/S1414-32832010000200008.

6. Berbel NAN, Gamboa SAS. A metodologia da problematização com o Arco de Maguerez: uma perspectiva teórica e epistemológica. Filosofia e Educação (Online) [ internet ]. 2011 out - 2012 mar [ Acesso em2 Set 2011 ] 3(2). Disponível em: http://www.fae.unicamp.br/revista/index.php/rfe/article/view/2363/2635.

7. Bardin L. Análise de conteúdo. 1 ed. Revista e ampliada. Lisboa: Edições 70, 2011. 280 p.

8. Ministério da Saúde (Brasil). Resolução nº 466 de 12 de dezembro de 2012. Dispõe sobre as diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. Diário Oficial da União, nº 112, p. 59, 13 jun 2013; Seção 1.

9. Secretaria de Educação Superior. Comissão Nacional De Residência Multiprofissional Em Saúde (Brasil). Resolução nº. 2, de 13 de abril de 2012. Diretrizes Gerais para os Programas de Residência Multiprofissional e em Profissional de Saúde. Diário Oficial da União, nº. 73, p. 24-5, 16 abr 2012; Seção 1.

10. Silva GCC, Koch HA, Sousa EG, Gasparetto E, Buys RC. Ansiedade e depressão em residentes em Radiologia e Diagnóstico por Imagem. Rev. Bras. Educ. Med., 2010: 34(2): 199-206.

11. Secretaria de Educação Superior. Comissão Nacional De Residência Multiprofissional Em Saúde (Brasil). Resolução nº. 3, de 04 de maio de 2010. Dispõe sobre a duração e a carga horária dos programas de Residência Multiprofissional em Saúde e de Residência em Área Profissional da Saúde e sobre a avaliação e a frequência dos profissionais da saúde residentes. Diário Oficial da União, nº. 84, p. 14-5, 05 mai. 2010; Seção 1.

12. Skare TL. Metodologia do ensino na preceptoria da residência médica. Rev. Med. Res. (Online) [ internet ]. 2012 abr-jun [ Acesso em 10 ago 2013 ] 4(2). Disponível em: http://www.crmpr.org.br/publicacoes/cientificas/index.php/revista-do-medico-residente/article/view/251.

13. Moura ECC, Mesquita LFC. Estratégias de ensino-aprendizagem na percepção de graduandos de enfermagem. Rev. Bras. Enferm. (Online) [ internet ]. 2010 set-out. [ Acesso em 10 jan 2014 ] 63(5). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672010000500016

14. Wangensteen S, Johansson I, Björkström ME, Nordström G. Critical thinking dispositions among newly graduated nurses. J Adv Nursing (Online) [ internet ]. 2010 jun 14. [ Cited 2012 Oct 10 ] 66(10). Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2010.05282.x/pdf. Doi: 10.1111/j.1365-2648.2010.05282.

15. Gasparin JL. Uma didática para a pedagogia histórico-crítica. 5 ed. Campinas – SP: Autores Associados, 2009. 190 p.

16. Sinclair B, Ferguson K. Integrating Simulated Teaching/Learning Strategies in Undergraduate Nursing Education. International Journal of Nursing Education Scholarship. (Online) [ internet ]. 2009 [ Acesso em 17 ago 2011 ] 6(1). Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/19341357.

17. Silva MG, Fernandes JD, Teixeira GAS, Silva RMO. Processo de formação da(o) enfermeira(o) na contemporaneidade: desafios e perspectivas. Texto Contexto Enferm. (Online) [ internet ]. 2010 jan-mar. [ Acesso em 12 jan 2014 ] 19(1). Disponível em: http://www.scielo.br/pdf/tce/v19n1/v19n1a21.pdf

18. Missaka H. A prática pedagógica dos preceptores do internato em emergência e medicina intensiva de um serviço público não universitário. Rio de Janeiro. Dissertação [ Mestrado em Educação em Ciências e Saúde ] – Núcleo de Tecnologia Educacional para a Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, 2010.

19. Ministério da Saúde (Brasil). Portaria nº 754, de 18 de abril de 2012. Altera a Portaria nº 1.111/GM, de 5 de julho de 2005 que Fixa normas para a implementação e a execução do Programa de Bolsas para a Educação pelo Trabalho. Diário Oficial da União, nº 77, p. 47, 20 abr 2012; Seção 1

All authors participated in the phases of this publication in one or more of the following steps, in According to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the versión submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received: 9/22/2013
Revised: 12/1/2014
Approved: 12/1/2014