PRECEPTORY AND THE TEACHING-LEARNING PROCESS IN OBSTETRIC NURSING RESIDENCES: INTEGRATIVE REVIEW

RESUMO

Objetivo: Descrever evidências sobre a preceptoria e o processo ensino-aprendizagem durante a pós-graduação lato sensu, sintetizando contribuições para a enfermagem obstétrica na modalidade residência. Método: Revisão integrativa nas bases BDENF, MEDLINE e LILACS, nos idiomas inglês, português e espanhol, na linha temporal de 2016 a 2022. Resultados: Do quantitativo de 264 artigos, 23 produções adequaram-se à revisão. Os desafios referendados dentro da preceptoria em outras especialidades da enfermagem são os mesmos da preceptoria em residência obstétrica. A interpretação de dados gerou: Preceptoria: oportunidade de conciliação de conhecimento teórico-prático; Necessidade de capacitação pedagógica para preceptores; Preceptoria como elo entre ensino-serviço-comunidade.Conclusão: O cenário científico brasileiro da enfermagem carece de estudos sobre a temática com foco propositivo e interventivo. É premente que os programas de residências obstétricas instrumentalizem seus preceptores com formação pedagógica, meios de enfrentar o estresse, apoio institucional e financeiro do bojo de projetos e programas de saúde.

Descritores: Enfermagem Obstétrica; Preceptoria; Capacitação Profissional; Educação em Enfermagem; Educação de Pós-Graduação em Enfermagem.

 

ABSTRACT

Objective: To describe evidence on preceptorship and the teaching-learning process during the lato sensu postgraduate course, summarizing contributions to midwifery in residency. Method: Integrative review in the BDENF, MEDLINE and LILACS databases, in English, Portuguese and Spanish, in the timeline from 2016 to 2022. Results: Of the quantitative of 264 articles, 23 productions were suitable for the review. The challenges endorsed within preceptorship in other nursing specialties are the same as preceptorship in obstetric residency. Data interpretation generated: Preceptorship: opportunity to reconcile theoretical and practical knowledge; Need for pedagogical training for preceptors; Preceptorship as a link between teaching-service-community. Conclusion: The Brazilian scientific scenario of nursing lacks studies on the subject with a propositional and interventional focus. It is imperative that obstetric residency programs equip their preceptors with pedagogical training, ways to deal with stress, institutional and financial support from the core of health projects and programs.

Descriptors: Obstetric Nursing; Preceptorship; Professional Training; Education Nursing; Education Nursing Graduate.

 

RESUMEN

Objetivo: Describir evidencias sobre la preceptoría y el proceso de enseñanza-aprendizaje durante el posgrado lato sensu, resumiendo aportes a la enfermería obstétrica en la modalidad de residencia. Método: Revisión integradora en las bases de datos BDENF, MEDLINE y LILACS, en inglés, portugués y español, en la línea de tiempo de 2016 a 2022. Resultados: Del cuantitativo de 264 artículos, 23 producciones resultaron aptas para la revisión. Los desafíos endosados ​​dentro de la preceptoría en otras especialidades de enfermería son mismos que los de la preceptoría en residencia obstétrica. Interpretación de los datos generados: Preceptoría: oportunidad de conciliar conocimientos teóricos y prácticos; Necesidad de formación pedagógica de los preceptores; La preceptoría como vínculo entre enseñanza-servicio-comunidad.Conclusión: El escenario científico brasileño de la enfermería carece de estudios sobre el tema con enfoque propositivo e intervencionista. Es imperativo que los programas de residencia obstetricia doten a sus preceptores de formación pedagógica, formas de lidiar con estrés, apoyo institucional y financiero desde el seno de los proyectos y programas de salud.

Descriptores: Enfermería Obstétrica; Preceptoría; Capacitación Profesional; Educación en Enfermería; Educación de Postgrado en Enfermería.

 

INTRODUCTION

In terms of care from childbirth to the puerperium, reproductive planning in the Unified Health System for the mother-child binomial, the Rede Cegonha recommends conciliation with other networks of maternal and child health care in development in the Brazilian regions. 1 Therefore, the development of new care models is urgent and this involves the maturation, qualification and improvement of obstetric residency programs, especially nursing.

Thus, by recognizing preceptorship as important and common among instances involved in this training process, actions were listed to qualify preceptorship and teaching-service integration, with a view to strengthening Nursing training, highlighting the need to promote pedagogical training for preceptors and to plan training in an articulated way, involving the protagonists of the world of work and health education. 2

The pedagogical training of preceptors enables the qualification of in-service teaching, since the reduction of education to mere technical training weakens its formative and human character. It is also observed that the challenging situations of the obstetrical nursing work are not part of the contents worked on by the preceptors, as they are perceived as limiting the in-service teaching of the residents. 3

It is asserted that the theoretical-practical relationship brought barriers, however the construction of praxis overflows the existing gaps, which established and organized since professional training, is fundamental in improving the quality of care for women in natural childbirth. Currently, the complexity required to care for the population makes residents agile in clinical judgment and critical thinking, requiring training and support from experienced and prepared preceptors. 4-5

In view of the above, the objective of this review is: To describe evidence on preceptorship and the teaching-learning process during the lato sensu postgraduate course, summarizing contributions to obstetric nursing in the residency modality.

 

METHOD 

This is an integrative review (IR), a method that enables the synthesis of evidence and the generation of new knowledge. To achieve this, six steps were taken: identification of the theme and selection of the hypothesis or research question; establishment of criteria for inclusion and exclusion of studies/sampling or literature search; definition of the information to be extracted from the selected studies; assessment of the quality of included studies; interpretation of results; and synthesis of knowledge. 6

Based on these recommendations, the following question was elaborated: What is the evidence from studies on preceptorship and the teaching-learning process during postgraduate studies, which allow introjections for obstetric nursing in the residency modality? After formulating the research question, the descriptors were defined and the search strategy was planned.

The terminology of the Descriptors in Health Sciences (DeCS/Bireme) was used: [Preceptoria], [Educação em enfermagem], [Educação em Enfermagem de Pós-Graduação], [Enfermagem obstétrica]. The search was performed with isolated and associated descriptors using the Boolean operator “and” and “or”. After defining the descriptors, the following databases indexed in the Virtual Health Library (VHL/BIREME) were selected: Lilacs (Literatura Latin America and the Caribbean in Health Sciences), Medline (Online Medical Literature Search and Analysis System) and BDENF (Nursing Database).

The following inclusion criteria/filters were established: 1) Language: Portuguese, English and Spanish; 2) Period: last six years (2016 to 2022); 3) Availability: full texts available online; and 4) Content: focus on post-graduation in obstetrical nursing in the residency modality. As exclusion criteria: tangency to the topic addressed, monographs, editorials, reflections and secondary studies.

A validated instrument adapted for extracting information such as title, authors, databases, method, level of evidence and year was used. 7 Data organization took place in Microsoft Word tables and storage of documents in pdf format by the researcher.

To establish Evidence-Based Practice, the seven levels of reference were adopted: level 1 – studies from systematic review or meta-analysis of relevant randomized, controlled clinical trials or from clinical guidelines based on systematic reviews of randomized controlled clinical trials; level 2 – evidence derived from at least one well-designed randomized controlled clinical trial; level 3 – evidence obtained from well-designed clinical trials without randomization; level 4 – evidence from well-designed cohort and case-control studies; level 5 - evidence from a systematic review of descriptive and qualitative studies; level 6 - evidence derived from a single descriptive or qualitative study; level 7 - evidence from the opinion of authorities and/or report of expert committees.8 The interpretation of the results took place between December 2021 and March 2022, with the formation of axes of debate in a descriptive way.

 

RESULTS

264 articles were identified as results. 241 productions were excluded, so the final sample for analysis and interpretation consisted of 23 articles, as illustrated in Figure 1.

 

Figure 1 – Database search flowchart, 2022.

Source: elaborated by the authors, 2022.

 

Of the totality of 23 studies, they were divided into twelve (12) national ones and eleven (11) international ones, and the national studies were carried out in only 03 regions of the country: Midwest, South, Southeast and Northeast. We highlight the need to produce knowledge on the subject in other regions, with emphasis on the North region.

An analytical reading was carried out to identify recording units that enabled the elaboration of three categories. The subject of preceptorship and the teaching-learning process in residency is mostly addressed in other articles, in the various nursing specialties, and it is perceived that the challenges encountered within obstetric preceptorship are the same, regardless of the specialty.

 

TABLE 1 – Synoptic table, 2022.

TITLE	METHOD/ LEVEL OF EVIDENCE/ DATABASE/ YEAR
Training in the residency modality in obstetric nursing: a hermeneutic-dialectic analysis (A formação na modalidade residência em enfermagem obstétrica: uma análise hermenêutico-dialética)	Qualitative/ VI/ LILACS/ 2020
In-service teaching of obstetrical nursing residents from the perspective of preceptorship (Ensino em serviço de residentes de enfermagem obstétrica na perspectiva da preceptoria)	Qualitative/ VI/ BDENF/ 2019
The teaching-community service integration in the nursing course: what the preceptor nurses say (A integração ensino-serviço comunidade no curso de enfermagem: o que dizem os enfermeiros preceptores)	Qualitative/ VI/ LILACS/ 2020
Effect of Nurses’ Preceptorship Experience in Educating New Graduate Nurses and Preceptor Training Courses on Clinical Teaching Behavior	Qualitative/ VI/ MEDLINE/ 2021
Elaboration of a pedagogical project for preceptorship of nurses in cardiac intensive care (Elaboração de projeto pedagógico para preceptoria de enfermeiros em terapia intensiva cardiológica)	Qualitative/ VI/ BDENF/ 2020
Strategies for changing the activity of preceptorship in nursing in Primary Health Care (Estratégias para a mudança na atividade de preceptoria em enfermagem na Atenção Primária à Saúde)	Qualitative/VI/ MEDLINE/ 2021
Experiential knowledge of nursing residency preceptors: an ethnographic study (Conhecimento experiencial de preceptores de residência de enfermagem: um estudo etnográfico)	Qualitative/ VI/ LILACS/ 2017
Nursing preceptorship in a public health service (Preceptoria em enfermagem em um serviço público de saúde)	Qualitative/ VI/ BDENF/ 2019
Does Nurse Preceptor Role Frequency Make a Difference in Preceptor Job Satisfaction?	Quantitative/ VI / MEDLINE/ 2021
Preceptorship as part of the recruitment and retention strategy for nurses? A qualitative interview study	Qualitative/ VI/ MEDLINE/ 2021
Contributions of the Education through Work Program to Primary Health Care preceptors (Contribuições do Programa de Educação pelo Trabalho aos preceptores da Atenção Primária à Saúde)	Qualitative/ VI/ LILACS/ 2020
Elaboration of a support manual for preceptors of undergraduate students in Primary Health Care (Elaboração de um manual de apoio para preceptores de alunos de graduação na Atenção Primária em Saúde)	Qualitative/ VI/ LILACS/ 2019
Teaching in health residencies: preceptors' knowledge under Shulman's analysis (Ensino nas residências em saúde: conhecimento dos preceptores sob análise de Shulman)	Qualitative/ VI/ LILACS/ 2020
Preceptorship in obstetric nursing: training-intervention in health work (Preceptoria em enfermagem obstétrica: formação-intervenção no trabalho em saúde)	Qualitative/ VI/ LILACS/ 2020
Fifteen years of Multiprofessional Residency in Family Health in Primary Health Care: contributions from Fiocruz (Quinze anos da Residência Multiprofissional em Saúde da Família na Atenção Primária à Saúde: contribuições da Fiocruz)	Qualitative/ VI/ LILACS/ 2021
A preceptorship model to facilitate clinical nursing education in health training institutions in Botswana	Qualitative/ VI/ MEDLINE/ 2021
A Clinical TeachingBlended Learning Program to EnhanceRegistered Nurse Preceptors’ TeachingCompetencies: Pretest and Post test Study	Quantitative/ VI / MEDLINE/ 2020
Transition Shock, preceptor support and nursing competency among newly graduated registered nurses: A cross-sectional study	Quantitative/ VI / MEDLINE/ 2021
Nurse preceptors’ perceptions of benefits, rewards, support, and commitment to the preceptor role in a new preceptorship program	Quantitative/ VI/ MEDLINE/ 2022
Preceptors' perceptions of support, commitment to the preceptor role, and preferred incentives: A cross-sectional study	Quantitative/ VI/ MEDLINE/ 2022
Development and Preliminary Evaluation of the Effects of a Preceptor ReflectivePracticeProgram: A Mixed-Method Research	Quantitative and Qualitative, descriptive/ VI/ MEDLINE/ 2022
The Obstetric Nursing Residency Program at Sofia Feldman Hospital from the perspective of residents: potentialities and challenges (O Programa de Residência em Enfermagem Obstétrica do Hospital Sofia Feldman sob a perspectiva dos residentes: potencialidades e desafios)	Qualitative/ VI/ MEDLINE/ 2022
The teaching of good obstetric practices from the perspective of the Residency preceptors (O ensino das boas práticas obstétricas na perspectiva dos preceptores da Residência)	Qualitative/ VI/ LILACS/ 2022

Source: authors' analysis, 2022.

 

The analysis of the level of evidence resulted in all studies (23) as level VI, being descriptive studies and precisely lacking proposals and interventions in the Brazilian scientific scenario.

 

DISCUSSION

 

Preceptorship: opportunity to reconcile theoretical and practical knowledge

The dialectic relationship between theory and practice was perceived, presenting theoretical disparities in the scientific knowledge acquired in the residency and the practice of nurses between the empiricism of nurses, in addition to disputes between professionals in the obstetric scenario as part of the challenge to be overcome. 4-5 

It is still present today that the teaching of residents is organized in a hierarchical way, but it is known that such roles do not favor dialogicity between the actors involved in the training process and causes the breakdown of the empathic relationship necessary for professional dialogue. Such an option brings a deficiency in training, as it does not lead the resident to have the necessary attitudes to critically reflect on the practical reality of the specialty. And even though residents are encouraged to adhere to humanized care, the training focus of some residencies is more focused on distancing from medicalized practices than on reflecting on and facing the factors that determine their persistence in health institutions. 3

Some studies on preceptorship bring the perspective that active learning values problematic situations and favors the learning process. In this way, real work situations encourage preceptors to seek other sources of knowledge to solve them, thus improving knowledge. Therefore, a preceptor who has been practicing for a long time has better knowledge of the position, as the experience itself guarantees the exercise of the profession and the experience is transformed. Preceptors create their own means of teaching through experiential knowledge, forming an identity, a professional personality. In order to teach, an inseparable dialogical process of teaching-learning is fundamental, based on problematizing and liberating education. Teaching cannot be decontextualized from practice, since preceptors bring to light knowledge: disciplinary, curricular, professionalizing and experiential. 9-10

The role of preceptorship within this teaching context must maintain a reflective practice, associated with appropriate didactics. It is explained that the preceptor participates in health training, articulating work with teaching, being a protagonist in the teaching-learning process of the residency program, and he needs to have knowledge that goes beyond knowledge about practice. It is necessary, for the exercise of preceptorship, that the professional has mastery not only of clinical knowledge, but is able to transform the experience of the professional field into learning experiences. It strengthens that for residency programs in health in lato sensu training, education at work, the teaching-learning process in the service, articulating theory and practice, or praxis, is essential. 11

Highlighting all these arguments, it is emphasized that preceptorship is an opportunity to reconcile theoretical and practical knowledge and improve pedagogical skills for the professional who transmits this knowledge. Therefore, there is a need to stimulate critical thinking and the aptitude of these preceptors for research in the educational phase. In addition, the support of the educational institution through formal training based on needs, regular assessment and updated feedback on the activities developed, result in the balance of the preceptor's role, which, consequently, lead to an improvement in nursing competence among residents. 12 

 

Need for pedagogical training for preceptors

First, the preceptorship must have effective conditions to adequately exercise its role in the planning, development and evaluation of the residents' teaching, in a participatory manner in the scope of theoretical and practical activities. There is an absence of constant dialogue between Higher Education Institutions (HEIs) and health services, teachers and preceptors, the lack of didactic-pedagogical training of the latter, and the discontinuity of the HEI's presence in services. 3

In the first study to investigate nurse preceptors' perceptions of benefits, rewards, support, and their commitment to their role in a new nurse preceptorship program in Iran,   the level of commitment found was moderate, mostly associated with perceived benefits,   rewards and support. Preceptors feel little supported and have a huge workload, a reality that calls for a broad debate on how to achieve success in a residency program without improving such commitments, and making interventions necessary to remedy such preceptorship dilemmas. 13

Thus, macro-scale interventions can be implemented to reduce preceptor nurses' burden and stress. The Preceptor Reflective Practice Program, guided by the precepts of sharing experiences and emotions with fellow nurse preceptors, had the effect of increasing emotional intelligence and coping with stressful situations. 14

Although residency programs are part of public policies for the qualification of specialist professionals for the SUS in Brazil, there are limited incentives to promote pedagogical training courses for preceptors. This fragility impairs the development of the pedagogical knowledge necessary for the teaching-learning of the residency and knowing how to transform daily care experiences into significant learning experiences and knowledge for the human and professional formation of the residents. Therefore, the university and the service are co-responsible for this process and for the educational bases necessary to achieve the objectives of training midwives in the residency modality. Future research should bring new data to analyze the content of training programs and develop training programs that can improve preceptors' behaviors. 15

The authors state that preceptors who, in a way, are closer to the academic environment, mainly through Stricto Sensu Graduate courses, feel more secure in carrying out their preceptor role. It is about knowing how to teach the practice and adequacy of knowledge so that the resident understands and learns. In this process, preceptors develop the model of reasoning and pedagogical action, building and rebuilding their knowledge about health practice. 16 

In the view of the study residents at the Sofia Feldman Hospital, the personal characteristics of the preceptors are an intricate factor for the development of the practical and theoretical-practical activities of the Residency Program. Some residents experience a paradox, satisfaction, security and fulfillment because they are in contact with theoretical and practical issues on a daily basis, but feel physical and emotional exhaustion due to the accumulation of tasks. Another element that causes obstacles are conflicts with the care models used by preceptors, which block the learning process. Pedagogical preparation is believed to be necessary to guide preceptors to what they should know and do, and what knowledge they need to master to anchor their practice, since qualification affects the quality of their teaching. 16-17

In obstetric nursing, the preceptorship process is developed, contributing to in-service training as a possibility to use improvement/updating in favor of the institution and intervene in the work of maternity hospitals. It is opportune to characterize that the teaching-learning relationships, when experienced in a dialogical-critical-reflective way, based on exchanges of information and practices based on updated evidence, through self-assessment in the maternity hospitals that were the field of practice. 18

To improve the teaching-service articulation in a theoretical-methodological dimension, a praxis support needs to be used, thus, the model of childbirth care itself has the potential to base the political-pedagogical project and the residency curricula. There are harmful behaviors established in teaching in residences, this makes it urgent to establish and discuss a specific curriculum for childbirth care that permeates the universe of action and also teaching knowledge. Sharing knowledge between preceptors and residents must go beyond technocratic repetitions and encourage collective meetings, in a perspective of democratic co-management, providing opportunities for analysis of training, attention/care and management work. 18-19

A cross-sectional study revealed that preceptors were more interested in compensation (such as financial compensation) for their services, not evaluating the gain in terms of professional development as well. Therefore, it is asserted for the allocation of greater resources for the development, training and work of preceptors. 20

Therefore, it is ratified that the preceptorship model must be based on training and support for preceptors who must be promoted to effective preceptorship. Giving incentives to preceptors can motivate more nurses to develop an interest in assuming the role of preceptors, preparing for clinical teaching will increase satisfaction with the role and sustain the desire to act as a preceptor. Organizations can consider integrating flexible intellectual and learning platforms into preceptorship education, such as web-based learning approaches, case-based and combined due to new trends in nursing practice, as clinical environments are increasingly complex and challenging, understanding that only from changing the way of caring for, treating and monitoring the health of Brazilians, it is possible to transform the way of teaching and learning. 21-23

 

Preceptorship as a link between teaching-service-community

The development of the nursing process stands out as an important agenda point, aiming to strengthen nursing as a profession, as well as the appreciation and autonomy of nurses, benefiting SUS users. Nursing preceptorship faces many challenges for the consolidation of this training modality that develops in the practice scenario, within which teaching-service integration plays an essential role. 2

Based on the speeches of the preceptors, it is verified that the presence of the resident in the health services triggers important reflections in the professionals, who start to carry out their activities in a more attentive and adequate way to the needs of the population. In this way, it is concluded that the integration of teaching, service and community enables gains for all those involved, whether HEIs, teachers, students, professionals and the community, providing a greater capacity to develop responsible and socially committed health and education activities. 24-25

For the preceptorship's work to be more efficient in the teaching-service-community integration, it is necessary to think about the possibility of investing in technical support, such as permanent training of preceptors, and perhaps payment of incentive grants for them as a form of financial retribution. Another perspective states that preceptorship should be seen as a social, collective and organizational responsibility, rather than the responsibility of individual preceptors. Creating a welcoming work environment for residents may therefore require changes in leadership, culture, and organizational structure. 26-27

 

CONCLUSION 

It is concluded that preceptorship in residencies in the area of nursing and mainly in the specialty of obstetrics is of great importance due to its essentially practical character, however, studies point out that the preceptor has a behavior of valuing practice too much to the detriment of theory, possibly this phenomenon occurs due to their distance from training institutions and because they are in the routine of the hospital service, which is more evident are practical situations of the practice of the specialty.

The lack of pedagogical training for preceptors was also highlighted in almost all studies, as HEIs do not prepare this professional to receive the resident in the field of practice, which makes the teaching-learning process difficult and, consequently, the performance of this future professional, who finish the residency course without adequate theoretical preparation on their expertise.

Finally, the integration of teaching-service-community must be seen as a social responsibility in the Unified Health System. There was a lack of knowledge about preceptorship and the teaching-learning process in the postgraduate program in obstetrical nursing in the residency modality. There are still few studies that directly address the preceptor's relationship, motivations and satisfaction with the role he performs in this context, the preceptor's mental health impacts and that bring the results after training for preceptorship provided by an HEI, with this, more research should appear in the area to fill this theoretical gap.

 

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