Open-access Supervised internship in undergraduate education in nursing: integrative review

La etapa curricular supervisada en la graduación en enfermería: revisión integrativa

ABSTRACT

Objective:  to analyze the evidence available in the literature on the contributions of the Supervised Internship in nursing training in Brazil and the teaching-learning methods employed.

Method:  integrative review of the literature, with search of articles published between 2002 and 2016, in PubMed, LILACS, SciELO and Eric databases.

Results:  Of the 4,699 articles consulted, 14 met the inclusion criteria. The analysis of these studies revealed three thematic categories: the understanding about the role of Supervised Internship; the teaching-learning processes employed; and their contributions to the training of nurses.

Final considerations:  this is a fundamental element in the academic training, since, depending on the didactic-pedagogical organization, it makes possible the (re) signification of the acquired knowledge throughout the course and realizes the professional competences. The teaching-learning methods are structured by the critical pedagogy, being the active methodologies the main choices of the authors.

Descriptors: Teaching; Learning; Nursing Education; Internships; Higher Education

RESUMEN

Objetivo:  analizar las evidencias disponibles en la literatura sobre las contribuciones de la Etapa Curricular Supervisionado en la formación en Enfermería en Brasil, y los métodos de enseñanza-aprendizaje empleados.

Método:  la revisión integrativa de la literatura, con búsqueda de artículos publicados entre los años 2002 a 2016, en las bases de datos PubMed, LILACS, SciELO y Eric.

Resultados:  De los 4.699 artículos consultados, 14 atendieron a los criterios de inclusión. El análisis de estos estudios reveló tres categorías temáticas: la comprensión acerca del papel de la Etapa Curricular Supervisada; los procesos de enseñanza-aprendizaje empleados; y sus contribuciones a la formación del enfermero.

Consideraciones finales:  es un elemento fundamental en la formación académica, pues, dependiendo de la organización didáctica pedagógica, posibilita la resignificación de los conocimientos adquiridos a lo largo del curso y concreta las competencias profesionales. Los métodos de enseñanza-aprendizaje están estructurados por la pedagogía crítica, siendo las metodologías activas las principales opciones de los autores.

Descriptores: La Educación; El Aprendizaje; Educación en Enfermería; Etapas; Enseñanza Superior

RESUMO

Objetivo:  analisar as evidências disponíveis na literatura sobre as contribuições do Estágio Curricular Supervisionado na formação em enfermagem no Brasil e os métodos de ensino-aprendizagem empregados.

Método:  revisão integrativa da literatura, com busca de artigos publicados entre os anos de 2002 a 2016, nas bases de dados PubMed, LILACS, SciELO e Eric.

Resultados:  Dos 4.699 artigos consultados, 14 atenderam aos critérios de inclusão. A análise desses estudos revelou três categorias temáticas: a compreensão acerca do papel do Estágio Curricular Supervisionado; os processos de ensino-aprendizagem empregados; e suas contribuições para a formação do enfermeiro.

Considerações finais:  é um elemento fundamental na formação acadêmica, pois, dependendo da organização didático-pedagógica, possibilita a ressignificação dos conhecimentos adquiridos ao longo do curso e concretiza as competências profissionais. Os métodos de ensino-aprendizagem estão estruturados pela pedagogia crítica, sendo as metodologias ativas as principais escolhas dos autores.

Descritores: Ensino; Aprendizagem; Educação em Enfermagem; Estágios; Ensino Superior

INTRODUCTION

Nursing education has been the focus of many studies and debates, mainly after the establishment of the National Curriculum Guidelines (DCN- Diretrizes Curriculares Nacionais) in 2001(1), generating a series of restructurings in professional training, such as not reducing the professional training of nurses development of technical and instrumental skills, incorporation of active learning methodologies, promotion of professional edification guided by the principles of integral care, considering the Brazilian Unified Health System (SUS) as the structuring axis of the training process(2), in addition to the incorporation of Supervised Internship (SI). All the restructuring proposed since 1996, the year of the promulgation of the Law of Directives and Bases of National Education (Lei de Diretrizes e Bases para a Educação Nacional- LDB) has contributed to the teaching of nursing to move towards the development of complex thinking, aiming to train more critical and reflexive professionals capable of acting in the different situations, proposing solutions to the problems encountered(3).

The Brazilian Nursing Association (ABEn- Associação Brasileira de Enfermagem) has been a protagonist about the technical, scientific, ethical and political development of the profession and, in 1994, through the 1st National Seminar on Guidelines for Nursing Education (SENADEn- Seminário Nacional de Diretrizes para Educação em Enfermagem), inaugurates one of the main structuring spaces in relation to nursing education in Brazil(4). The debates that took place in the 13th SENADEn, was held in the capital of Pará State in 2012, succeeded the Carta de Belém para a Educação em Enfermagem (Charter of Belém for Nursing Education). This paper presents a series of propositions regarding the processes of training of nurses in the country. Among them, it is necessary to rethink the practice of SI and the challenges encountered in the implementation of this teaching-learning method in vocational training(5).

The IS presents itself as a tool to approach the academy and services, since it can enable the use of knowledge, skills and professional attitudes seized by the student, who at the moment of the training strengthens their competences inserted in the work processes of health institutions. The objective is to lead the student to articulate theory and practice in a process of participatory training, permeated by the interlocution between teaching and learning in outdoor environments, with the active participation of professionals from the field of training, university and community(3).

The SI subsidizes the construction of a critical, curious and knowledge-building subject. Its methodology must collaborate to sharpen the faculties of observation of the future professional, besides developing the need to seek new knowledge of communication, flexibility and decision-making. Thus, the SI is immersed in the field of complexity of the training process, because it is through it that the student has the possibility of becoming an individual that boosts changes, once it is led to reflect on the reality of work processes and propose solutions to real problems experienced(4).

Thus, the future professional must have a differentiated vision of the field of work, being able to develop activities inherent to the exercise of Nursing. The context of the work encourages the professional to develop autonomy, responsibility, freedom, creativity, commitment, mastery of practice and social role, deepening knowledge and encouraging the professional to take on a transforming praxis(6).

Among the difficulties and challenges faced by undergraduate courses, the Belém Charter emphasizes the lack of clear conceptualization between practical activity, laboratory activity, theoretical-practical activity, clinical practice and SI; lack of clarity regarding the role of the field of nurses in SI activities; and the difficulties in broadening and regulating the offer of clinical practice fields and SI, among which the charter cites improving the conditions to accommodate students, tutors and professors for the development of clinical practices(5).

In response to the questions raised in that SENADEn(5), the Federal Nursing Council (COFEn- Conselho Federal de Enfermagem) published Ordinance 441/2013, positioning itself on the participation of the nurse in the supervision of the practical activity and the supervised internship of nursing students in the different levels of professional training, besides clarifying the concepts among the different activities(7). However, there are no reviews in the national literature that could help the discussion about the means, methods of teaching in SI, their results and their importance for the professional training of nurses, thus triggering the need for an integrative literature review.

OBJECTIVE

To search and analyze the evidence available in the literature on the contributions of Supervised Internship in nursing training in Brazil, in addition to the teaching-learning methods employed.

METHOD

This is an integrative review, which includes theoretical and empirical literature, as well as studies with different methodological designs (qualitative and quantitative). Its conclusion is the construction of a conclusion based on the synthesis of the main findings, making possible the analysis of preexisting knowledge about the subject investigated(8).

For its accomplishment, six stages were covered: identification of the theme and selection of the research question; establishment of inclusion/exclusion criteria (sample selection); definition of pre-selected and selected studies; categorization of studies; analysis and interpretation of results; and presentation of knowledge review/synthesis(8-10).

The Patient/population strategy, Intervention or issue of interest, Comparison intervention or issue of interest, Outcomes and Time (PICOT) strategy(11-12) was used to construct the guiding question. Component C was not used as it is not intended to make comparisons with other teaching methods.

Therefore, the following guiding question was defined: What is the scientific production that presents the contributions of Supervised Internship to the process of training nurses, their means and methods of teaching in Brazil, from 2002?

Chart 1 presents the elements used to construct the research question, and the descriptors and keywords from the PICOT strategy (11-12).

Chart 1
Description of the strategy Patient/population, Intervention or issue of interest, Comparison intervention or issue of interest, Outcomes and Time (PICOT)(11-12)

For the selection of articles, the following databases were used: Latin American and Caribbean Literature in Health Sciences (LILACS), Scientific Electronic Library Online (SciELO), US National Library of Medicine/National Institutes of Health (PubMed/MEDLINE) and Education Resources Information Center (ERIC) between June and July 2016. EndNote® software was used to manage references and to import articles from databases by organizing articles into groups called “selected for reading in full” and “deleted after reading title and abstract”.

The combination of descriptors and keywords was carried out using the Boolean operators AND (restrictive combination) and OR (additive combination), and the descriptors/keywords of the same acronym of the PICOT strategy(11-12) were used. OR, and for the combination of different acronyms, the AND(11-12).

The inclusion criteria were: original studies (quantitative, qualitative, quanti-qualitative, experience reports and case studies) available in full; published in Portuguese, English or Spanish, that portrayed the practice of SI at the national level, published in national and international journals and that were within the time frame from 2002 to 2016, considering that the publication of the DCN occurred in November 2001.

The exclusion criteria were: surveys that dealt with internships in the high school of nursing and/or undergraduate nursing courses; to investigate the internships and/or practical classes in the field of specific subjects, for example, nursing administration subjects; who had used the SI moment to analyze the whole process of training and/or implementation of a new curriculum structure; that did not present the students’ perspective about SI, but only one of the actors involved with the process (tutor or professor).

In order to extract the data, a spreadsheet in the Microsoft Excel 2007® program was prepared from an instrument validated and authorized by the author(13), with the following items: main author, country, language, year of publication and type of scientific journal; institution of the study (university, hospital, research center, single or multi-center institution); (clarity, type of study, location, characteristics of the subjects, method of data collection and analysis and methodological rigor - level of evidence(14)); results (SI concept, means and methods for its performance), conclusions or final considerations and implications for practice(15).

After the bibliometric analysis(16), the findings were analyzed, which were grouped by similarity and organized into thematic categories, resulting in the presentation of the knowledge review/synthesis(8).

RESULTS

The results were obtained after systematically covering all stages of the Integrative Review. The search strategy in the databases raised 4,699 articles, of which 40 were chosen to read the full text and 14 composed the work, as shown in the flowchart of Figure 1.

Figure 1
Flowchart of the methodological steps that made up the integrative review for the selection of articles

It was verified that the 14 selected studies were published between the years 2006 and 2014, with 28.6% occurring in 2014. There was a fair distribution among the journals that published research on the subject, considering that the articles were disclosed by 11 different journals, one article was published in an international journal and all articles were available in Portuguese. Regarding the classification of publication vehicles, it is observed that 50% and 28.6% of the journals were classified with Qualis Capes(17) B1 and A2, respectively, which shows the interest of the journals by the theme.

We found 35 different descriptors, of which 27 were controlled and the most frequent were: Nursing (42.8%), nursing students and nursing education (both with 35.7%). No specific controlled descriptors were observed, with supervised internship classified as a keyword, which makes it difficult to retrieve the scientific material for two reasons: the descriptors used are broad and portray nursing teaching in general, and the journals have opted for the use of descriptors and not keywords, making it impossible for the SI to be declared as a descriptor.

Most articles selected (85.71%) were obtained through the LILACS VHL database and only two were captured from SciELO. The surveys mainly portrayed the experience of the Public Universities, two portrayed the teaching in Private Universities, and one came from the service. The authorship is distributed among master’s degree (64.28%) and PhD (35.71%). The level of evidence of the studies can be considered low, since of the 14 selected, 7.15% had Level of Evidence IV(14) and 92.85% were classified with Level of Evidence VI(14). The student’s experience in the SI was the main focus of the studies (50%), followed by the teaching strategies (28.57%) used. Chart 2 shows the data used for the bibliometric review(16) of the studies.

Chart 2
Bibliometric analysis of the studies, according to year of publication, journal titles/classification, country of origin/language, database and level of evidence

The synthesis of knowledge was carried out through the following findings: objectives of the SI and/or concepts that the authors use teaching-learning methods employed during the SI and contributions to nursing education, considered as outcomes. The synthesis table is presented in Chart 3.

Chart 3
Distribution of selected studies, second title, objectives and/or concepts of Supervised Internship, means and methods of teaching learning and outcomes

DISCUSSION

Once the findings were organized and analyzed, the data were discussed through three thematic categories that best describe the results found: the understanding about the role of SI; the teaching-learning processes employed in the development of SI; and the contributions of the SI to the training of nurses.

Understanding the role of Supervised Internship

The SI has a core role in the professional training of nurses because it is not restricted to the academy nor to the technical and mechanical development of the future professionals to perform work activities inherent to the profession. It enables the student to be inserted into the health system of the Brazilian Unified Health System, as it is presented, without manipulations or even adjustments for the realization of teaching-learning processes(18-20,23-25,28,30).

By inserting the student into the real world of work, tutored by the concrete figure of the nurse professional, mediated by the didactic-pedagogical organization of the professor, with the objective of making real interventions in the work processes, seeks to ensure that teaching- part of the training process. This will aid the process of building professionals capable of making praxis (theory-practice articulation) subsidize collective reflections, resulting in changes in real health situations(18-19,23-24,28).

Mentoring has been recognized in the international literature as a strategy to maximize the benefits of nursing education in terms of acquisition of knowledge and skills, safety and professional socialization. Professionals play a fundamental role in the socialization, teaching and evaluation of nursing students, helping them to integrate theory with practice(32).

This, therefore, is a complex moment in the process of professional training, since the student who enters the SI requires the knowledge, skills and attitudes to develop the professional competence that so longs for, that is, to develop the capacity to mobilize, consciously and systematized, their cognitive, psychomotor and attitudinal functions in health decision making, whether clinical or management(33).

For some schools, it is during the SI that the student will exercise the role of nursing care manager, fostering the development of management skills: leadership, decision making, teamwork, communication, among others(20,22,25,29,33). This perspective attributed to the SI comes from the historical construction of the professional nursing training process in Brazil, because in 1972, Opinion 163/72 and Ordinance 04/72, both of the Federal Council of Education (COFEN), introduced the term Supervised Internship and linked this format to the discipline of administration applied to Nursing, which should be done at the end of the undergraduate course(3,34).

The development of management skills introduced the concepts of innovation, flexibility, teamwork and decentralized decisions in the work processes of the professionals who are in front of teams, guaranteeing the most effective participation of all those involved in the administrative and operational processes of an institution. Considering the role that nurses play in health teams, the discussion on management competencies has gained prominence both in the scope of work and professional training. In this sense, considering that of the six competencies pointed out by the DCN(1) five are management and one is considered indirect purpose of the management work(33), it is justified the tendency of the SI to work with administrative tools and management competencies.

In order to carry out the IS, the student must be matured in his professional training process and be able to mobilize theoretical and practical knowledge acquired in the various disciplines that integrate the curriculum, in order to contribute to the development of his own professional qualification(19,28). Therefore, it is clear why DCN determines that 20% of the total course workload should be allocated to the SI, and this should be developed in the last year of the course. Throughout their training, the student should be tooled by theoretical disciplines, disciplines that contemplate teaching through controlled practices, enabling skills training, and disciplines that contain clinical practices capable of developing in the student the ability to make clinical decisions(1,3).

Definitely, the practical class is not characterized as SI; therefore, this class has the purpose of leading the student to perform the practical part of certain content already worked in the classroom through theoretical studies. It also happens in health institutions, however, the student is constantly accompanied by the professor, learning to perform, prioritized, technical procedures, also mobilizing prior knowledge and developing professional attitudes through the real cases contained in the theory(7). Not to value the SI as a pedagogical strategy can lead to gaps in the learning process, contributing to the devaluation of Higher Education, since it collaborates in an important way for the development of critical thinking and for the improvement of the quality in the training of professionals(3).

The teaching-learning processes employed in the development of the Supervised Internship

All the teaching-learning methods presented by the authors are based on a real situation experienced by the student, who, supported by the internship nurse and the professor, reflects, theorizes and proposes strategies that can transform the local health reality into a movement of action-reflection-action(18,22-24,27-28,30-31).

Methods that introduce the student to the world of work, such as the questioning through the Arch of Maguerez, lead him to reflect on this reality, subsidizing the re-signification of concepts and knowledge that have as theoretical reference the liberating education, also called critical pedagogy. This pedagogical perspective argues that the student will only be critical if he knows reality, understands it, understands it in order to reflect, and, from this reflection, appropriates a critical character about it(33,35-36).

The teaching-learning methodology that was most cited by the authors is the Problem-Solving Methodology(20,23-24), which aims to solve work problems, whether in education or in other sectors through the indispensable association between theory and practice. Such a method aims to bring students closer to the reality of the profession, allowing them to learn from it, obtaining elements to take something back to that reality, in the form of reflections or suggestions to answer or solve specific problems, or at least soften them(36).

Other strategies from the science of management, for example, Normative Planning, Situational Strategic Planning (PES), Simplified Strategic Planning and the Altadir Method of Popular Planning (MAPP) have also been cited as a means of delivering interventions in reality. Administrative tools start from the perception of a problem, in which the student must collect data, systematize them, analyze them, reflect on these data and propose interventions for the real problem experienced at work(18,22,24,27-31). The use of these tools in the teaching-learning process characterizes the use of active teaching methodologies.

Realistic simulation is also used as a way to guarantee the student greater security and autonomy for the activities that make up the SI(21). It is one of the active learning methods used in health education for the development of basic nursing skills. However, currently, the simulation has taken more contemporary approaches, offering opportunities to develop work experiences through complex clinics in safe learning environments. The American Association of Nursing Colleges recently released a report stating that there has been a large increase in the use of realistic high fidelity simulation in Higher Education in Nursing for the potential to develop clinical reasoning and decision making in a controlled and safe manner(37).

Active methodologies are in line with the need to review old traditional, content-oriented, professor-centered training processes(35) and advance to those that can develop complex thinking, decision-making, and differentiated skills, transposing personal characteristics that have simple and primary mental processes that are incapable of guaranteeing prominent positions in the competitive and fast labor market today(36).

Thus, in both situations, the student mediated by the teaching work will be using a process that is born of observation and reflection and culminates in the transforming action. This allows him to see that in order to change he has to develop the capacity to intervene in reality, a very complex task, but which guarantees him the development of new knowledge, skills and attitudes, making him subject to history and not mere object(35), coming to the meeting of the role of the SI in the professional training of nurses.

The contributions of Supervised Internship to the training of nurses

The SI is the moment in which the student is expected to be able to insert himself in the reality, experiencing the professional work of the nurse in its historical, political, social, cultural and financial context, guided by the teaching action and supervised directly by the nurse who actively collaborates with the process of professional development. In this way, the student is able to build knowledge, skills and values in articulation with the nursing and health team of the partner institution, fostering the construction of the professional identity of the future nurse(3).

All articles raised contain the contributions to the training and many of them because they are reports of experiences highlight the student’s vision of their experience in supervised internship.

The authors defend that the IS gives the student opportunities and action settings capable of building professional practice; to develop the transformative praxis fostering the safe and quality action; to consolidate occupational skills and safety for the realization of the professional role in the labor market; assists in the critical reflection on the professional practice and health institutions, developing moral values, ethics and respect, clarity in the understanding that it is necessary to break with traditionalistic nursing and teaching practices, besides fomenting the development of managerial competences. The evaluation processes that have been used strengthen the promotion of the student’s responsibility and commitment to their learning, preparing them for working life(18-31).

Regarding the pedagogical practices, they affirm that the activities simulated before the SI guarantee independence and autonomy during internship. Due to the active involvement of professors, field nurses and health services, the IS also makes it possible to strengthen teaching-service-community links(18-31).

These contributions, as a tool to break paradigms of attention and health training, become a reality if the student is inserted early in the health services. In these settings, the actors involved in the development of the SI are fundamental pieces for the construction of competences, considering that nurses professors are professors linked to higher education, or nurses who work in the fields of internship in health institutes are the bearers of the profession and have the task of ensuring that nursing students have the competence to act in the clinical-dynamic setting(38-39).

The teaching-service-community dialogue, one of the principles of IS, has the potential to contribute to the training of professionals anchored in the biopsychosocial vision of the user in the system, directing them to the analysis of the social determinants of health of the society itself and the demands for she generated(35,38).

In addition, health services are growing in complexity, which creates diverse learning opportunities. This implies that the nurse, professor or health care professional has the challenge of educating future professionals to obtain skills and knowledge critical to prioritizing, manipulating ambiguous situations and tolerating uncertainties that are part of the work processes(32). However, professors, students and nurses must be committed to reducing the existing dichotomy between theory and practice, during academic training and between discourse and concrete action observed in reality(39).

It is necessary to emphasize here the role of the nurse, who symbolizes the profession materialized for the student, in the effectiveness of educational practices in a real work setting. Nurses must carry out their services within the highest quality standards and the ethical principles of their profession, especially when it is believed that the responsibility of Health Care does not end with professional work, but with the resolution of the health problem, both individually and collectively(38).

Study limitations

There are no exact descriptors for the subject, which justifies the number of articles raised in the first stage of the selection, in which, after analysis, there were many denominations and understandings related to this moment of training. Due to the amplitude of the searches, we found research that dealt with the issue from the perspective of other actors involved with IS: the internship nurse and the professor. However, the scope of this study was to identify the contributions of SI in the perception of those who are the target of the formative process - the student.

Contributions to the sector of Nursing

The SI, although it has been described in the DCN since 2001, has been the subject of forums, debates and resolutions, since its realization in the Brazilian Nursing Schools is not yet agreed, nor is its existence in some curricula that practice it as practice at the end of undergraduate course, generating a gap in training. The many concepts of SI and the ways of doing it, in nursing undergraduate education in Brazil, reveal a gap in the training processes and also in education research, indicating the need to strengthen the debates on this subject.

FINAL CONSIDERATIONS

Evidence shows that Supervised Internship is one of the fundamental elements in the nursing education of nurses, since it allows the re-signification of the knowledge acquired during the course, fostering the development of the capacity to identify problems, to critically analyze the factors that make up the situation experienced and to propose solutions based on area references. Supervised Internship enables the development of critical thinking, communication skills, leadership and decision making in the real world of work. The means and methods of SI development are structured by critical pedagogy, with active methodologies being the main choices of the authors.

There is no research in the national literature that portrays the way in which Nursing Schools operate their Supervised Internships, which have been the hourly loads destined for this moment of training, what is the qualification of the teaching staff to act at that very complex moment, what contributions from the Supervised Internship to the professional practice in nursing or even if the Nursing Schools have performed SI, or only clinical practices at the end of the undergraduate course.

It is necessary to consider the necessity of the development of more robust researches from the methodological point of view. From the arsenal that composed this SI, a research was classified as Level of Evidence IV(14), quasi-experimental research. The others are evidence derived from a single descriptive study of unique experiences.

  • FUNDING
    Coordination of Improvement of Higher Level Personnel - CAPES.

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Publication Dates

  • Publication in this collection
    2018

History

  • Received
    16 May 2017
  • Accepted
    16 Oct 2017
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