Interprofessional collaboration: a case study between managers, teachers and family health professionals

Abstracts

The present case study uses a qualitative exploratory approach to analyze the collaboration between managers and teachers from three Higher Education Institutions (HEI) - Private Institutions that adopt the Family Health Strategy (FHS) as their curricular training ground for their students, managers and professionals from the FHS teams in Juazeiro do Norte-CE. The theoretical framework that guided the research design and the subsequent analysis of the body of data was a typology of interprofessional collaboration. Data was collected during 2011 and 2012, using the following techniques: field diary, document review and 25 open interviews with managers and teachers of HEI, managers and health professionals of the Municipal Secretary for Health. The interprofessional collaboration between FHS professionals and teachers of the three HEI analyzed was found incipient, showing the need of the promotion of knowledge and practice in this field.

Interprofessional relations; Continuing Health Education; Family Health

Estudo de caso, de abordagem qualitativa, do tipo exploratório, com o objetivo de analisar a colaboração interprofissional entre gestores e docentes de três IES privadas que adotam a Estratégia Saúde da Família (ESF) como campo de estágio curricular para os seus discentes, gestores e profissionais das equipes da ESF, em Juazeiro do Norte-CE. O referencial teórico que orientou o desenho da pesquisa e a posterior análise do corpus de dados foi uma tipologia da colaboração interprofissional. A coleta de dados, realizada em 2011 e 2012, utilizou as seguintes técnicas: diário de campo, revisão de documentos e 25 entrevistas abertas com gestores e professores das IES, gestores e profissionais de saúde da Secretaria Municipal. A colaboração interprofissional analisada foi considerada incipiente, apontando a importância de se fomentarem saberes e práticas neste campo.

Relações interprofissionais; Educação Permanente em Saúde; Saúde da Família

El presente es un estudio de caso con enfoque cualitativo y exploratorio, elaborado con el fin de analizar la colaboración interprofesional entre los directivos y los docentes en tres instituciones de educación superior privadas que adoptan la Estrategia de Salud de la Familia (ESF) como un campo de entrenamiento curricular para sus estudiantes, directivos y profesionales de los equipos de la ESF en Juazeiro, estado de Ceará, Brasil. El marco teórico que guia el diseño de la investigación y el posterior análisis del corpus de datos es una tipología de colaboración interprofesional. Para la recolección de datos, que se realizó entre 2011 y 2012, hemos utilizado las siguientes técnicas: diario de campo, revisión de documentos y 25 entrevistas abiertas con los directivos, profesores de IES, gerentes y profesionales de la salud de la Municipalidad local. La colaboración interprofesional entre los profesionales de la ESF y profesores de las tres instituciones educativas analizada fue considerada aún como incipiente, apuntando la importancia de fomentar prácticas y saberes en este campo.

Relaciones interprofesionales; Educación Continua in Salud; Salud de la Familia

Introduction

The concept of collaboration can be both understood as a human process and articulation implying cooperation, integrating several professional categories for teamwork in various contexts of practices, as well as in the interorganizational and interinstitutional work^1,2. It is related to the tendency to new organization forms of social work and health services that require the building of service networks and integrated care to meet the citizens’ needs. They are increasingly acquiring more space, even due to the frequent inclusion of interprofessional education programs in undergraduate healthcare courses^3-5.

There is a significant number of authors who have explored the concept of interprofessionalism as an integrative part of the groundwork for health and social service area initiatives aiming at promoting the interprofessional education and collaborative practice^1,2,6. Interprofessional work teams, by definition, comprise two or more professional categories sharing knowledge and practices for planning and carrying out projects and activities in their work context⁷. Other definitions of the term are found in the literature. One of them is the process by which professionals can reflect upon and develop practices providing an integrated and coherent response to meet the needs of users, their families and communities, involving a longitudinal interaction and knowledge sharing among professionals, organized to continuously solving or exploring a variety of issues regarding education and care, and seeking to encourage user’s participation^1,2,6.

On the other hand, acting collaboratively in work environments does not actually imply a change or an adoption of new practices which are easy to be implemented^8,9. This challenge demands responsibility not only from professionals involved in practical fields, but also from the managers. They have the need to assert progressively the interest in promoting a transition from a fragmented healthcare to a collaborative practice that meets the health needs of people who use healthcare services^1,9.

Studies analyzing the teaching-service integration process gain importance with the need - stated in the Brazilian National Curriculum Guidelines for undergraduate healthcare courses - for a contextualized education¹⁰ and, consequently, the inclusion of students and professors in healthcare services, especially in the Family Health Strategy (FHS), as it constitutes the structural model and main gateway to the Brazilian National Health System (SUS – Sistema Único de Saúde)¹¹. For this reason, this study aims at analyzing the process of interinstitutional collaboration through the analysis of interprofessional collaboration between municipal health managers and Higher Education Institutions (HEI), as well as among professors, preceptors and professionals of the Family Health Strategy in the city of Juazeiro do Norte, located in the Brazilian state of Ceará.

Methodology

This is a qualitative exploratory case study for the possibility of approaching the subject studied in its multiple relations and incorporating the issue of meaning and intentionality as inherent to acts, relations and social structures^12,13.

The creation, design, data collection process, guideline for conducting the open interviews and data analysis integrated to the fieldwork draws on the theoretical framework on interprofessional collaboration and on D’Amour’s structuration model and typology of interprofessional collaboration^1,8, leaving room for other elements to emerge. The Interprofessional Collaboration Typology (ICT) is rooted in organizational sociology. It was developed based on the study conducted in Primary Healthcare Units and tested in work teams, among organizations and in healthcare networks. The model adopts the four dimensions of the model of collaboration operationalized by ten indicators associated with these dimensions to analyze the collective action⁹.

Relational dimensions involve relationships between individuals, while organizational dimensions involve the organizational environment. Relational dimensions are: 1) common objectives and shared vision, concerning the existence of common objectives and its appropriation by the work team, and the recognition of differing reasons. Their indicators are shared objectives and prioritizing users’ needs versus other interests; and 2) internalization, regarding the sense of belonging and knowledge of values, discipline and mutual trust of the professionals involved, having as indicators interdependence and trust. Organizational dimensions, on the other hand, are: 3) formalization, clarifying expectations and responsibilities of the collaborative process, having as indicators Formal Agreements Signed and Information Exchange; 4) governance, referring to the leadership roles which give support to collaboration, directing and giving support to professionals in order to implement innovations related to interprofessional, interorganizational and interinstitutional collaborative practices. Governance indicators are centralization, leadership, and support for innovation and connectivity. The dimensions are interrelated, thus influencing each other. The interaction among them may capture the process inherent to interprofessional collaboration, although this is subject to the influence of external factors, such as resources, financial and political constraint.

This case study research was carried out in the city of Juazeiro do Norte, located in the Southern region of Ceará state, 514 km from the capital Fortaleza¹⁴. The city has primary, secondary and tertiary network services. It integrates the regionalized and hierarchical network of the Brazilian National Health System, taking over a local management responsibility that is a macro-regional reference. Juazeiro do Norte was selected as a study setting due to being a large city that, together with the city of Crato, holds the main university center in the countryside of Ceará.

Three private institutions - Leão Sampaio College, Juazeiro do Norte College, and Estácio College of Medicine of Juazeiro do Norte - offering undergraduate healthcare courses in the city of Juazeiro do Norte and promoting internships programs in the Family Health Strategy units were investigated, as well as the Municipal Health Department in Juazeiro do Norte and the Family Health Units receiving students from each institution. Data collection was divided into two phases: in August 2011 and in October 2012.

The Management Report of Juazeiro do Norte was reviewed as part of the documental analysis. It presented both the management plan for the period 2009-2013 and the agreement model applied by the Higher Education Institutions together with the Municipal Health Department in Juazeiro do Norte.

Twenty-five open interviews were conducted, from a previously prepared interview script, with the following representative actors of both institutions investigated - the Higher Education Institution and the Municipal Health Department in Juazeiro do Norte: three professionals from the central level of the Municipal Health Department in Juazeiro do Norte directly involved with the collaboration process with the Higher Education Institution, and eight managers of the Family Health Units who received undergraduate students in their units. The interviews were conducted in the Higher Education Institutions with two directors, six coordinators of undergraduate courses, and six internship professors/preceptors.

Each institution was analyzed separately by correlating the interviewed directors’, coordinators’ and professors’ reports to the healthcare units managers’ reports taking into account their respective internship fields. The findings are presented in terms of the four dimensions and indicators of the interprofessional collaboration model for each case. From the evidence identified in the document review, particularly concerning the research respondents’ reports, the development stage of interinstitutional and interprofessional collaboration was categorized as incipient and/or potential collaboration, developing collaboration, and active collaboration, according to D’Amour’s model of Interprofessional Collaboration Typology^1,8,9.

The research was developed and grounded in accordance with the ethical principles of the Resolution 196/96 of the National Health Council on Guidelines and Norms Regulating Research Involving Human Beings¹⁵, meeting all specific requirements and regulations of this Resolution. The Research Ethics Committee of the State University of Acaraú Valley (UVA) approved this study under Protocol No. 911.

Result analysis

Document review – agreement model granting internship

The agreement model addresses the required conditions for students with active enrollment carry out curricular internships, allowing access for professors and students to the services provided by the Municipal Health Department in Juazeiro do Norte according to the contractor’s information (JUAZEIRO DO NORTE, 2011). Establishing a legal-normative instrument as an agreement comprises the formalization dimension of the Interprofessional Collaboration Typology and its indicator of agreements signed^1-6.

The work plan can be a reference for performing actions that contribute to the quality of healthcare services by supporting the Family Health Strategy professionals, besides triggering the internalization dimensions¹ from a proposition of joint activities, reinforcing the idea of work teams and common objectives^1-4. With regard to the governance dimension, it may be deduced from the managers’ attitude of this process, as they are the formal leaders of the institutions surveyed in this study.

Annual management report/ Financial year 2009

The Annual Management Report is a basic planning tool. It is held fundamental to the construction process of the Brazilian National Health System. For the decentralization process accomplishment, every collegiate body of the Brazilian National Health System - in this case, the city of Juazeiro do Norte - must have a health plan whose development and results must be stated in the Management Report.

The analysis of the Annual Management Report indicated the following records of interprofessional collaborative projects^1-5 implying the teaching-service integration: the management commitment towards healthcare qualification through continuing education of professionals; and a reference of professional development for high school and university students acting as multipliers of a lifelong learning process in the detection of leprosy cases. On the other hand, the records showed no reference to partnerships that could be established with the Higher Education Institutions.

When analyzing the collected data from the dimensions of interprofessional collaboration^1-5, it can be usually considered that the absence of a more systematic reference in the Family Health Strategy context to partnerships between the Higher Education Institutions and the Municipal Health Department in Juazeiro do Norte highlights: the fragility of shared goals and vision; the internalization and governance of the teaching-service integration processes; and the lack of management involvement towards collaboration with the Higher Education Institutions. We understand that the corresponding document has no elementary components for indicators assessment of the Interprofessional Collaboration Typology.

Analysis of the interprofessional collaborative process – coordinators, professors/preceptors of the higher education institutions, managers of the municipal health department in juazeiro do norte, and managers of the family health strategy units

Respondents’ reports showed that some actions triggered interprofessional collaborative activities^1-5 among preceptors, students and professionals of the Family Health Strategy in the three Higher Education Institutions analyzed in this study, although not characterizing Interprofessional Collaboration Typology^1-5,9. A summary of these actions will be presented, followed by the description of how key informants assessed that these actions can contribute to healthcare and health education.

In brief, the aforementioned actions were:

• Care and organization of spontaneous demand, which occurs by dividing the number of appointments among professionals, students and preceptors for streamlining appointments and organizing users in the waiting room. These actions aim at reducing waiting time with appointments and at guiding users on the care flow;

• Programs undertaken either by life cycles or chronic diseases: they take place from the appointment division of the scheduled demand and health education in the waiting room. The participants are students, preceptors and health professionals. It is accomplished in the healthcare unit, in the programs defined by the National Primary Healthcare Policy¹⁶.

• Collective activities scheduled in the community in significant or commemorative dates are suggested by the municipal health management in order that the actors of the Higher Education Institutions contribute to the work conducted in partnership with healthcare professionals;

• Extension projects carried out on a regular basis in the community, schools and hospitals, aiming at providing quality healthcare to the community. Some extension project experiences have the support of healthcare professionals, while others take place directly in the community, under the sole coordination of the Higher Education Institutions.

From this perspective, it was found that, in general, according to the perception of the Higher Education Institutions preceptors, the Municipal Health Department managers, and the Primary Healthcare Units (PHU) managers, these joint activities allow for: greater outpatient care organization; stronger community confidence towards the work team; identification of the need for work process adaptation; information to the community on healthy practices and healthcare unit organization; identification of other healthcare environments, such as the school, the community, and home care; diversification of activities fostering healthcare, such as environmental care, self-care, among others; empowerment of intersectoral coordination; recognition of the need towards relativizing knowledge and academic practices regarding popular knowledge; variety of teaching-learning scenarios; openness to interdisciplinary and/or interprofessional engagement; promotion of actors’ commitment to meet the community needs; and strengthening of docent learning¹.

Analysis of the interprofessional collaborative process among coordinators and preceptors of the higher education institutions, municipal managers and managers of the family health strategy units by higher education institutions

The Higher Education Institution A (HEI A) has currently four units in operation, with six undergraduate healthcare courses, of which only the Nursing and Social Work undergraduate courses offer internship programs in the Family Health Strategy. The field diary record and responses of the interviewed manager show that the institution recognizes the importance of qualifying the work process and the professional development, aiming at the Brazilian National Health System and the Family Health Strategy social needs.

The interviewees of the Higher Education Institution A recognized as satisfying the partnership established with the municipal health system, despite identifying some extreme situations within the framework of the Interprofessional Collaboration Typology^1-5,9. As regards shared objectives, the respondents’ statements allow us to classify as potential the integration of the Higher Education Institution A with the Family Health Strategy. They also indicate lack of common goals or conflict of goals:

We saw the need to broaden the field for the service to be accompanied by the nurse, as sometimes the nurse prevents the work of the preceptor of the educational institution. At times, we have to make negotiations [...]. In most cases, what can be seen is the financial issue: “If I’m here, if I’m a nurse and I can earn a bit more, why wouldn’t I?” (Coordinator 5).

The actors of the Higher Education Institution A restrict interprofessional collaboration¹ to the support received through the opening of the internship field by the Family Health Strategy professionals to ensure the development of curricular internship. In other words, according to their view, collaboration is focused on the professional development of students, thus possibly favoring unilateral interests of the partnership. On the other hand, they feel uncomfortable when they notice the professionals are expecting payment due to receiving students in service.

With regard to the dimension of internalization, some respondents reported acting together, with confidence in the partner, showing a developing collaboration process:

[...] Then, we created a demand and a service that I think it is the great contribution of the college, isn’t it? We’re expanding the service provided and they, on the other hand, gave us a place [...] I think this is the major contribution of both sides, isn’t it? And it’s valuable because one doesn’t act without the other (Coordinator 6).

According to respondents, there is interdependence among the Higher Education Institution A and professionals of the Family Health Strategy. Nevertheless, their reports also show that the proposition of actions in the service was mainly coming from the Higher Education Institution A coordinators. The conception or formulation of these actions is not understood as a common product, given that the health services provide only the space. As shown in the statement below of a health professional, they are not responsible for the students’ professional development:

The doctors or nurses who are there to receive those students are just spectators and monitors. Why? Because they’re health professionals, and they’re responsible for the health unit and for the people who are using the municipal equipment. They’ve just the obligation to observe them [...]. (Professional 1).

From the above reported statement, it is worth questioning: how can the professionals behave just like spectators, given that the students are taking part in the healthcare process of users under their responsibility?

As for the issues dimension, common objectives and shared vision, the dissonance between the professionals of the Higher Education Institution A and the professionals of the municipal health system led the collaboration process to be categorized as potential.

Furthermore, it was observed a low frequency of formal and informal meetings between the members of the Higher Education Institution A and the Family Health Strategy. Therefore, the indicator mutual knowledge of the internalization dimension was considered potential. As for the indicator trust, it was categorized as developing because, according to the research participants’ statements, the students’ involvement in actions brings safety to health professionals for expanding healthcare to users, while to professors, for allowing students more learning opportunities.

In terms of governance, the findings showed that there was potential collaboration regarding the indicator connectivity: “[...] it was the only time we had territorialization of the internship field, and in that territorialization they demanded us to present a work plan, but we had no return [...]” (Coordinator 5).

When addressing the need for connectivity, Albuquerque¹⁷ underlines that the creation of intersection spaces between teaching and service are of great importance for the Brazilian National Health System consolidation and for professional development in health. Hence, it is understood that it is from the dialogue in collegiate bodies that common strategies and tactics are formulated and conflicts are solved.

According to respondents, the leadership is punctual, fragmented and conducted with no focus by several actors, thus showing the lack of a coordinator to lead the collaboration process among health professionals, preceptors and students.

I think [there needs to be] more communication, right? I think that, in this way, at the time we request the internship, one of the conditions - perhaps even the partner’s condition - was that we really had biannual meetings with the coordinators responsible for the municipal health strategies [...]. (Coordinator 6)

Even though research participants’ reports indicate lack of support for collaboration to occur, it is still possible to identify in the statements a stimulus for innovative practices:

We end up having survey data collected that ultimately raise some possibilities of intervention in the community [...]. We already have some projects and new ones are created, other things [are created] to meet the needs of this community. (Coordinator 6)

With regard to the formalization dimension, collaborative relationships in the Higher Education Institution A with the Municipal Health Department were based on an agreement. Hence, the indicator is considered as developing.

In the matter of information exchange mechanisms, they do not have a collegiate body allowing the alignment of concepts, objectives and practices in order to ensure professional development and quality healthcare. The interviewees’ statements highlight the lack of integration to discuss issues related to responsibilities of each organization, bringing forward suggestions to make it happen.

Therefore, synthetizing both dimensions and indicators of D’Amours’^1,8,9 Interprofessional Collaboration Typology, the ongoing collaboration process between the Higher Education Institution A and the Municipal Health Department in Juazeiro do Norte can be classified as potential.

Higher education institution B

The Higher Education Institution B (HEI B) is a private institution with three undergraduate healthcare courses. However, we have selected just one of them - the medical school - for our survey due to being the only course of the institution that develops its activities especially in the Family Health Strategy¹⁰. As indicated by the Brazilian National Curriculum Guidelines, a combination of active teaching-learning methodologies guides the pedagogical approach. As an educational strategy, case studies and reflecting upon movies are widely used teaching methodologies. On the other hand, as a professional development strategy, the Higher Education Institution B encourages professors to participate in an online graduate course of Teaching Higher Education developed by a partner institution. Moreover, from the field diary records, it is understood that the search for constructing an institution coherent with the principles of Primary Healthcare and focused on the local-regional needs has guided the teaching-service integration activities in the Higher Education Institution B¹⁰.

The information provided by the Higher Education Institution B manager indicates that the School of Medicine offers the Family Health and Community Medicine as the backbone of the Pedagogical Political Project and Curriculum. Among faculty members, there are those who work as preceptors of the Family Health and Community Medicine, in addition to the professors of the respective disciplines. This double insertion is a pedagogical policy, as it leverages the teaching-learning process and qualification in the students’ professional development, consistent with the dimensions and indicators of the Interprofessional Collaboration Typology^1-5,9.

It is also noteworthy that the Higher Education Institution B is a singularity in interprofessional colaboration^1-5,9 due to offering disciplines with internships developed in Primary Healthcare over all semesters, along with the actors’ understanding of the need to strengthen the bond between teaching and service to improve the professional development and user’s healthcare. Notwithstanding, the interviewees have also reported some weaknesses of the relationship with the Family Health Strategy because, even though they have positively rated the partnership of the institution with the Family Health Strategy, they have also vehemently underlined the possibility of expanding that relationship in order to contribute to the healthcare quality in the city of Juazeiro do Norte.

With reference to common objectives, the Higher Education Institution B highlights, from some interviewees’ reports, that there is interest in the interprofessional collaboration of healthcare by involving students in the field, combined with the preceptor’s contribution in the healthcare service.

[...] The patients are the stars; you work for them. They’re the main actors. They’re the ones you have to care; then, they’re the ones who will win. I think that when there’s this interpellation, with hand in hand from both sides, the one who wins in general is the patient [...]. What I see as positive is that the community is the greatest winner. (Coordinator 1)

The aforementioned statement shows that the Higher Education Institution B understands that the professional development process goes beyond ensuring students’ technical competence. It should also contemplate social and political competence for the provision of care in the Brazilian National Health System. Both Higher Education Institutions - HEI A and HEI B - provide inputs for the development of activities by students and preceptors as a counterpart for the Municipal Health Department in Juazeiro do Norte.

Taking into account common objectives^1-5,9, the analytical reading of the interviewees’ reports allowed us to understand them as potential regarding interprofessional collaboration, given that, in spite of the existence of purposes indicated by the actors of the Higher Education Institution B, no sharing of these purposes by the actors of the Municipal Health Department in Juazeiro do Norte was observed.

In the matter of internalization dimension^1-5,9, we found evidence in the interviewees’ reports showing that students, preceptors and professionals shared spaces in the Higher Education Institution B through regular activities over the internships. As reported by Professional 4, “the newcomer students come with all the strength, perform a lot of education and health services, visit patients, help with bandages. Then, in this way, they are an additional group to give us support”.

Given that managers and professors of the Higher Education Institution B believed in the internship potentiality at the Family Health Strategy as a teaching-learning space, as well as in the permission of using that space by the managers of the Municipal Health Department in Juazeiro do Norte and by the Family Health Strategy professionals, the confidence indicator may be seen as developing.

Regarding the governance dimension, it was characterized by weak centrality due to not setting the process central authority, thus preventing a clear direction of actions. Furthermore, neither the promotion of innovative practices nor their support by both institutions was observed, besides regular meetings for planning and assessing the partnership not have been mentioned.

On the subject of formalization dimension, the agreement signed by the Family Health Strategy and the Higher Education Institution B through a compromise is not deemed sufficient to ensure collaboration between institutions, despite being perceived as an addition to the process.

Given the previously outlined on each dimension and their indicators¹, what we can infer on this relationship is that collaboration^1-5,9 is still in a potential stage, with the possibility to start the developing process of the Interprofessional Collaboration Typology. We can also infer that the lack of a stronger articulation between partners weakens this possibility. We understand that the Higher Education Institution B has a pedagogical political project and teaching strategies consistent with the interprofessional collaboration dimensions, in addition to having a clear guidance towards the professional development of well-prepared doctors to work in the Family Health Strategy. Nonetheless, on the other hand, we have also observed that the Municipal Health Department in Juazeiro do Norte had no strategies to strengthen that process.

Higher education institution C

The Higher Education Institution C (HEI C) is a private education institution that offers three undergraduate healthcare courses. It has an agreement with the Municipal Health Department in Juazeiro do Norte to the activities developed in Pharmacy, Nutrition and Nursing undergraduate courses. However, only the last one offers internship programs in the Family Health Strategy.

Taking into account the common objectives^1-5,9, the information gathered with the Higher Education Institution C manager and the field diary records enabled us to verify the following: (1) each discipline has a professor for the internship program - called preceptor - who monitors five to six students in service; and (2) the institution has a rather close relationship with the Family Health Strategy for corresponding to an internship field that allows teaching, research and extension activities, and for the presence of key players operating in both institutions.

We understand that there is a collaborative process between the potential indicators^1-5,9 aiming at establishing trust and interdependence of the parties by actions performed in common areas and by the managers’ acknowledgement of the need to strengthen the partnership in order to meet the organizational interests and, consequently, benefit the population covered by the Municipal System of Juazeiro do Norte.

The analysis of the respondents’ reports shows that health professionals are not able to share actions with the preceptors of the Higher Education Institution C, although some of the statements suggest that actions developed in the Family Health Strategy focused on meeting the needs of the assisted community. Nevertheless, the weakness in the collaborative governance dimension resulted in fragmented, timely and unilateral actions.

I think within that process could have a work with the professionals of the units towards their understanding of what is the true objective of contributing and having a partnership with teaching within the units, because sometimes this relationship isn’t very clear [...]. Then, it ends up hindering activities being carried out satisfactorily. (Preceptor 5)

As concerns the internalization dimension, the majority of the reports show that the relationships are harmonious, pointing towards a trend of both institutions incorporating the idea of a work team within the field of Family Health Strategy. It was noticed that, although trust was being established for ensuring partnership, a weakening factor was the lack of moments for meeting and reflecting upon the process between health professionals and preceptors.

Consequently, the partnership develops into much less collaborative, being restricted to the timely replacement of the work of the Family Health Strategy professionals by the work of students and preceptors in specific activities. Hence, even though this type of partnership allows establishing some level of trust, it has no correspondence to a collaborative practice with knowledge exchange amongst actors due to partnership occurring simultaneously rather than transversely.

[...] The nurse really opens up space. We have, I consider I have, free will in the unit, you know? We’re there to help, right? One helps the other. We’re not there to disrupt; on the contrary, we’re there to try to help. For example, sometimes you can’t make a visit, but there’s something else to do and you do it, you know? (Preceptor 4)

As for the issue governance, the data collected show the absence of a central authority, causing the blurring of better defined responsibilities of both organizations so that they can contribute to the collaboration process. According to many interviewees, there needs to be more engagement of municipal managers and healthcare units so that a collective approach may take place.

I think the manager should be better linked to colleges, you know, precisely to promote more interaction between the nurse of the unit and the preceptor nurse, because we go there, but, somehow, you just go there if you also have friends there, and say: “Look, this is done here like this, like that.” You don’t talk openly and you can’t go there and criticize the healthcare unit or the professional because you respect them [...]. (Preceptor 4)

With reference to the indicator of innovative practices¹, we were able to capture in the statements of the Higher Education Institution C professionals only some actions towards collaboration, although with little impact, corresponding to the category of potential collaboration in the theoretical framework adopted in this study.

The analysis of the formalization² dimension showed that, despite the responsibilities and obligations established being defined in the agreement signed by both organizations, it incorporates neither initiatives nor work plans that can ensure actions taken together. In fact, the articulation occurred informally, being sometimes conflicting rather than consensual.

It was not observed in the interviewees’ reports the presence of common spaces for information exchange. There were only occasional meetings, taking place prior to internships, to organize the distribution of students in the healthcare units. Summarizing the analysis, we consider that collaboration^1-5 is shifting and developing.

Final remarks

In this study, we aimed at investigating the process of interprofessional collaboration between Higher Education Institutions and the Municipal Health Department in Juazeiro do Norte by adopting a case study research anchored in the Interprofessional Collaboration Typology^1-5,8,9. Our findings showed that the collaboration process of the Municipal Health Department in Juazeiro do Norte with the three Higher Education Institutions surveyed was in its potential stage, seeming to have contributed, albeit timidly, to the quality of professional development and healthcare.

We understand that continuing education policy in health with the potential for integration was neither registered in the documents reviewed nor reported by the interviewees as an objective.

With regard to relational dimensions, there were not identified common objectives and active internalization in the teaching-service integration, notably concerning interprofessional collaboration^1-6,9.

As for the issue internalization dimension, it was observed its occurrence as potential and/or developing through processes of trust between the surveyed institutions. This has allowed the Municipal Health Department in Juazeiro do Norte to open space of the Family Health Strategy units for students’ and professors’ participation in the work processes. With reference to the Higher Education Institutions, it allowed focusing on the potentiality of teaching-learning processes in those work contexts. Nevertheless, the limited opportunities of formal and informal meetings reduced the possibilities of mutual understanding.

Regarding the organizational aspects of the governance dimension, a municipal manager for involvement in the collaboration process with the Higher Education Institution has not been identified. It is noteworthy mentioning that the workspace does not seem to be seen as an effective field of collective action for professors and health professionals. We assume that this perception probably results from the lack of social actors who lead to the integration and collective planning of activities.

We believe that a formal engaged leadership would be able to promote a better participation of the Family Health Strategy professionals in the process. The report of the Higher Education Institution B manager showed commitment and interest in collaborating with the Municipal Health Department in Juazeiro do Norte for the development of the Family Health Strategy. Notwithstanding, his desire seemed to be one-sided. On the other hand, we underline that some preceptors have reported the development of new healthcare actions both in the units and in their territory, assuming the role of informal players of the process.

As for the formalization dimension, although formal agreements were established, there was no record of tools or mechanisms for information exchange.

Briefly, from the analysis undertaken, we consider that the interprofessional collaborative processes^1-5,9 between the Municipal Health Department in Juazeiro do Norte and the participants of the Higher Education Institutions surveyed in this study are in a potential stage. The political prioritization of the process, both by the Municipal Health managers and by the Higher Education Institutions managers, as well as the expansion of the actors’ view, represent an important device towards this direction.

A Typology of Interprofessional Collaboration^1-6,9, on the one hand, was useful for a qualitative understanding of the integration between the Municipal Health Department in Juazeiro do Norte and the Higher Education Institutions, showing the different elements that should be developed for strengthening this process. On the other hand, however, it also has some limitations, given that it considers no internal and external factors, such as financial constraints, influencing the interprofessional work. Finally, we find relevant to recognize that the failure to include students and users in the survey represents a limitation to the study.

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Publication Dates

• Publication in this collection
  16 Feb 2016
• Date of issue
  Apr-Jun 2016

History

• Received
  04 June 2015
• Accepted
  05 Oct 2015