ORIGINAL ARTICLES

Experiential knowledge of nursing residence preceptors: an ethnographic study

Letycia Sardinha Peixoto Manhães1, Cláudia Mara de Melo Tavares1, Rejane Eleuterio Ferreira1, Fernanda Laxe Marcondes1, Pâmela Gioza da Silveira1, Thainá Oliveira Lima1

1Fluminense Federal University

ABSTRACT

Problem: the preceptor assumes responsibility in the process of teaching. Guidance and follow-up with residents are challenges due to the environment to which they are exposed. Aims: to identify how experiential knowledge mobilizes pedagogical knowledge in the preceptors of nursing residency, and to discuss training strategies for preceptors. Method: this is a qualitative and ethnographic research. A seminar, participant observation and interviews were conducted, following Resolution 466/2012 of the CNS, under opinion number 183,578. Result: the preceptors highlighted their experience as the foundation of knowledge and as a precondition for the educational action of the preceptor. Discussion: the pedagogical training of the teacher must take place according to learning demands, in order to guide them in the construction of a pedagogically active position, enabling the resignification of work and knowledge. Conclusion: experiential knowledge provides integration with the work context; the experience itself ensures the practice of the profession.

Descriptors: Preceptorship; Education, Nursing; Education, Graduate; Hospitals, Teaching.

INTRODUCTION

Nursing higher education institutions are committed to training professionals capable of performing their practice with citizens in different collective spaces, and willing to understand the real challenges of society and their role as devices of change, articulating theoretical and practical knowledge(1). This area of human resources in the health service includes the teaching preceptors of nursing residency. These individuals are the professionals who accompany, supervise and participate actively in the educational process of training nurses specialized in this modality. Therefore, it is necessary for these preceptors to follow a pedagogical practice capable of arousing new, creative, and sensitive approaches to knowledge in the nurses, in which learning is related to discovery, curiosity, understanding, construction and reconstruction of knowledge(2).

The preceptor’s involvement can be opportunities for supportive meetings, with an authentic and lively interaction to exchange experiences that will highlight the role of nursing in the real world, where knowledge is acquired through meaningful learning mediated by day-to-day experiences(3).

Experiential knowledge is highlighted as the "flagship", because it results from the teaching activity itself. It can be experienced in school situations and in the relationships established, both with students and with professional colleagues(4). Preceptors must have theoretical, didactic and political knowledge and their experience is fundamental to unite and articulate graduation to the job market. It does not only play a role in the formation of skills and techniques specific to the profession, but also influences the humanization, ethics and opinion formation of those who accompany it(5).

The residence is considered to be a modality of in-service training that permeates the students’ learning by their daily practice. It is based on experiences of real work situations, experience in conflict resolution, interpersonal relations, specific skills and ethical aspects of the profession, in order to provide opportunities to participate in situations that the work process itself presents(6).

An international study emphasized that clinical practice enables the development of clinical skills in students. Preceptors were presented as facilitators for individualized education that favors the articulation of knowledge to practical skills, collaborating with reflexive learning through interdisciplinary education(7). Thus, the objectives of this study are to identify how experiential knowledge mobilizes pedagogical knowledge in nursing home preceptors, and to discuss the strategies for pedagogical training of the residency preceptors in the area.

METHOD

This is a qualitative research that used an ethnographic approach. It should be noted that ethnography works on the meaning, on the way people see, not only themselves, but also their experiences, and on the world around them. Its principle is the prolonged relationships in the field, the openness to the knowledge of common sense from a vision from within and close-by that allows an understanding of the way of thinking and acting of those involved in the context of the researched reality(8). The study was conducted in two teaching hospitals (TH) linked to a higher education institution in the state of Rio de Janeiro, which were identified as scenarios A and B. The subjects of the study were nurses who worked as preceptors and accompanied undergraduate nursing students in a residential modality. Those eligible were classified according to the following inclusion criteria: being higher-level nursing professionals (nurses); Being in full exercise of their functions; Being preceptors of the nursing home for at least one year. Night service professionals were excluded as residence activities were not undertaken during this shift.

A total of 12 preceptors were interviewed, five in scenario A and seven in scenario B. In both scenarios, the sector coordinator and the routine nurse were interviewed, and the remainder included the managers of day-care nurses. Of the 12 interviews conducted, two were elite, performed with the heads of the sectors and ten were simplified, performed with preceptor nurses on duty and day care. The data were obtained in a period of four months, starting in the first quarter of 2013, after the approval of the ethics committees CAAE under number 09475612.3.0000.5243, following CNS Resolution 466/2012 with the approval of opinion number 183,578. The first month was dedicated to the pilot test, and the following three months for collection of data in the research fields. It took approximately five weeks for each TH, and the first week was used for the approximation with the field and with the subjects. The following three weeks were reserved for participant observation, which followed a specific script, where the objectives of the research and the reference were related to the work situations of the preceptor where we could find data. In the last week, individual interviews were conducted using closed and open questions, following a pre-established script, in a reserved space. This allowed the participant to respond in an open and flexible manner. The interviews were recorded and later transcribed with the knowledge of the participant.

All subjects signed the Informed Consent Term (TCLE) and were identified numerically. The data was analyzed in the light of Tardif’s thinking and based on the assumptions of an ethnographic research.

RESULTS

Table 1 represents the professional profiles of the participants in relation to the preceptory of the research subjects:

Picture 1: Characterization of the subjects of the research in scenarios A and B. Rio de Janeiro, 2013.

Picture 1

Source: authors

Only one participant was male, which also reaffirms the prevalence of the female sex in nursing. No participants under the age of 30 who met the inclusion criteria were found in the scenarios. With regard to specialization, all preceptors of both scenarios have at least one lato sensu postgraduate, and only one has postgraduate Stricto Sensu. In scenario B, all preceptors had the same amount of experience in preceptorship, since the residency program had incorporated this sector as a training scenario in service for just over two years. Professional experience was cited for periods of time regardless of the year of graduation of each subject. Although they were more than 20 years old, some participants only began working in their later years, and some had passed more than 10 years without professional experience, and only began to work in the profession from the approval in public contest.

Of the five interviewees in scenario A, three subjects had participated in residence programs. However, in scenario B, only two of the seven interviewees had been residents. In those preceptors who had already participated in the residence program, a more empathic accompaniment of the resident was identified. This shows that their own professional experience, which resembles that the resident is currently following, can assist the preceptor in the development of their pedagogical practice.

The preceptors themselves claim that having the "mandatory" responsibility of the preceptor makes it difficult for their actions to be more qualified, since the preceptor profile is not found in all TH nurses:

And I think it's very simple: "Oh! He is a preceptor ", but what is the profile of the preceptor? We don't know. So, I think these are things that have to be built: what is the profile? What does he need? Does he need to be an expert? Does he need to have a master's degree? So, I think these are things to be thought about and they need to improve a lot. (Preceptor 1)

The preceptors tried to describe, during the questions, what relationship they maintain with their body of knowledge. In their opinion, good training is reflected in a better knowledge of how to do tasks, based on practice that is guided by the scientific world. Thus, preceptorship covers knowing how to do tasks and knowing how to act; this knowledge is built by the experience of these events. According to one preceptor’s account(7):

I think it influences. If you are a newly trained professional, you have a different perspective from a professional who has been in service for ten years. So, there are a few things that I know that I have learned through the experience that I had previously, even as a resident, not just as a neonatal ICU professional. (Preceptor 7)

The preceptors highlighted that experience was the foundation of knowledge and a precondition for the educational action of the preceptor, so that the work itself establishes the foundation of the preceptor’s practice, as can be seen in the following speech: I think this is decisive because, from my point of view, a person who has no experience and who does not know the field of action will not be able to demand from the resident or from the person whom he is supervising a direct action. If he does not know the subject, he can't talk about it. (Preceptor 3)

The complex situations experienced during nursing work expose the residents to the mobilization of several other types of knowledge. That is to say, experiential knowledge is a precursor, summoning professionals to develop and use other types of knowledge. Therefore, according to the preceptors, they constitute the foundation of practice:

I think the experience makes all the difference. It’s wrong for a student to leave the undergraduate course and follow another student. If you don't have practical time, something is going to be missing. I can't tell him how to act in a situation without ever having performed it. How am I going to teach? (Preceptor 6)

In view of this need to articulate the theory with the practice, and the responsibility for training during residence, some preceptors believe that opportunities to discuss the clinical situations would also contribute to the residents’ training, as well as to their care practice:

I think I had to have more clinical sessions, more nursing rounds, scientific discussion moments, and case study presentations. It is very difficult, but I think it is necessary to associate professional practice with clinical discussion, with scientific practice: they have to work together, always. (Preceptor 2)

It is not only the experience of work, but also the general experience of the preceptor, which is part of his professional and life history, that affects the preceptor:

The very experience of residence, of preceptorship, adds experience to this activity as well. The more you practice the preceptorship activity, the more it adds experience, because every year there is a new group, with new experiences and new behaviors. So, over the years, it also adds to the experience of how to deal with situations and it will also let you relax when leading situations. (Preceptor 1)

They emphasized the importance of feeling "part of the institution", and not marginalized because they are preceptors and not teachers in a university. They felt the need to be more engaged with each group of residents, so that everyone created a relationship from their first contact:

I think we need the preceptor to be engaged in hospital processes. We, the on-callers, are very much on the sidelines. We need to discuss how this on-call preceptor can always follow the evolution of those residents on the other shifts, because that is what happens to me. (Preceptor 3)

In fact, I was not prepared to be a preceptor. I was prepared to be a nurse. So, our practice is shown to them, but we don't have a formal routine or something like this with them. (Preceptor 10)

The approach adopted in each sector was identified as one of the paths to be followed for the improvement of preceptorship. Following the same logic as the organization of the program, the professionals understand that they should talk and meet to outline their actions with the residents of each new group, present opinions, and add ideas from other preceptors. They believe it to be a pertinent question for those responsible for residents in the service:

I think we could have a moment with all the nurses whenever a new group comes along. We should start with an orientation script every day. Things are running out of control nowadays. We should be better able to give them our attention. (Preceptor 9)

Some dialogues below demonstrate the ideas, demands, and needs of the preceptors interviewed regarding professional qualification: I think courses or meetings could be done in order to prepare these preceptors to really know what their role is before the residents arrive. (Preceptor 7)

There should be the distribution of a script, for example, to the nurses who are following what residents must achieve in their period of residence. (Preceptor 11)

I think the first thing is to train a group of preceptors so that it is a homogeneous practice. Raise awareness in the sector team. I think there has to be a continuing education program. (Preceptor 6)

In this sense, some preceptors reflected on what they considered to be strategic training for preceptorship:

The preceptorship course cannot focus on the formation of programmatic content, but rather on how it has to deal with the resident. It must interface this knowledge with teaching, because preceptors do not always have this common sense. Because there are some days of the week, some moments during shifts in which preceptors are also affected by emotions, whether personal or professional. And if they do not have an understanding in terms of how to deal with this relationship with the residents, they end up transferring it to the residents and the residents lose interest. They move away from those preceptors who may have a great deal of theoretical, academic, and practical mastery. (Preceptor 5)

At all times, the preceptor demonstrates his practice of care as the center of his knowledge whilst undertaking the preceptorship. And so, they bring a reflection of the non-fragmentation of the academic and care areas:

I think this is something we can offer, empowerment for our nurses as well. This is also a way. I think continuing education has to be parallel to the many processes that are developed in nursing. Now, I see the question of the student and the preceptor wanting this as an impeding factor, because that should not be obligatory, it should be a will. (Preceptor 1)

In order to broaden the discussion and reflect on the findings, based on the presupposition of ethnography that respects the view of a phenomenon from the perspective of the subject who lives it, the following discussion will cover two thematic axes. First, that experience is the foundation of knowledge and second, how the preceptors could be trained.

DISCUSSION

Work experience as the foundation of knowledge: the base of practice

From the perspective of Tardif, if there is a consensus that knowledge does not come from a single source and that the preceptors tend to operate in a hierarchical way, where those who are most motivated at work gain greater professional value, individuals with experience are the foundation of practice and professional competence, since experience will be the condition for acquiring and producing their own knowledge.

The knowledge that originates in experience is defined as a set of updated knowledge, acquired and required in professional practice. It is argued that the knowledge of experience does not constitute a knowledge group, but the flagship of teachers’ professional competence(4). It is formed from all the other types of knowledge and originates from practice and experience in the real and professional context. Corroborating this idea, pedagogical practice is not limited to theoretical encounters - it happens in daily life. Thus, this practice is a social event through lived experience. There are essential components, such as planning, evaluation, content, strategies and didactic resources, so that it cannot be summarized as simply reproductive actions. It allows all of those involved to have their participation assured and to achieve a transformation of reality(1).

During the questions, the preceptors tried to describe how they exposed their knowledge. In their opinion, good training is reflected in a better and more informed knowledge of how to perform tasks and in a scientific-oriented practice. A well-founded practice results in a better developed preceptorship, thus, the following expressions were frequently stated during the interviews: "If you have never done it, how can you teach it to anyone?"

The relationship between the preceptors’ external experiences and knowledge contributes to the valorization of the knowledge resulting from experience, since this is where they find ways to legitimize each aspect of knowledge, whether curricular, disciplinary or professional training. The daily routine enables preceptors to experience concrete situations that lead to the need for the mobilization of creation, improvisation, and decision-making, which allow the construction of successful strategies for pedagogical action.

Experiential knowledge is rooted in a teaching system that is developed in the context of diverse interactions and represents the conditioning factors for the teacher’s performance(4). Preceptors deal with these constraints, which are related to actual situations at work, and working with them becomes a learning opportunity. Knowledge is the result of an intellectual experience, not of a subjective representation. The knowledge of how to do a task presents the need for the mastery of work tools. This has a technical character and, if well done, optimizes time and productivity in the work. However, it is in the knowledge of how to act that personal interests arise. This includes personality, curiosity and innovation, and it is from this perspective that the individual is able to face challenges and to accept changes(9).

In addition to reaffirming what Tardif says in terms of knowledge based on experience, the preceptors cited a factor that also reiterates the "conductive threads of knowledge." The preceptors who were nursing residents bring with them a sensitivity to the tutoring practice that contributes to their understanding of the learning demands of the residents and enables them to use the best way to teach. Active learning values problem situations and favors the process of learning to learn. The preceptors can suggest reflection on the daily problems of the profession, in order to research an event and propose a solution(6). The actual work situations instigate preceptors to seek other sources of knowledge to solve them.

Experiential knowledge is integrated into the work context over the years. Therefore, a preceptor who has been in practice for a long time has better knowledge of the position, inasmuch as experience itself ensures the practice of the profession and the experience is transformed. Preceptors create their own means of teaching, and by experiential knowledge they also form an identity, a professional personality.

How to train a preceptor

Given the research problem, one of the objectives of the study was to outline training strategies for preceptors, since there is a notable lack of training for this job. Considering that a study using ethnography is based upon the representation of the individual who experiences the study subject, the training of preceptors should also start from the basis of what they believe to be necessary and important for their qualification.

When preceptors were approached to direct the authors on how to qualify a future professional for the position, they responded almost instantly to the questions, as if they had already reflected on the matter, or were expressing their view of how they would like to be empowered to "deal" with situations (a term frequently used during interviews with residents).

It is essential that preceptors have a "pedagogical disposition" associated with their practice with residents. This is the inseparable dialogical process of teaching and learning, based on problematizing and liberating education. It is capable of transposing the mere transmission of content and enabling daily difficulties to be overcome and innovative solutions to be constructed(10). It is necessary to consider the perspective of education as a practice of freedom to train preceptors. Taking into account the dialogical self and a liberating education for the nursing residents, it is necessary that the professionals are of the same molds. Then, they will be able to understand this form of education as a practice of freedom, which is the "being in the world", how to be dialogical and how to explain it in an authentic, reflective, creative and curious way.

It is believed that the preceptors demand an organization and systematization of their actions in harmony with the institution and the residence program. In fact, they would like to feel part of the specialization training process through the preceptorship. The professionals demonstrated the need to recognize themselves as preceptors due to the reciprocity of the institution. In this case, the issues to be considered with regard to training the preceptors are the qualifications that they can obtain and the fact that their daily work does not become worse.

The cellular organization of teaching work is not only a spatial device, but also a temporal and social device, since it governs the working time and forms of collaboration within the work collective of the establishment(11). The collaboration of the various actors, including institutional actors, for the training of preceptors is also necessary. More than one preceptor presented the planning of actions carried out by themselves as a training strategy, through a collective space of ideas that will be shared and developed. This reaffirms the idea that knowledge is also social from the moment it is shared by a group of agents who have a common goal, and who are subject to the same constraints and resources that are comparable, because of the collective structure in which they are found(4). Thus, the preceptors themselves are the individuals who can actually direct how they will carry out the task in a more effective, qualified and resolute manner towards the residents.

The preceptors felt the need to plan their actions. The lack of planning, according to them, exposes the work to potential disqualification, since they have not planned for those actions, which are not changed, or reflected on the subjects. The needs of the work direct the preceptorship and contribute to superficial relations. But, this work requires deep investment, both affectively and cognitively, in the human relationships with the residents. Moreover, in terms of the difficulty of recognizing their educational role, the preceptors take residents as an "extra task", which overloads and hinders their own nursing work. Some cannot effectively articulate the practice of assisting preceptor activities.

In the course of life, man seeks his personal and professional development; therefore, we must emphasize that these processes occur both in formal teaching situations and from independent studies or lived experiences. In the health area, specifically, this search should be considered to be even more critical(12). The authors are of the view that, in addition to offering training courses, there is the challenge of creating a qualification for the preceptorship. The investment in this case is institutional, sectoral, personal and professional, and encompasses several factors that incorporate the decision-making power of each actor involved. The result would be that, in this way, one really thinks about authentic professional development.

The preceptorship is focused on in-service training, as well as specialization in the residence modules. Well-founded practice is a clear daily requirement for preceptors and a demand from residents. Concomitant to this, it is emphasized that a good residency program is essential for the success of nurses who are in transition to continuing education. In order to do so, it is also essential to invest with a focus on the development of characteristics and preceptor skills(13).

Teaching cannot be decontextualized from practice (a fundamental point of discussion), since the preceptors who embrace disciplinary, curricular, vocational and, especially, experiential knowledge, ultimately become involved in the technicality of the profession, and also recognize the importance of scientific knowledge, but always linked to practice.

Professionals also highlighted that continuing education is a strong capacity building strategy. Thus, this concept must be reoriented to what is known as continuing education, which works in a collective and multi-professional perspective, and aims to transform practices. It is based on problem-solving for institutional changes when necessary, favoring the active appropriation of scientific knowledge and the strengthening of the teams(14).

Therefore, in addition to thinking about strategies that contemplate the policy of permanent education, it is necessary to think about the identity, the person and the personality of the professional to be trained. The preceptors embrace professional knowledge that enlivens their practice and legitimizes their professional life, bringing with them values, beliefs, culture and ethics that deserve to be known and well worked.

It is necessary to note that TH is already a formative institution and is the extension of the university itself, where nurses who have entered this field of work already recognize the educational nature of the institution and cannot necessarily abstain from this commitment.

The preceptors must first know and recognize their educational role in the nursing residency, to lead a path to passion for the practice. Even in the face of all of the difficulties presented, preceptors play an important and essential role in the training of these specialists. They are professionals who deserve investment for their contribution throughout their residency - a contribution that involves physical and emotional exhaustion, availability, love, knowledge, theoretical foundation and professional practice. Much knowledge is learned by preceptors in a single day of residence; thus, imagine their role over the two years of the program.

CONCLUSION

The knowledge arising from experience comes from the experience itself and is validated by it. At the same time, it is incorporated into the individual and collective construction of such knowledge from everyday life and praxis, of knowledge related to activities, and knowledge in terms of being.

The question of the work process as a reflection of the way preceptorship is exercised leads us consider the challenges that were observed in the complex process of nursing work. The attempts to perform these roles fuse the responsibilities of the preceptor and the nurse. However, the merging of roles, which is often not so clear to preceptors, can make their personal investment in the assistance greater. Thus, the preceptor can be somewhat left on the sidelines of the action. However, even if assistance becomes a priority, the actions of the preceptorship should be foreseen in the daily work. Preceptors are influenced by determinants and the conditioning factors of their educational practice, considering the institutional and sectoral contexts to which they are submitted, as well as the values and rules that interfere in the relation of knowledge. Experiential knowledge provides integration with the work context, and experience ensures practice and transformation. Preceptors create their own means of teaching, and through experiential knowledge they form a professional identity.

It is also understood that the pedagogical training of preceptors must be developed according to their learning demands, providing means to guide them in the construction of a pedagogically active position in their actions, allowing resignification in terms of work and knowledge. In this article, there has been no idealization of a preceptor, since this position has a singular character. Pedagogical practice is to some extent subjective due to the influence of aspects from the preceptor’s own experiences. Thus, there is no model, but a guiding ethic that will direct his educational role.

In the present study, some epistemological obstacles to highlight were the data construction time, the number of scenarios studied, and the preceptors studied, as well as the differentiated residence profile in each HE. However, the research has contributed to the beginning of an understanding of the subject of the preceptor and the utilization of their knowledge in the completion of nursing work daily.

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Received: 01/27/2016 Revised: 01/31/2017 Approved: 02/06/2017