ORIGINAL ARTICLES

Impacting factors on preceptorship development in an HIV/AIDS specialized service: an ethnographic research

Cosme Sueli de Faria Pereira1, Cláudia Mara de Melo Tavares1, Ann Mary Machado Tinoco Feitosa Rosas2
1Federal Fluminense University
2Rio de Janeiro Federal University

ABSTRACT

Aim: to identify the factors impacting on the development of preceptorship as an educational method. Method: this is an ethnographic study with a qualitative approach. Five preceptors of a Multidisciplinary Residency Program took part in the research. Data collection happened between April and June 2014. The data collected were interpreted and analysed using content analysis, while Edgar Morin's thoughts were used as the theoretical framework. Results: it is evident that the lack of training, motivation and good working and ethical conditions represented factors which influenced the teaching and learning process. Discussion: the identified impacting factors are challenges that accompany the preceptors during their journey. Given this, it is recommended that there be an association between the seven facets of essential knowledge as proposed by Morin, and practice. Conclusion: while teaching residents, there is a long and rough path to be followed when seeking quality support for people with HIV/AIDS. In conclusion, it is necessary for preceptors to specialize in this area of education in order to improve the teaching of residents.

Descriptors: HIV; Preceptorship; Interpersonal Relationships; Acquired Immunodeficiency Syndrome.

INTRODUCTION

Multidisciplinary Residency Programs were created after the approval of the Law No. 11.129 of 2005, and are based on the principles and guidelines of the Brazilian Unified Health System (SUS), taking into account local and regional needs and realities(1). The residency program is run in health institutions under the guidance of recognised technically-experienced professionals, who are called preceptors.

The preceptor is defined as a professional who does not have an essentially academic position; his(her) role is to help newly qualified graduates in the process of inclusion and socialization in the work environment(2). Another peculiarity of the preceptor is having at least three years experience in his(her) area of professional development or the academic title of specialist or resident(3).

This professional, who is employed within the health services, takes part in the supervision and guidance of interns in order to develop their knowledge using his(her) know-how and methods of working. In addition, the preceptor is considered to be an agent of pedagogical practice, which is known as a part of a social process(4).

The exercise of preceptorship is a collective construction, always based on meetings, such as between those seeking knowledge about their health/lifestyle - the healthcare user; those seeking knowledge of a certain process of health and collective and/or individual sickness - the student; and the one directing or facilitating this cognizant process - the preceptor. It is hoped that in these meetings, the preceptors acts as a mediator and an enabler between the student and the healthcare user, qualifying and enhancing the power of health actions(5).

The exercise of preceptorship happens in multiple healthcare scenarios. We highlight the Specialized Care Service in HIV/AIDS because of its use of multidisciplinary staff and because it follows the healthcare principles of voluntariness, confidentiality, anonymity and agility(6).

It is necessary to remind ourselves that the Acquired Immunodeficiency Syndrome (AIDS) was acknowledged to exist in 1981, when the Centers for Disease Control and Prevention (CDC) in the United States, identified the appearance of a disease of a probably infectious and transmissible aetiology, which affected the immune system, leading to severe immunosuppression. Nowadays, it is known that the HIV virus, responsible for causing AIDS, is transmitted through sexual intercourse, exposure to body fluids which are contaminated with the virus, and also, through mother-to-child transmission(7).

AIDS is currently an epidemic in terms of its biological dimension, as it places all of us in the forefront of events related to social and behavioral matters, such as prejudice, stigma and neglect(8).

The Brazilian response to the AIDS epidemic is based on the belief in the right to health as being a right of all, as guaranteed by the Brazilian Unified Health System (SUS), allowing the State therefore to compile a program of universal access to actions and services for its prevention, its treatment, and care in terms of all its dimensions(9). In this perspective, the AIDS epidemic can now be considered a chronic illness, with a considerable increase in the life expectancy of HIV-infected people(10).

One must remain alert to the needs of the professional in terms of being capable of learning on a continuous basis, both in his(her) continuing education, and in practice. Bearing this in mind, healthcare professionals should learn how to learn, and to have responsibility and commit to the education and training of future professionals, providing conditions for mutual benefit to exist between the students and the professionals involved(11). Enabling future professionals represents a challenge, not only for the teaching hospitals, but also for all the professionals involved in the process. Thinking about the complexity of executing this task, this study aims to identify the factors that impact on the development of preceptorship as a pedagogical practice of the Outpatient Specialized Care Service in HIV/AIDS Multidisciplinary Residency Program.

METHODS

This is a descriptive ethnographic study with a qualitative approach. Five healthcare professionals who work as preceptors in the Outpatient Specialized Care Service in the HIV/AIDS Multidisciplinary Residency Program of São Francisco de Assis Healthcare Attention Institution (HESFA), took part in the research. They were engaged in their normal academic activities during the period used for data collection. The healthcare professionals who work as preceptors in the Outpatient Specialized Care Service in the HIV/AIDS Multidisciplinary Residency Program, and who are registered in this area with the Ministry of Education, belong to the following professional categories: one (1) physician, two (2) nurses, one (1) social worker and one (1) psychologist. Data collection took place from April to June 2014.

Participant observation and semi-structured interviews were used as data collection tools. The data so obtained were analysed using the content analysis method and interpreted in the light of Edgar Morin's theoretical framework. The content analysis aimed to develop a general reflection about the production conditions and a perception of the significance of articles written in various fields of research. It incorporates research techniques that allow, in a systematic manner, the description of the messages and behaviors linked to the context of the participant’s narrations, as well as the inferences from the collected data(12). This research is in conformity with the ethical regulations established by Resolution No. 466/12, approved under Ruling No. 576.714(13). Each research participant was assigned a different color for identification purposes.

RESULTS

It could be verified that the lack of training, lack of motivation, lack of working conditions and lack of ethics were the factors that had an impact on the matter of teaching and learning, in terms of the intentional behavior of each participant and in the institutional physical work conditions.

Figure 1 presents the impacting factors on preceptorship, set out schematically:

Figure 1

Lack of training

For these reasons, one of the preceptors approaches the question of training for preceptors:

[...] Another thing that comes to my mind is the need of training for preceptors, like a real educational course for preceptors. I think that's it. (Red)

Lack of motivation

Another preceptor approaches the matter concerning the lack of motivation:

Maybe the lack of motivation. I'm not as motivated as I used to be. In the past, when I was younger, I was more motivated to go to work, but now I don't have the same motivation I had in the beginning, when I came to work here in the HESFA. (Orange)

By reading the statement above, we can verify that the lack of motivation is a factor that interfered with the preceptorship process. This lack of motivation may be related to the years of service, to a lack of professional incentive, to the difficulties encountered when it comes to developing their work, amongst other factors.

Lack of good working conditions

However, three preceptors claims that the impacting factors are the working conditions:

[...] the institution working conditions, the physical area, the organization of the service flowchart and the organization of other needs that the sector requires. Inserting the role of preceptorship in the middle of this organizational system can be quite difficult sometimes. The physical working conditions, sometimes the unhealthy working conditions, the lack of physical space, working under conditions that make you envision the structure you need. (Red)

[...] Sometimes I have ten things on my desk to sort out, and on that day, I sort out fifteen, but I can barely do those ten things correctly because those were the demands, and we always have to iron out last-minute problems. So that's a thing that can get in the way. I can have a certain schedule to go over with the interns that day, but the work demands interfere, and then I have to change it, modify my schedule. Therefore I think that if something is inherent to the job, that is constant, that is happening there all the time, then it interferes with this purpose of the need for change." (Yellow)

At this point in time, what is affecting us here is the matter of physical space. For some time now our working has been increasingly reduced, and also the aspect of the unit at this moment, the clientele matter... this is impacting on us a lot because, for some time now, the unit hasn't been dealing with new patients as it used to... so the clientele is dramatically reduced and I think this is having a big influence, making the Residency Program a little harder. We can see that most of the times, the interns are here, are available, at the unit, but in terms of practicing with the clientele at the moment, it is a little tough, at least for the Psychology Residency participants. (Blue)

The statements above reflect the current working conditions of the study scenario: these are being affected by its physical layout (which, currently, is being remodelled, as it is one of the oldest hospitals in Rio de Janeiro); it was designated as a historic landmark, and is therefore not receiving the renovations that fit the needs of its services. Consequently, at this point in time, the healthcare assistance is precarious.

Lack of ethics

Another impacting factor that was pointed out was the lack of ethics on the part of the interns.

[...] Well, suddenly I might realise an intern is unethical or isn't humble, although that doesn't happen very often. I think it has happened with just one or two times from hundreds of the students and interns that have been here. (Green)

For the preceptor above, one of the impacting factors with regard to having a smoothly performing residency program is definitely, the lack of ethics on the part of some interns. This factor, despite not being encountered very often in the groups, seems to be a defining one from the point of view of this participant.

DISCUSSION

Regarding the first impacting factor encountered, lack of training, we consulted the Ministry of Health Ordinance No. 1000/05, which states that the preceptor is responsible for supervising the teaching-healthcare actions, being the one who executes the activities related to the organization of the learning and guidance process as it applies to students (...). Given that, this preceptor must have, at minimum, three years of experience in his(her) area of professional development or an academic title (14).

In the Outpatient Specialized Care Service in the HIV/AIDS Multidisciplinary Residency Program, preceptorship must be carried out by healthcare professionals who have a theoretical-pedagogical foundation in the area of mediation and articulation of the intern's theoretical-practical knowledge, aiming to give foundation to the significant process of learning(15). The need to invest in training teachers who hold, in addition to technical knowledge, ethical and political values, is based on legal questions, together with a commitment with regard to training competent professionals and citizens able to lead us on the path to a fairer world, as well as to the social acknowledgment of the profession(16).

Another important factor to be considered by the preceptors of the Outpatient Specialized Care Service in the HIV/AIDS Multidisciplinary Residency Program is the lack of motivation.

In this context, even though the education actions directed in terms of SUS are increasingly present in the Ministries of Health and Education agendas, the initiatives that favor actions related to the introduction of permanent qualifications on the part of professional healthcare educators are still fragile and rudimentary(17).

Edgar Morin, on his sixth facet, "Teaching Comprehension", discusses the matter of communication, asking for incomprehension to be addressed. Intellectual comprehension differs from human intersubjective comprehension, as this goes beyond explanation, being constituted as the relationship between one subject and another(18).

The lack of appropriate working conditions was also pointed out by the preceptors who took part in the research as an impacting factor on the preceptorship. This was because those employed in healthcare institutions such as medical intermediate care units and hospitals, either private or public, that are part of the institutions, cannot face demmands, even with the efforts on the part of the staff involved in terms of promoting high quality health assistance and education, as can be seen in the situation of the study scenario.

Edgar Morin's fifth facet, "Confronting Uncertainties", emphasises the statements given by Red, Yellow, and Blue, when it points out that even though progress has been achieved, it is impossible, even using the best technologies available, to predict the future. The future remains open and unpredictable. The future's name is uncertainty(18).

In fact, the preceptors and interns of the Outpatient Specialized Care Service in the HIV/AIDS Multidisciplinary Residency Program, as well as the patients, the administrators and other components of the Institution’s staff, don't have the governability, the autonomy, and the power of decision making to manage the building architecture, as it is considered a public asset and a historic landmark, even after the staff was able, after several tries, to provide for external restoration in conjunction with possible adaptations of the internal area that fit the current needs of the Healthcare System.

One of the impacting factors for the good future development of the Outpatient Specialized Care Service in the HIV/AIDS Multidisciplinary Residency Program is the lack of ethics on the part of some interns. Regarding the above, Edgar Morin's seventh facet, "Ethics for the Human Genre", indicates that one must not desire for others what one does not desire for oneself18). Anthropoetics is based on three elements: Individual, Society and Species.

We agree with Morin when he claims that respecting, at the same time, an individual’s individuality and his/her uniqueness, leads to the development of a sense of solidarity ethics, of comprehension, and teaching human genre ethics.

Even though this impacting factor was mentioned only by one of the preceptors of this specialized care service, it demonstrates that such behavior isn’t associated with the profile of the students and the interns of the institution. To teach is to offer possibilities to shape a professional who will function effectively in society, respecting individualities, differences, feelings, postures, beliefs, power, social classes, behaviors, ideas, creativity and being humanistic. Only then can we become able to be a part of the transformation of society.

The impacting factors presented above are challenges that face the preceptors of the Outpatient Specialized Care Service in the HIV/AIDS Multidisciplinary Residency Program in their journey, and turning the situation around isn't an easy task. This is why an association between Morin's seven facets and daily practice is proposed.

CONCLUSION

Based on the interviews held with the study participants, it was possible to determine and analyse a number of categories. Through them we are able to comprehend that, to the preceptors involved daily in the HIV/AIDS specialized assistance, there are many barriers to the achievement of an individualized and comprehensive healthcare, given the impacting factors.

It can be seen that, in terms of the education of interns, there is a long and arduous path to be covered with regard to providing high quality healthcare assistance for people with HIV/AIDS. It is necessary to specialize in this area and to improve the training of interns without leaving aside the need to improve the working conditions of the professionals and administrators concerned.

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Received: 02/25/2016 Revised: 11/03/2016 Approved: 03/11/2016