Learning experiences in community health of nursing students

Experiencias de aprendizagem em saúde comunitária de estudantes de enfermagem

ABSTRACT

Objective:

Understand the learning experiences on health promotion and prevention of nursing interns during their community practice.

Method:

This is a descriptive-interpretative study, with a qualitative approach, obtaining data from 19 nursing interns from a public university in Lima-Perú, using 3 focus groups.

Results:

Three categories were structured: considering the importance of the nursing teacher in their training; experiencing complexity in training for the prevention and promotion of health in the community; and considering the preventive-promotional area as a future professional practice.

Final Considerations:

The students perceived the complexity of community practice in the prevention and promotion of health. They stated that teachers and students should know the context where they develop their practices and that teacher’s exercise leadership in the community. The inclination of some nursing interns for their future professional practice in this area was also evident.

Descriptors:
Community Health; Students; Nursing; Learning; Health Promotion

RESUMO

Objetivo:

Compreender as experiências de aprendizagem sobre promoção e prevenção da saúde do interno(a) de enfermagem durante a sua prática comunitária.

Método:

Trata-se de um estudo descritivo-interpretativo, com abordagem qualitativa, obtendo dados de 19 internos(as) de enfermagem de uma universidade pública de Lima-Perú, utilizando 3 grupos focais.

Resultados:

Três categorias foram estruturadas: considerando a importância do professor de Enfermagem em sua formação; experimentando a complexidade na formação para a prevenção e promoção da saúde na comunidade; e considerando a área de promoção preventiva como uma futura prática profissional.

Considerações finais:

Os estudantes perceberam a complexidade da prática comunitária na prevenção e promoção da saúde. Eles afirmaram que professores e alunos devem conhecer o contexto em que desenvolvem suas práticas e que os professores exercem liderança na comunidade. A inclinação de alguns estagiários para a futura prática profissional nesta área também ficou evidente.

Descritores:
Saúde Comunitária; Estudantes de Enfermagem; Enfermagem; Aprendizagem; Promoçao da Saúde

RESUMEN

Objetivo:

Comprender las experiencias de aprendizaje sobre promoción y prevención de la salud del interno(a) de enfermería durante su práctica comunitaria.

Método:

Se trata de un estudio descriptivo-interpretativo, con abordaje cualitativo, obteniéndo datos de 19 internos(as) de enfermería de una universidad pública de Lima-Perú, utilizando 3 grupos focales.

Resultados:

Se estructuraron 3 categorías: considerando la importancia del docente de Enfermería en su formación; vivenciando la complejidad en la formación para la prevención y promoción de la Salud en la comunidad; y considerando el área preventivo-promocional como futura práctica profesional.

Consideraciones Finales:

Los estudiantes percibieron la complejidad de la práctica comunitaria al realizar la prevención y promoción de la salud. Manifestaron que los docentes y estudiantes deben conocer el contexto donde desarrollan sus prácticas y que los docentes ejerzan liderazgo en la comunidad. También se evidenció la inclinación de algunas internas por el futuro ejercicio profesional en esta área.

Descriptores:
Salud Comunitaria; Estudiantes de Enfermería; Enfermería; Aprendizaje; Promoción de la Salud

INTRODUCTION

In the 21^st century, we are currently living in an era of uncertainty characterized by profound changes and complex restructuring of economic, social, political, cultural and environmental order that affect society in general and people’s lives, in particular, as stated by Zanetti⁽¹⁾. This new global configuration brings new challenges, namely the search for innovations and ways of thinking and learning. Therefore, “it is important to guarantee the formation of highly qualified human resources and the construction of knowledge through democratic work processes committed to ethical, humanistic and egalitarian values in a supportive and constructive organizational environment”⁽¹⁾.

Considering that health provides integral well-being, both the biological and genetic determinants of human beings are important, as well as environmental interactions that favor adaptation behaviors manifested through the life-health paradigm, as affirmed by Fernandez et al:

In our time, health care requires an inter professional exercise, where each professional possesses scientific knowledge and attitudes of professional, ethical and social commitment to face and resolve comprehensively the problems that prevent the timely detection of risks, self-care with health, the prevention of diseases, as well as the diagnosis and reduction of diseases and their individual and social consequences ⁽²⁾.

The Pan-American Health Organization (PAHO) published the resolution Human Resources for Health:

Expanding access to qualified health professionals in health systems based on primary health care, where the performance of advanced nursing professionals in health systems based on Primary Health Care in Latin America is particularly important⁽¹⁾.

Many Latin American countries are committed to the training of nursing professionals for advanced practice. However, it is necessary to expand the training strategies of these professionals with experience in the areas of critical content, such as community health.

Santos et al⁽³⁾ conducted one of the studies on nursing care training in the community in Perú. It included penultimate year students of five professional schools, among which we find the School of Nursing of the Faculty of Medicine of the National University of San Marcos (Spanish acronym: UNMSM). In the cited study, it was found that first-year nursing students consider family and community care experiences as life lessons. The approach to community life has changed students’ view on what nursing is. In other words, they realize that nursing not only develops care work in hospitals, but also in community care through centers and health units, where they acknowledge cultural, social, political and spiritual aspects more clearly.

The approximation of students to community health must be developed by raising their awareness for intervening in health problems that affect family and community health. Therefore, some questions have risen among researchers, such as: What is the experience of nursing interns in promotional-preventive community care during their training? What is the meaning of community practice for nursing students?

PURPOSE

To understand the learning experiences of nursing interns of a Peruvian public university on health promotion and prevention during their community practice.

METHODS

Ethical aspects

The study was approved by the Ethics Committee of the Ethics Institute of the San Fernando School of Medicine of the National University of San Marcos of Lima, Peru, where the study was conducted. Detailed information about the study, including the purpose and process of the study, was given to the interns and they signed the informed consent. The anonymity of participants was maintained by using fictitious names of precious stones. Students’ autonomy was also respected, and they were informed of the freedom to withdraw from the study at any time. All ethical aspects in research with human beings were respected.

Theoretical-methodological framework and type of study

This is a descriptive-exploratory qualitative study. By means of this approach “it is possible to know the realities of the environment where the educational process is developed and to resize or design solutions according to the real expectations of the communities”⁽⁴⁾. The Life-Health paradigm was used as a theoretical reference, according to which, health is considered as a term that can have different meanings depending on the use and context. “From the philosophical point of view, health is a psycho-organic habit at the service of life and the person’s freedom, which consists both in the possession of a normality and in the physical capacity to conduct vital projects of the person” ⁽²⁾.

Methodological procedure

Place of the study and period

Data collection was conducted in classrooms of the nursing school in the medical faculty of a public university in Lima, Peru between August and October, 2014.

Population and sample. Inclusion criteria

Data sources were the nursing students attending the internship program during the 5^th year of professional training in the selected public university. The sample (19 interns) was established by the saturation level, i.e., until data did not bring anything new to what was known⁽⁵⁾. Within the inclusion conditions, was that participants should be students regularly enrolled, who had attended all years of training at the nursing school where the study was conducted, and that their participation was voluntary.

Data collection technique and instrument

The focus group technique was considered for data collection, and the average duration was of 1:30 to 1:45 hours. Groups of six to seven students were formed. The number of focus groups (three) was decided by the saturation point. Each focus group was immediately recorded in order to identify the information obtained, and when there was no different or new information, the group meetings were finished. A focus group guide was used as an instrument with the following guiding questions: How was your experience of promotional-preventive learning in community health during your academic training? What does the community practice mean to you in your training as a nurse?

The interns participated with a lot of spontaneity and emotion when evoking their experiences of community work throughout their training years, when they had direct contact with people and authorities of the community in the search to provide good care and participate in the improvement of people’s quality of life. They stated these experiences helped them in their personal and professional formation.

Data analysis

The qualitative analysis of data was performed through the thematic analysis according to Minayo, which includes the stages of pre-analysis, material exploration and treatment of results⁽⁶⁾. Data obtained in the focal groups were transcribed and was performed an initial reading. Then, data were organized, and units of analysis were formed in order to establish the codes that subsequently constituted the categories. When these were very extensive, were established the corresponding subcategories. Finally, the objective of the study was coordinated with empirical data and the theoretical content addressed.

RESULTS

Three categories were structured, namely: Considering the importance of the nursing teacher in their training; Experiencing complexity in training for the prevention and promotion of health in the community; and Considering the promotional-preventive area as future professional practice of the nursing intern.

1. Considering the importance of the nursing teacher in their training

The study participants consider the teacher’s support is very important during their training both in theory and in practice. They listed certain necessary characteristics of teachers for an adequate training in prevention and promotion of health in community care, namely: constant physical presence, guidance and orientation of the teacher in their practical experiences in primary care health facilities, as shown in these statements:

[...] because my teacher also explained what health promotion was, little by little I believe we were trained [...] (Diamante)

[...] thankfully, in the first year I had a good guide, a good teacher who taught me about health promotion [...] (Esmeralda)

According to students, teachers not only instruct them, but also encourage them to make decisions, observations, perceive relationships and work with questioning by developing the ability to solve problems. This way, they encourage the development of skills and attitudes that lead to the acquisition of technical power and autonomy for acting towards benefits for the society. As the testimony of one of the participants demonstrates:

[...] but at the same time, the teacher also leaves issues behind, so we independently know how to solve the problems because also, as she can guide you, she also leaves some parts so you can solve them on your own, and that helps to have more capacity of problem solving. (Ojo de Tigre)

2. Experiencing complexity in training for the prevention and promotion of health in the community

This category consists of three subcategories:

• Importance of knowing the context and reality of health for community care.

• Highlighting nurses’ educational role in community care.

• Considering the importance of the participation of members and leaders of the community in activities of health prevention and promotion.

These subcategories are detailed below.

Importance of knowing the context and reality of health for community care

An important aspect mentioned by interns was the need for a teacher working in community care in the health unit where they perform their practices. Someone who knows the context where care is being provided and the health reality of that community:

the teacher must be a nurse who works in community care and knows the place, if the nurse is not from the place, he/she is not accepted in the community [...] (Jade 2)

The teacher must also motivate community members, be a leader and have social skills:

I think if the tutor is not a leader, little progress is made in the community. (Zafiro 2)

[...] our teaching nurse must be from the area, must have experience in public health, be a community nurse, be a leader, have social skills [...] (Jade 2)

Highlighting nurses’ educational role in community care

Students place the health education developed in their community practice as an important function of nurses. As students, they reported that learning to prepare educational material is a self-taught activity in which they use their creativity and adapt the contents according to what is required by the population, and this leads to the strengthening of their leadership skills:

[...] although it is true that year after year we are reinforced about what is prevention and promotion of health, and we also somehow arrange our educational materials in a self-taught manner, little by little, we gain more leadership skills to speak before a larger group of people [...] (Cuarzo)

As the practice develops, students will gain confidence, security and originality to generate creative products and include their own details in their work. They also value teamwork with other health professionals and are convinced that working as a group leads to their greater development:

[...] it was like in the third year that I acquired a little more confidence [...] I could get to the population a little more, in the fourth year, the community work was also a very nice job with the group, because I am one of these people who believes that by working as a team one can do many things, because it is a community area and, where I am seeing a better result now is in the part of community interns. (Rubí)

Considering the importance of the participation of members and leaders of the community in activities of health prevention and promotion

The interns believe it is difficult to carry out activities of health prevention and promotion without the participation of all community members. Leaders have a great influence on the other community members. For them, gathering the members of a community was not easy. Initially, they tried to motivate them with invitations to participate, but people did not attend, which made them feel frustrated as students. When leaders such as those from the Vaso de Leche (organization of family mothers) were present, the situation was different because more people attended. The following statement demonstrates that situation:

[...] I had expectations in the first year, in the community course, that I was going to see 20 people there, maybe a little more, but I found myself with the sad reality that the community was reluctant and few attended, in the beginning, there were eight, then ten, at the most we reached fifteen, but when we invited the presence of the leader of the Vaso de Leche, it was really a nice job, there were more people. (Cuarzo)

3. Considering the promotional-preventive area as a future professional practice

Some nursing interns say that community care is attractive and rewarding and they can perform in this area because it is a development field for nurses. In this area, they consider work is independent and modifications can be made, but it should be better remunerated in order to make it even more attractive:

[...] community care attracts me, nurses are quite independent, in community, and changes can be done with knowledge within the team [...]. The nurse in Nueva Esperanza is working in mines applying what is prevention and promotion. (Amatista 2)

[...] I think it is a development field for nurses and nursing. (Esmeralda)

[...] I think it is an attractive field, but it should be better paid. (Zafiro 2)

Interns also consider the development of health promotion would improve the economic situation of the country and the prestige of the nursing profession. Some participants aim at specializing in public health to work in this area.

[...] if we worked as we should work on what health promotion is, the population would improve, the economy of the country would improve, there would be more people working and therefore, less poverty and above all, our career would be booming. (Rubí)

[...] my position is, I do like what promotion and prevention are and for that reason I would like to specialize in what is public health in order to be able to see the prevention and promotion of health in the future [...] (Jade)

Students consider that in the search for improving people’s quality of life, there is a vast field for the development of nursing in this area. However, they only focus on people’s lifestyles without considering the social determinants:

[...] these beautiful practices in the community with which I identify quite a lot [...] but I think it is necessary to promote healthier lifestyles, there is still a lot more to do in health promotion [...] because I believe that before complaining, we must prevent, and prevention is in community work [...] (Jade)

Students reported feeling more freedom to work in health promotion under scientific and legal technical support. They prepare for their professional future during the internship program; in care that demands social, natural and nursing sciences with use of both soft and hard technologies; and in the professional attitude that shows initiative, creativity, independence, freedom, and coordination, among others, as revealed by their speeches:

[...] in community, one is free and has the ability and capacity to make one’s own work plan and implement it. The greatest experience I am gaining is in the community internship. (Rubí)

[...] in the fifth year, one is independent as an intern, and as we go as a group, we decide by ourselves on what we are going to work with the community and there is a bit more freedom. (Agatha)

DISCUSSION

The expressions of nurses participating in the study demonstrate that teachers are a key point in the teaching-learning process in university education. They are considered facilitators, mediators between the object of learning and students for building their own knowledge. When referring to nursing teachers’ characteristics, Paz and Álvarez ⁽⁷⁾ Stated:

Nursing is a profession of service in which the focus is on the care of people. To obtain the necessary knowledge and skills to deliver quality care, health schools, and especially teachers, must recognize the importance of their work as trainers of professionals and develop behaviors and skills in the direction of achieving it.

“The teachingf nursing requires different spaces and micro spaces for recreating the environment of being a nurse. The construction of students’ ontological vision requires the foundation on special learning environments”⁽⁸⁾. In university teaching and in nursing, there is a peculiarity that teachers should have dual specialty, i.e., they must be specialists in a particular field of knowledge (community) and in teaching.

The process requires a great effort from teachers towards the students’ understanding of this other way of conceiving health that is by promoting it. A different vision of human beings is needed in the life-health process, one that involves thinking about our society and the concrete environment in order to think and rethink about the work of health and nursing professionals, in particular. It is necessary to think of another form of health care by seeking to improve the quality of life of community members.

According to Félix, when following the teachers’ process of knowledge construction, mainly regarding the nursing practice, the inclusion of care situations, experiences and activities is key for motivating students’ reflection and the transformation of their capabilities, knowledge and skills. “It is important that teachers stop considering themselves as supervisors who inspect the work of students, and that they begin to see themselves as facilitators, which implies making the performance of care easy and possible through guiding, sharing experiences, providing support, collaboration and feedback”⁽⁹⁾.

The interviewed students perceived the complexity of their training aimed at performing actions of prevention and promotion of health in the community. Their proper training requires that both teachers and they are aware of the importance of knowing the context where their practices are developed. Furthermore, such practices should be carried out in coordination with other health professionals (interdisciplinary) and active participation of nurses.

Students’ proper preparation is important for their interaction with community members and for encouraging their empowerment in terms of decision-making about their health. To this end, students must be aware of the complex context and health reality of the community. As put by Morin⁽¹⁰⁾ “The ability to contextualize and globalize is a fundamental quality of the human spirit that is atrophied by the parceled education and on the contrary, the pertinent knowledge is the one that should be developed since it can place all the information in its context”.

The proposals built from experiences in community work are of great value. However, their application requires multiple adaptations according to the addressed populations, that is, they must be in agreement with the context where work will be performed. Nursing curricula must provide a solid political education, so nurses can enter the spaces where public policies affecting health are defined. Likewise, nurses must counteract the globalization effects such as exclusion, inequality, poverty, among others, with actions that allow the design and implementation of policies aimed at the promotion of health and life. This will be the starting point for nursing undergraduate training with a social focus, commitment and civic responsibility by envisioning a holistic and humanized care in the first level of health care.

These influences should be reflected in higher education where the university must redefine its current role in society by considering its social responsibility. Academic consensus on the university role and objectives in the current globalized world must be understood, analyzed and proposed. In other words, the university must face the role of formation of citizens directly linked to the political and economic processes of its country.

The interns perceive the importance of the participation of community members and leaders in activities of health prevention and promotion. One of the central contributions of the life-health paradigm is the participation and recognition of social actors in educational processes, no longer seen only as passive recipients and beneficiaries, but as active subjects participating critically in the construction of alternatives oriented towards individual and collective well-being.

The results of the present study are similar to those obtained by Santos⁽¹¹⁾ in his doctoral thesis. First and second-year Nursing students of a Brazilian federal university reported greater understanding of their community practice in the second year as they interacted with the community members, and also associated the nurse profession with health promotion because of its bond with the community, closer contact with people, and the aspect of educational development during their practices.

The students understand the prevention and promotion of health and their relationship with the nurse profession and discover their educational role, which they consider essential for the better quality of life of people who acquired knowledge on their health care. This means that teachers with experience in professional practice, updated knowledge and in line with their reality, knowledge of the community, local and health authorities, formal and non-formal organizations, will have the freedom to plan the materials with educational content better used by students. In addition, the procedures and experiences will help to achieve the objectives proposed in Health Promotion.

Health promotion works through concrete and effective community actions in the development of priorities, decision making, definition of strategies and their implementation for better health conditions. The center of this process is the greater power of communities, the positioning and control of their own efforts. In the case of students’ training in health professions, Carvalho⁽¹²⁾ suggests the need to “rethink health education practices that take into account a more active role of the public for whom they are intended”.

Nursing interns showed their satisfaction in developing educational activities, which is similar to the findings in the study by Da Rocha et al ⁽¹³⁾. In one of its categories, the student describes health education during their formation process as very satisfactory. The experience of being directly in the field, as reported by the interns of the present study, makes them feel satisfied with the possibility of experiencing health education practices, which contributes to their personal growth.

However, we must bear in mind that the educational practices referred by students are related to the Behaviorist Current of Health Promotion. According to Carvalho, this line of thought emphasizes aspects concerning people’s responsibilities for their health, that is, in case of illnesses “the victims are blamed, they are responsible for health problems whose causes are often beyond their control, such as pollution, unemployment, lack of environmental sanitation, housing, inadequate income, etc.”⁽¹²⁾.

As most students still do not perceive the social determinants of health, these aspects should be emphasized during their training. They must be aware of the reality and health problems of the country and, consider that health does not obey an exclusively individual order, but is a complex and socially determined process. Such a process is not present in public health thinking given the prevailing biomedical vision that “reduces the problematic to the narrow limit of individual disorders or discomforts, their healing and individual prevention. Social determination comes and goes dialectically between the general, particular and singular dimensions: it reproduces from the general to the particular, and is generated from the particular to the general”⁽¹⁴⁾.

“In the health sector, policies and practices still focus disproportionately on approaches that propose solving problems (closer to the pathogen or the deficit)⁽¹⁵⁾. However, there are alternatives with an approach to the common work of services with people and communities that makes the most of their strengths, talents and abilities.

In the training of students, they must be made aware of the health reality of their country so they will become professionals who contribute to the improvement of health and therefore to people’s quality of life, as stated in the paradigm of Critical Epidemiology. It works in the popular-academic construction of a society centered on life, equity and full biosecurity (socio-biocentric) through intercultural, interdisciplinary and community-based research that seeks to nurture a process of critical reform, in which the strategic axis is the support from the epidemiological science until the defense of citizens’ rights.

Some interns show an inclination of their future professional performance towards the community area, which is related to their vision on their professional vocation, the consolidation of their professional identity and the projection of what they want for their future. As Ramírez et al. refer:

The excellence and ability to produce changes are elements of great motivation to students’ future professional life. By seeing themselves as professionals, students reflect on the development of self-confidence and the challenges to become the professional they desire. They realize how far they have come, begin to trust their own judgment and increase their perception of who they can become⁽¹⁶⁾.

In their community practice, students reflect creativity, which is the ability to capture reality in a unique way by generating and expressing new ideas, values and meanings. This gives them satisfaction, which is an emotion that emerges as the internship experience progresses and the student feels confident to face the challenges of the professional role.

They find satisfaction in developing community care and mention a broad field of nursing development in this area, as stated by Ferreira et al.: “The analysis of the daily practice in our service, of data of various studies on nurses’ practice in primary care [...] allows the deduction that in some aspects, nurses feel satisfaction in their work and envision a broad field of action to be built”⁽¹⁷⁾.

Students find their own style and rhythm, begin to feel a connection with the team and the health center that provides community care. When they feel accepted, their perception of the experience changes significantly. The support is perceived through interactions with the tutor nurses when these professionals integrate students into the team, support them and strengthen their knowledge and skills that will be developed in their professional future.

Study limitations

The main limitation of this study was that it was conducted only with students of a nursing school of a public university. Thus, it is recommended that further studies are performed in other educational institutions, faculties and schools of nursing and of other health professions.

Contributions to the areas of nursing, health and public policy

This study will contribute to the education of students of nursing and other professions in community health so that they get involved with ethical and social commitment in the integral and sustained solution of needs in the life-health process of the population. The university must have a more active participation in the training of professionals who are aware of the complexity of health problems and fulfill their role in social responsibility. Similar studies should be conducted in primary care, as this is an important area for the improvement of people’s quality of life.

FINAL CONSIDERATIONS

Participants of the study perceived the complexity of community practice when performing the prevention and promotion of health and in its relationship with life-health. They stated that teachers and students should know the context where they develop their practices, and that teachers should exercise leadership in the community and develop the necessary interdisciplinary practice with students of other disciplines of health sciences, social sciences and others.

Students place health education as an important role of nurses. They demonstrated feeling satisfied by transmitting their knowledge to the community members. They mentioned learning the preparation of educational material by themselves (self-taught way), using their creativity and adapting it to the contents required by the population. They strengthen their leadership in this activity.

Participants mentioned they had positive experiences in their formation that helped them in their personal lives according to the group with which they worked. Such experiences were very enriching, of great value for their development as future professionals in this field and to perform group work.

Likewise, for performing well in the field of health promotion, students need teachers’ guidance to advise them how to coordinate, make alliances with the community and its leaders. They also emphasized the importance of having adequate tutoring to help them in their training and that nurses must be leaders in the community.

Some students reported that community work is attractive and rewarding and they would like to work in this area as professionals because they can be more independent. They see a vast field for the nursing development in this area by seeking a better quality of life for people. However, students focus the health promotion only on what concerns changing the lifestyles, but without considering the social determinants, which is why these issues should be more emphasized during their training.

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Publication Dates

• Publication in this collection
  19 Aug 2019
• Date of issue
  Jul-Aug 2019

History

• Received
  04 July 2017
• Accepted
  29 Mar 2019