Preceptorship in the qualification of Health Agents in Brazil: analysis of the characteristics of instructors in the Saúde com Agente Program (PSA)Abstract
This article analyzes the sociodemographic, educational, and professional profile of preceptors linked to the Health with Agent Program (Programa Saúde com Agente - PSA). A cross-sectional, descriptive study was conducted through an online questionnaire. Data were classified into three dimensions: “sociodemographic profile”, “educational profile and professional experience”, and “characteristics of the professional bond.” The sample consisted of 3,834 participants. Findings showed that 88.5% were female and 52.2% were black or brown. Regarding education, 99.7% of the preceptors reported having a higher education degree, with 83.3% having studied Nursing. Additionally, 48.3% have 10 or more years of experience in Primary Health Care (PHC). Regarding professional status, 39.8% act as statutory civil servants in their municipalities, 20.6% have fixed-term contracts, 19.7% are public employees, 9.1% hold commissioned positions, and 7.5% are under the Consolidation of Labor Laws (Consolidação das Leis do Trabalho - CLT) regime. Among the preceptors, 61.7% work in urban areas and 14.1% in rural areas. Understanding the outcomes of the performance of these preceptors, who are professionals within the Unified Health System (SUS), is of paramount importance for the effectiveness of continuing education in health throughout the country.
Key words:
Preceptorship; Health education; Family Health; Primary Health Care
Resumo
O artigo analisa o perfil sociodemográfico, de formação e trabalho dos preceptores vinculados ao Programa Saúde com Agente (PSA). Foi realizado um estudo transversal, descritivo, através da aplicação de um questionário on-line. Todos os preceptores vinculados ao Programa Saúde com Agente (PSA) foram convidados a responder o questionário, auto preenchível com perguntas estruturadas. Para a presente análise os dados foram classificados em três dimensões: “perfil sociodemográfico”, “perfil de formação e experiência profissional” e “características do vínculo profissional”. A amostra é formada por 3.834 participantes, 88,5% eram do sexo feminino e 52,2% eram negros. Em relação à escolaridade, 99,7% dos preceptores declararam ter concluído o ensino superior, sendo 83,3% do curso de Enfermagem; 48,3% têm 10 anos ou mais anos de experiência em Atenção Primária à Saúde. Verificou-se que 39,8% dos preceptores atuam como estatutários nos municípios, 20,6% possuem contrato por tempo determinado, 19,7% são funcionários públicos, 9,1% possuem cargos comissionados e 7,5% se encontram sob o regime da Consolidação das Leis do Trabalho (CLT). Dentre os preceptores, 61,7% atuam em áreas urbanas e 14,1% em áreas rurais. Compreender melhor os resultados da atuação dos preceptores, que são profissionais do Sistema Único de Saúde (SUS), é de suma importância para a efetividade da educação permanente em saúde no país.
Palavras-chave:
Preceptoria; Educação na saúde; Saúde da Família; Atenção Primária à Saúde
Resumen
El artículo analiza el perfil sociodemográfico, de formación y laboral de los preceptores vinculados al Programa Saúde com Agente (PSA). Se realizó un estudio transversal, descriptivo, mediante la aplicación de un cuestionario en línea. Los datos se clasificaron en tres dimensiones: “perfil sociodemográfico”, “perfil de formación y experiencia profesional” y “características del vínculo profesional”. La muestra estuvo conformada por 3.834 participantes. El 88,5% eran del sexo femenino y o 52,2% son negros. En cuanto a la escolaridad, el 99,7% de los preceptores declararon haber concluido la enseñanza superior, de los cuales el 83,3% cursó Enfermería. El 48,3% tiene 10 años o más de experiencia en Atención Primaria de Salud (APS). Se verificó que el 39,8% de los preceptores actúan como estatutarios en los municipios, el 20,6% posee contrato por tiempo determinado, el 19,7% são funcionarios públicos, el 9,1% posee cargos de confianza y el 7,5% se encuentra bajo el régimen de la Consolidación de las Leyes del Trabajo (CLT). Entre los preceptores, el 61,7% actúa en áreas urbanas y el 14,1% en áreas rurales. Comprender mejor los resultados de la actuación de los preceptores, que son profesionales del SUS, es de suma importancia para la efectividad de la educación permanente en salud en el país.
Palabras clave:
Preceptoría; Educación para la salud; Salud Familiar; Atención Primaria de Salud
Introduction
In the health field, a preceptor is generally a professional with a higher education linked to health services. They are responsible for the training process of students in the daily practice of health services, contributing to the formation of a professional profile geared towards the political and health needs of Brazil1,2. Preceptorship experiences have been reported in the literature, documenting the importance of the preceptor’s activity in the training of undergraduate and postgraduate students3-6. Few studies prioritize preceptorship carried out in technical training courses.
The National Policy on Continuing Education in Health recognizes the importance of preceptorship in the training of health professionals7. However, it highlights the challenges in terms of defining the roles and profile of the preceptor in different worker training scenarios. The document points to the need to know what the most appropriate professional profile would be for the role of preceptorship, reinforcing the need to consider career progression processes that value the performance of this function.
Since the publication of Law No. 13,595, of January 5, 2018, which deals, among other issues, with “the reformulation of the duties of Community Health Agents (CHAs) and Endemic Disease Control Agents (EDCAs)”, the scope of the duties of CHAs has been expanded, and the need for technical training for these workers has been recognized by the Law itself. With the goal of improving the training of health professionals, the Ministry of Health, through the Secretariat for Labor Management and Health Education (Secretaria de Gestão do Trabalho e da Educação na Saúde - SGTES) and in partnership with National Council of Municipal Health Secretariats (Conselho Nacional de Secretarias Municipais de Saúde - CONASEMS), launched the Health with Agent Program (Programa Saúde com Agente - PSA) in 2020. This initiative aimed to offer nationwide technical-level training for CHAs and EDCAs, offering 200,000 places in its first edition. In addition to training, the PSA also aimed to improve the integration process between health surveillance actions and health actions developed within Primary Health Care (PHC) services.
Thus, in partnership with the Federal University of Rio Grande do Sul (UFRGS), a hybrid training model was developed, with some activities carried out through Distance Learning (Educação a Distância - EaD) and practical activities dispersed throughout the territories. The teaching-learning model included active methodologies, based on the inseparability of theory and practice. Theoretical activities were accompanied by tutors, and in-person practical activities were conducted under the supervision of preceptors.
The preceptors who worked in the PSA were selected through a public call for proposals. Requirements included being linked to public health services, preferably having a higher education degree in the health field with a diploma recognized by the Ministry of Education, and having authorization and agreement from the local manager regarding the development of preceptorship activities within the Program.
The preceptors were responsible for classes of up to 25 students, and were required to carry out educational actions of pedagogical guidance within the scope of the agents’ professional performance, in accordance with the National Policy for Continuous Education in Health8. All preceptors also participated in training and supervision activities carried out in the UFRGS Virtual Learning Environment, where materials about the course and the practical activities of the subjects were available. It was the preceptor’s role to stimulate learning, monitor the development of practical activities (dispersed activities), and evaluate student performance according to the teaching plan of each subject and the grading system.
The experience of the PSA, as well as the literature, demonstrates that the training and qualification processes of health professionals demand teaching-learning strategies that, in their educational objectives, include elements that enable the student to recognize and respond to the needs of the community and the health system in which they are inserted. To this end, articulation and joint work between educational institutions and health services is essential, aiming to achieve effective training, coupled with the strengthening of the teaching-service-community integration5,6.
This article aims to analyze the sociodemographic, training, and work profile of preceptors linked to PSA. The goal is to contribute to the discussion of preceptorship in technical training as a qualified training strategy for SUS workers.
Method
This cross-sectional, descriptive study was conducted using an online questionnaire. All preceptors linked to the PSA were invited to answer the self-administered questionnaire with structured questions using the LimeSurvey platform. Preceptors received an email with an access link to the questionnaire, an individual password, along with the invitation to participate, and information about the purpose of the research. Completion of the research instrument was enabled after signing and acceptance of the digital Informed Consent Form (ICF) by the preceptor.
The instrument used for data collection consisted of 24 questions designed to understand the profile of preceptors linked to the PSA. For this article, data relating to the profile of preceptors were analyzed, classified into three dimensions: “sociodemographic profile”, “training and professional experience profile”, and “characteristics of the professional relationship”.
Data collection took place between July 3, 2023, and July 31, 2023, in which 9,649 invitations were sent to all active preceptors in the PSA during the data collection period. Only valid responses were considered for analysis, totaling 3,834 participants in the sample. The response rate obtained was 39.73%, a rate close to the average of other studies with specific populations using online data collection instruments. According to a recent meta-analysis that considered more than a thousand response rates from education surveys using online questionnaires, the average response rate was 44.1% when considering a specific population9. In the case of the present study, the response rate does not appear to have influenced the findings, since the distribution of respondents by sex, region, and educational level is in accordance with expectations, given that the vast majority of preceptors linked to the PSA were female and held higher education degrees. Moreover, the highest concentration of students was found in the Northeast and Southeast regions of Brazil.
For the analysis of the results of each dimension, a table was generated that includes the descriptive analysis of the profile of the preceptors linked to the PSA, considering the absolute and relative frequencies of response. The data collected were organized and analyzed using Microsoft Excel® software and Statistical Package for Social Sciences (SPSS), version 27.0.
The research project was reviewed and approved by the UFRGS Research Ethics Committee (Comitê de Ética em Pesquisa - CEP) in October 2022, logged under CAAE 60867922.60000.5347.
Results
Table 1 presents the sociodemographic characteristics of the preceptors participating in the study. The sample of participants consisted of 3,392 (88.5%) females and 442 (11.5%) males. The majority of preceptors who responded to the instrument (86.9%) identified as cisgender women, while 6 (0.2%) respondents identified as transgender women. Regarding the race/skin color of the participants, 52.2% are black (44.6% brown and 7.6% black) and 46.8% declared themselves to be white.
Regarding age range, a higher concentration of preceptors was identified in the 29-39 age range (47.4%), followed by the 40-49 age range (33.9%). In relation to education, 99.7% of the preceptors stated that they had completed higher education and 12 (0.3%) reported having completed high school. Our study found a higher percentage of preceptors working in the Northeast (36.0%) and Southeast (28.8%) regions of the country, a figure consistent with the distribution of PSA students.
Table 2 describes the results of the preceptors’ response frequencies for the dimension of “Training profile and professional experience”. Regarding undergraduate education, the vast majority (83.3%) have a degree in Nursing. At the postgraduate level, 80.9% have a specialization course, 8.2% have a Master’s degree, and 4.2% have completed a residency program.
Regarding supplementary training in the didactic-pedagogical area, participation in different training modalities was observed: 53.1% of the preceptors reported participating in workshops, 13.9% participated in scientific meetings, and 6.9% reported having participated in courses promoted by the SUS Technical Schools (Escolas Técnicas do SUS - ETSUS). It was also identified that 66.3% of the preceptors have experience as teachers and 61.9% have no prior experience as a preceptor.
Regarding the length of time working in PHC, 48.3% have 10 years or more of experience, and just over a quarter have been in the field for less than 5 years.
Table 3 presents the results found for the dimension of “Characteristics of the professional relationship”. Regarding the type of employment, it was found that 39.8% of the preceptors work as statutory employees in the municipalities, 20.6% have a fixed-term contract, 19.7% are public employees, 9.1% hold commissioned positions, and 7.5% are under the Consolidation of Labor Laws (Consolidação das Leis do Trabalho - CLT) regime. Regarding the field of activity, 42.3% work in the areas of assistance and management, 41.8% work only in the area of medical care, and 16.0% work only in the area of management. The vast majority of preceptors (83.6%) reported having a workload of 40 hours per week, and 73.0% reported not having other employment relationships besides their relationship with the municipality.
As regards the type of Family Strategy unit in which the preceptors work, it was observed that 61.7% work in urban areas and 14.1% in rural areas.
Discussion
The data regarding the sociodemographic profile, and the work and training of PSA preceptors, who were necessarily professionals linked to the municipal level SUS, presents a sample of the capacity of the human resources available to work in the professional training of SUS workers. This data is essential to guiding future proposals for qualification for teaching performance in PHC practice settings, particularly at the technical level.
The vast majority of this workforce is comprised of cisgender, black women, aged between 29 and 39 years. The feminization of health work has been widely studied for some decades, showing both the expansion of female participation in the labor market and specificities of the health sector, responsible for a significant contingent occupied by women. From a historical perspective, based on the analysis of Brazilian census data, Wermelinger et al.10 highlight that while in 1970 the participation of women with higher education in health work was 20%, in 1980 it increased to 39%, and in 2000 female participation in this segment represented 61.75% of the workforce. This trend of feminization is maintained in our data, indicating that women continue to be the main workforce in the health sector.
A new piece of data in this scenario identified in the present study is the presence, although still a small minority, of transgender women and non-binary people in health teams. In educational terms, this participation is extremely relevant, as it allows for experiences of acceptance and reflection on the diversity present in our society. The literature indicates the difficulty that transgender people face in completing a higher education course, with the university environment remaining a predominantly cis-heterosexist space11.
The identification of non-cisgender professionals as PSA preceptors signals the importance of including the gender identity variable in research, particularly in studies conducted in the health field. Studies on the teaching profile that include such variables as gender identity and/or sexual orientation are still scarce in Brazil. In recent years, there has been a significant increase in teachers who have undergone sex reassignment surgery and/or non-binary individuals who have started their careers as teachers; however, there is still no national mapping, which may obscure the importance of these actors in the academic setting and their pedagogical roles as educational agents.
The diversity of race/skin color among health workers who acted as PSA preceptors, and particularly the predominance of brown and black people, is another indicator of the social transformations related to access to higher education in the country. In the case of preceptorship in the technical courses for CHAs and EDCAs, where a significant portion of the students identified as black/brown, with a black/brown preceptor, can facilitate student identification and the teaching-learning process. Identification with the preceptor can also act as an incentive for professionals to seek other forms of professional development.
The significant presence of black/brown people in the role of preceptor in the PSA is possibly one of the effects of the adoption of affirmative action policies in Brazil, in both education and the public sector. The adoption of racial quotas (affirmative actions) in the country’s public universities has significantly contributed to increasing the representation of the black/brown population in academia12.
The significant presence of preceptors from the North and Northeast regions signals the potential for capillarity of educational initiatives in health in a country the size of Brazil. According to data from the 2022 National Household Sample Survey (Nacional por Amostra de Domicílios Contínua - PNAD), Brazil had 5.6% of people aged 15 or older who were illiterate, with the Northeast and North regions having the highest rates, at 11.7% and 6.4% respectively13.
It should be noted that the number of preceptors was related to the number of students enrolled in the technical courses offered; however, our data reveal that even in the most remote locations, it is possible to count on qualified professionals to practice preceptorship in PHC services. In one study conducted with students of specialization courses in preceptorship for the area of Family and Community Medicine offered within the scope of the National Program for the Training of Preceptors, Ferreira et al.14 identified a low participation of professionals from the North and Northeast regions, justified by the lower availability of residency positions in these regions. In the case of the PSA, significant participation was found for students from the Northeast (41%) and North (12%) regions, which corresponded to the participation of preceptors willing to accompany these students, which was a key element in the qualification of CHAs and EDCAs from these regions.
Regarding the training profile and professional experience of the preceptors participating in the study, it was identified that most of them have a degree in Nursing. And, although the preceptorship activity was open to different health backgrounds with the requirement of experience in PHC, the greatest demand for the activity came from Nursing. For Jönsson et al. (2021)3, preceptorship is considered a natural part of the Nursing profession, and nurses are expected to be able to develop it adequately. The author also identified in his study that the role of the preceptor was viewed positively and closely linked to the professional identity of the nurse.
Another factor contributing to the increased demand for nursing professionals within the PSA is the close relationship between these professionals and CHAs. A qualitative study conducted with CHAs, other health professionals, and users of health services demonstrated that nursing professionals are considered to be crucial in the CHA’s interaction process with the community, acting as leaders in this scenario15. The authors also highlight that the nurse-CHA relationship has a strong bond, since all of the CHA’s actions are directed by nurses, requiring patience and subtlety in the way they conduct these activities.
In the context of this study, in which preceptors develop activities of monitoring, supervision, and mediation of the teaching-learning process in service, for CHAs and EDCAs, the fact that most preceptors have a background in Nursing can be considered an important differentiator. This configuration follows the history of joint action by these professionals in the field of public health in Brazil, dating back to the Community Health Agents Program (Programa de Agentes Comunitários de Saúde - PACS), created in the early 1990s, prior to the Family Health Strategy (FHS) model. Furthermore, the findings of this study are corroborated by the fact that the activities of nursing professionals described in the National Primary Health Care Policy (Política Nacional de Atenção Básica - PNAB) include planning, coordination, and evaluation of the actions developed by the CHAs, in addition to facilitating the relationship between them and the multidisciplinary team7.
Another important finding of our study concerns the qualifications of the preceptors who worked in the PSA, since the vast majority have lato sensu postgraduate degrees. It is also important to note that a portion of these professionals working in SUS also have residency and even stricto sensu postgraduate degrees (Master’s and PhD). The work of Machado et al.16, analyzing data from nursing professionals registered with the Federal Nursing Council (Conselho Federal de Enfermagem - Cofen), indicates a trend among health professionals to seek professional qualification through continuing education courses and lato and stricto sensu postgraduate studies. According to the authors, the pursuit of qualification is one of the differentiation strategies for entering the labor market.
Teaching training and experience are part of the trajectory of more than half of the preceptors studied, indicating that this is also a field of activity for SUS professionals, as also verified by Machado et al.16. However, experience in preceptorship is less frequent. The importance of training for teaching is recognized by the health professionals themselves, who, while valuing practice, acknowledge the need to train themselves to act as teachers. Feuerwerker17 highlights that important challenges arise for health professionals who develop preceptorship activities within the context of configuring learning in the experience of health services. According to the author, preceptorship in PHC settings is more recent and follows a different logic than preceptorship developed in the hospital context. The experience in the exercise of preceptorship among health professionals differs according to the region of the country.
Training for preceptorship performance is one of the sensitive points among health professionals. Marins18, in a study on preceptorship in the health field, highlights the low percentage of preceptors with pedagogical training and knowledge of the use of active teaching methodologies in this type of environment. In the case of the PSA, preceptors participated in an online extension course for the exercise of preceptorship activities within the Program, in which they had access to materials on the role of the preceptor, active methodologies, and booklets on the practical activities foreseen in each discipline of the technical courses offered. They were also accompanied by supervisors whose role was to answer questions and assist in the search for appropriate teaching-learning strategies for each context. For Omena et al.19, didactic and pedagogical training for preceptors has the potential to promote meaningful learning, resulting in the training of professionals committed to the social and health needs of the community.
Within the context of PHC, which prioritizes the territory as a space for action, the preceptor’s connection with the health service and the territory is an important element in qualifying the activity. In the case of the PSA, one of the requirements for preceptorship was a connection with the municipality. The fact that almost 50% of the preceptors have 10 years or more of professional experience in PHC provides greater knowledge about the social and health issues of the territories in which the students are working. Insertion into the health service as a network professional is, according to the literature, a facilitator for the monitoring of students19. The authors highlight that, by contrast, this dual insertion-team professional and preceptor-can generate a workload overload, which needs to be evaluated so as not to interfere in the performance of both functions.
Final considerations
The methodology used by the PSA to offer technical-level training to 200,000 CHAs and EDCAs throughout Brazil was based on a dynamic learning process, mediated by preceptors, with the aim of overcoming the dichotomy between theory and practice. The role of the preceptor in this process was crucial in the production of new knowledge, skills, and professional competencies, aimed at responding to the social and health demands of communities and territories. Understanding the profile of the health professionals who acted as preceptors in this innovative project sought to contribute to the debate surrounding the importance of considering the influence of these professionals’ characteristics on the teaching-learning process. Our data on the training characteristics, professional affiliation, and experience of the preceptors enable us to identify positive aspects, such as qualifications and professional experience in PHC, but also point to gaps that require attention, particularly regarding didactic and pedagogical training geared towards the practice of preceptorship, as well as the precarious employment relationship that implies professional turnover. A better understanding of the results of the work of preceptors, who are professionals from SUS, in the technical training of health workers and professionals in other spaces integrating teaching, service, and community is of paramount importance for the effectiveness of continuous health education in the country.
References
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The data sources adopted in the research are indicated in the article’s body.
