INTRODUCTION

Data from the Pan American Health Organization show there are millions of people in the Americas who suffer from lack of access to health services, making it a challenge to guarantee quality services¹. To face the challenges related to the assistance and comprehensive health care, interprofessional education (IPE) in health has been a strategy for the development of collaborative practices that meet the health demands^2)-(5. IPE takes place when students from two or more professions learn about the others, with others and with each other through collaboration, favoring better health outcomes, aiming at the training of professionals with skills, knowledge and attitudes to develop collaborative care that contributes for the well-being of the community^2)-(6.

The alignment and collaboration between health, education services and the community involved in health and education promotion and assistance are essential for IPE to occur^1)-(7. In Brazil, the Unified Health System (SUS, Sistema Único de Saúde) is the current health management model and has as one of its guiding principles the integrality of care with a focus on quality of life, health prevention and promotion. For its consolidation, it is necessary to reorientate health training and work³. The IPE as an educational proposal favors training aimed at the SUS, as it contributes to the decrease in the fragmentation of care and relationships between professionals. Additionally, the IPE strengthens the health system by promoting the training of professionals who are more prepared to: 1) understand the user as the center of health actions and policies, 2) work collaboratively as a team and 3) recognize the interdependence of areas to solve problems, complex health needs, and necessary conditions for comprehensive health care^8),(9. Although the health training model is still predominantly uniprofessional, the process of changing the health professionals’ training in accordance with the SUS principles has been taking place since 1980 through several initiatives, such as the UNI program, the National Education Forum, Family Health, Multiprofessional Residency in Health (RMS, Residência Multiprofissional em Saúde) and integrative courses during undergraduate school^8),(10.

To support the professional training process, several contributory policies that promote IPE were developed^9),(10. At undergraduate school, the implementation of the National Curriculum Guidelines (DCNs, Diretrizes Curriculares Nacionais) of the Undergraduate Health Courses in 2001, indicate the adoption of an integrated and interprofessional-based curriculum that advocates training for teamwork from the perspective of integrality and quality of care^3),(10, although it does not yet explicitly mentions the IPE. It was only in 2014 that the IPE started to be associated as a policy that promoted training when it was mentioned in the DCNs of the medical courses^5),(11)-(12.

The Multiprofessional Residency in Health (RMS, Residência Multiprofissional em Saúde) was created in 2005 at the postgraduate school level¹³, where the specificities of each profession were preserved and the recognition of common areas of professional activity, aiming at the promotion and comprehensive health care, was established^4),(10. Other initiatives that promote IPE include the National Program for Reorientation of Professional Training in Health (Pró-Saúde) and the Education Program for Work in Health (PET-Saúde), which prepare students to provide comprehensive health care, by integrating teaching-service and teamwork^4),(9),(10.

The first studies on the results of Brazilian IPE for the promotion of comprehensive care in line with the SUS were published in 2011^3),(11; however, the effects of its implementation are little known. This study aims to map Brazilian scientific production on the learning of students attending health courses in the context of IPE, challenges and advances for educators and management, while seeking to contribute with data on the results of Brazilian IPE initiatives.

METHOD

The scoping review was adopted to comprehensively identify the existing literature on IPE¹⁵, considering the checklist proposed by PRISMA-ScR¹⁶. The scoping review was chosen because it allows the synthesis and analysis of available scientific knowledge¹⁷, without restricting the parameters for randomized clinical trials or requiring study quality evaluation¹⁸.

Five stages¹⁹ were used: (1) research question; (2) identification of relevant studies; (3) study selection; (4) data mapping; (5) grouping and summarizing data.

In stage 1, the research question¹⁹ was established, with P for Population: Brazilian health science students (undergraduate or postgraduate); Intervention: educational process; Issue of interest: interprofessional education; Result: learning opportunities; Time: studies published from 2010 to May 2020. The research question was: “How does student learning occur in formative processes that use the IPE approach from the viewpoint of students, educators and managers?”

Two independent researchers carried out stages 2 to 4; in case of discrepancies, a third evaluator was called in, who decided whether or not to include the article in that stage.

In stage 2, the search for studies took place between May 15 and 20, 2020 in the Web of Science, Capes Periodicals, Scopus and the Virtual Health Library (BVS) databases; the references of the included studies were also consulted in search for studies not identified in the databases. The search strategy was developed with the assistance of a health information specialist and included the keywords “educação interprofissional” OR “interprofessional education” for the Web of Science and Capes periodicals. In the Virtual Health Library (BVS) and Scopus, the descriptor “educação interprofissional” OR “interprofessional education” was used.

The filters included publications from the last 10 years (2010 to May 2020), language (Portuguese, English and Spanish), place of publication or country of origin of the study (Brazil); afterwards, the selection was performed manually. Studies in more than one database were considered only once.

In the third stage, studies that met the inclusion criteria were included: (1) original research carried out in Brazil; (2) research with undergraduate or postgraduate health students; (3) studies that included student learning outcomes.

Articles that (1) were not carried out in Brazil; (2) did not assess student learning outcomes; (3) reviews, comments, discussion or editorial articles, as well as theses and dissertations were excluded.

For the analysis of the included articles, the mapping of relevant information for the synthesis and interpretation of data represented the fourth stage. The data were extracted and mapped using an adapted instrument²⁰: study identification, study topic, objectives, type of research/study design, participants, study setting, main results and conclusions.

In stage 5²¹, the findings were grouped and summarized in a flowchart and then synthesized aiming to answer the review question.

RESULTS

The literature search resulted in 145 studies, of which 40 were read in full and 28 were included (Figure 1).

Figure 1 PRISMA flowchart of the article selection process, 2020²¹. 

No publications were identified that met the selection criteria in the years 2010, 2012, 2019 and 2020 (until May). Studies from the years 2011²², 2013^23),(24, 2014²⁵, 2015^3),(26)-(28, 2016^10),(29)-(32, 2017^33)-(36 and 2018^{5),(14),(37)-(45} were selected.

The studies were characterized as qualitative^{3),(5),(10),(14),(24),(26),(28),(30),(33),(36),(38),(41),(43}, quantitative^{31),(35),(37),(42),(44),(45}, experience reports^{23)-(24),(27),(29),(32),(34),(39} and mixed^22),(25),(40.

Of the total number of studies, 15 (53.6%) were developed in the Southeast^{3),(14),(22),(23),(25),(26),(30),(31),(34),(39)-(43),(45}; nine (32.1%) in the Northeast^{10),(24),(28),(29),(35),(37),(38),(44} and four (14.3%) in the South region^{5),(27),(32),(36}.

Of the 28 studies, 20 (71.4%) are related to the training of undergraduate students^{3),(5),(14),(22),(23),(25)-(32),(39),(42)-(45}; whereas eight (28.6%) address RMS^{10),(24),(31),(33),(37),(38),(40),(41}.

The IPE was investigated during practical teaching in primary care^{3),(5),(10),(14),(22)-(24),(26)-(32),(35),(37)-(43}, in the hospital environment³³, as an interprofessional discipline³⁶ or in the assessment of scales^25),(44),(45.

The target audience of the studies involved 2,343 students^{3),(5),(14),(22),(23),(25)-(30),(32),(34)-(37),(39),(42)-(45)} of Medicine, Physical Education, Nursing, Pharmacy, Physiotherapy, Speech Therapy, Nutrition, Dentistry, Psychology, Social Work, Occupational Therapy, Veterinary Medicine, Public Policies, Biological Sciences, Biomedicine and Public Health and 392 residents^{10),(24),(31),(33),(37),(38),(40),(41}; principals, professors, tutors, preceptors, managers of health units and hospital workers also participated, totaling 2,886 participants.

To answer the research question, the analyzed results were grouped into four topics: “IPE from the student’s perspective,”; “IPE from the educators’ perspective”; “Advances and challenges in teaching and health management,”; “Recommendations for IPE in the Brazilian context.’

DISCUSSION

This study showed that IPE has been implemented in several Brazilian contexts of professional training to qualify health care⁷ and promote the teaching-service-community integration².

Among the issues that facilitate learning, practical activity has been mentioned as a strategy to develop interprofessional relationships in health education^{3),(5),(10),(14),(26)-(36),(38)-(43} and create opportunities for coexistence with other colleagues and professionals^{5),(14),(22),(23),(25),(26),(28),(32),(36}, corroborating the literature in the area and international recommendations^{2),(46),(47),(48}.

Interprofessional learning in the practice setting requires the interaction between knowledge, the environment, real-world experiences, individual skills and social intervention initiatives to promote an active and experiential learning about work in the health area^49),(50. These experiences can stimulate academic protagonism in the way of thinking and doing health work⁵⁰, in line with the DCNs of health courses, by promoting the sharing of knowledge, comprehensive care, understanding of the participation and the autonomy of its users⁴⁹. Interprofessional practice also leads the students to develop a critical sense to make joint decisions with the team⁵⁰.

For IPE to favor training and become part of the work of future health professionals, this strategy should be implemented at the start of the training and extend throughout the professional career^7),(51. Similar to the findings of this scoping review on the Brazilian context^21),(30, a systematic review showed that novice students are more available for IPE than graduate ones^7),(51; moreover, they have a facilitator profile, are more motivated and open to new experiences, reinforcing the need for interprofessional activities to be offered throughout the course and in practical fields, so that graduates are trained to carry out interprofessional activities and collaborative practices⁷. However, in educational institutions that already use the interprofessional curriculum and the contact of students with collaborative activities^52),(53, there was no difference in the availability for IPE between students attending the first years and the last year. These results were possibly impacted by the interprofessional curriculum already used in these institutions.

The challenges reported by the educators for the implementation of IPE in learning^{3),(10),(11), (26), (28), (34), (36), (39), (42)-(44)} may result from the distancing between the academic universe and working in the real world⁵⁰, the lack of institutional support, an adequate teaching-service articulation, incompatible curriculum and faculty training^3),(26, which need to be overcome so that interprofessional work can be truly effective⁵⁴. Therefore, it is necessary for the actors involved in this process reinvent themselves as professionals^23),(34),(54. The depicted difficulties can be solved by collaborative networks between educational institutions to share learning experiences, curriculum remodeling, concept discussion and faculty development^{5),(48),(50),(54}.

Furthermore, it is the educator’s responsibility to recognize their role as a facilitator in the IPE^51),(53 to increase mutual appreciation, understanding and collaboration; to do so, the facilitator must learn from resources inside and outside the group, synthesize learning, eliminate the lack of communication and misunderstandings, resolve rivalries and conflicts, and transform problems into learning opportunities^{5),(7),(51),(53}.

The PET-Saúde program and practical integrative undergraduate disciplines that used the IPE facilitated their students’ learning and were also positively evaluated by educators, service workers and service users.

PET-Saúde is aligned with the DCNs and its results are relevant in interprofessional practice and teaching-service-community integration by placing a student inside a real-life scenario, bringing them closer to the population’s social and health context and allowing spontaneous, constant and critical learning, in addition to the development of skills to promote patient-centered care^28),(29.

The faculty’s participation in PET-Saúde, although challenging, is a positive experience for IPE. Interprofessional work makes educators review their teaching processes and seek creative solutions, bringing educators closer to those from other courses, reducing prejudice among professionals, increasing the recognition of roles and functions, and promoting learning about the service and SUS, improving collaboration. However, there is some resistance from the teaching staff to the inclusion of IPE in the curriculum and participation in interprofessional programs is usually the result of voluntary and personal motivations²⁶. For health workers, PET contributes to teaching-service integration, as network professionals act as preceptors while carrying out pedagogical training and developing skills for interprofessional work and collaborative practices^28),(29.

IPE experiences in integrative disciplines indicate that common activities contribute to training professionals who will value the integrality of care^23),(50 by developing and understanding common, complementary and collaborative competences through the recognition of the limits of each profession, respect for the differences and the need for the comprehensive care³⁰. The reported difficulties were academic standardization³⁴, stereotyped conceptions among course students, distancing and the need for reciprocity between colleagues so that teamwork can be positive¹⁴. These obstacles are solved throughout the interaction, reaffirming the importance of shared learning and collaborative practice activities between students from different courses since, after the training, they will need to work together with other professions²².

Studies on RMS, created according to the principles of the SUS and the IPE, demonstrated the need to reflect on the work process of all actors involved in the provision of care. It shows the same positive results in relation to student satisfaction, patient-centered care, improvement in the quality of care and also the main effectiveness difficulties disclosed by the PET-Saúde program, such as difficulty in creating teams and exercising interprofessional work, preceptorship and service unpreparedness. These data reinforce the need to promote actions aimed at teaching-service integration, with the objective of collaborating in the training of health professionals aligned with the SUS^10),(31),(33.

For the IPE implementation, the findings of this review are corroborated by research about the relevance of the work of teaching and health institutions to overcome bureaucracy^5),(54, the availability and teaching load of the faculty^5),(54; it is also the institutions’ responsibility to propose actions that motivate the work of the facilitator^7),(54 and pedagogical training^5),(54 to overcome uniprofessional training^10),(33),(55, normative instructors and those with poor communication skills^26),(43.

The studies involved in this scoping review on the IPE in the training processes of Brazilian students demonstrated advances in education and health management when they showed that the IPE was aligned with the principles and guidelines of the SUS, being understood as a powerful tool for transforming the training and qualification of care in the different training levels^{3),(21),(22),(24)-(33),(36)-(44}. The IPE was also recognized by management as a complementary strategy to support other reforms in the country, such as the integration between universities, health services and the community^21),(32),(33, in addition to being in line with the DCNs of undergraduate courses in the health areas and national policies for reorienting health education⁵⁶.

The implementation of IPE during undergraduate school can be difficult; however, the articles analyzed in this review made recommendations^{27),(28),(29),(33),(40} that can allow facing these challenges^{3),(5),(10),(22),(26),(33)-(35),(38),(40)-(42}. The successful implementation of the IPE requires a commitment from all those involved, both in the academic environment and in practice^{5),(57),(58),(59}. Thus, managers, health services, and educational institutions should review their programs and curricula, seeking to recognize and take advantage of IPE opportunities to promote articulated actions in its implementation⁵⁴. Among the actions suggested by the analyzed studies, the literature also highlights the promotion of an integrated curriculum and the promotion of the development of skills for collaborative practice^5),(54),(57; accreditation of health services that share the same purpose⁵, expansion of the infrastructure^54),(58; training and leadership of the faculty^5),(55),(58 and of health workers for interprofessional work and collaborative practice^54),(58.

Among the limitations of this review, it is necessary to mention the heterogeneity found in the reviewed studies, which may also have individual biases. The application of the presented results in different contexts can be difficult, as it portrays studies about the implementation of IPE in Brazil. However, there is the possibility of reproducing the method adopted in this scoping review to identify similarities or differences between countries regarding IPE.

It was understood that the IPE success depends on a cultural change in the exercise of health work by all the actors who participate in this process, so they can be agents of transformation, promoting better interpersonal relationships in the health service and promoting permanent education⁵⁰.

CONCLUSION

When mapping IPE in the Brazilian context, it was observed that the studies are aligned with the SUS for the transformation of training and qualification of care, demonstrating the potential of IPE for learning and developing the skills required in the DCNs, despite the various challenges faced by the students, educators and management.

There has been an increase in HEIs that introduced the IPE to readjust their courses to the DCNs, aiming at transforming the training and qualification of care according to the health demands of the population, the guidelines and principles of the SUS.

The IPE is a teaching-service-community integration strategy that creates learning opportunities for students in the context of practice, providing the development of collaborative skills capable of strengthening and expanding knowledge about the SUS and promoting the direction of professional interest to the context of comprehensive health care.

Even though the Brazilian scenario of public policies and guidelines are favorable to the IPE, there are flaws regarding its implementation, which are perceived in all the analyzed studies; to overcome them, collaborative actions between HEIs, health services and managers are necessary, to discuss and jointly build curricula that promote interprofessional training following the guidelines of the DCNs, the integrality of care in line with the principles and guidelines of the SUS.

Finally, further studies are suggested on the weaknesses and strengths of IPE as a teaching strategy that promotes the integrality of care and the improvement of the Brazilian health care.