INTRODUCTION

Delivery care requires an approach carried out by a multidisciplinary team based on scientific knowledge, techniques, and procedures according to the stages of labor¹.

Considering this collaborative model of childbirth care, the participation of nurses contributes to respecting the physiology of childbirth and rescuing the role of women, reducing unnecessary interventions, implementing good care practices that enhance favorable obstetric and neonatal outcomes, and humanization of care².

Physiologically, eutopic labor is characterized by the presence of painful, rhythmic, and continuous contractions, effacement, and cervical dilation that vary according to the phase (active and latent) and that culminate in total dilation, the expulsion of the fetus and its annexes³.

Thus, childbirth is a series of different events/phases divided into four clinical periods: dilation, expulsion, delivery, and the first postpartum hour, or Greenberg's period^3-4. During the expulsive period, a series of delivery mechanisms occur (descent, engagement, internal rotation, crowning, external rotation, and detachment of the uterine cervix), characterized by a set of active and passive movements performed by the fetus during the passage through the birth canal⁴.

Understanding these physiological aspects related to the clinical periods and mechanisms of childbirth is an important dimension to be addressed during health/nursing training to favor assessing the progression of labor, development of care, and early identification of complications^1,5. However, it should not be limited to the physical aspects as it should consider the meanings, social and subjective aspects, and humanization in childbirth care⁶.

However, during training, students find it difficult to understand specific theoretical contents and apply them in internship practices to articulate theory and practice, which requires incorporating active methodologies in the teaching-learning process and curriculum review⁷. In teaching about clinical periods and birth mechanisms, studies also suggest the incorporation of educational games5 and simulated practices^8-9 during nursing training.

In this sense, the training process of these professionals must be able to favor the acquisition of knowledge, skills, and attitudes for the development of an academic and professional profile that acts as an agent of change in the (re)organization of health practices in a critical way- reflective and humanistic¹⁰. Therefore, the educational processes in health experienced by nursing students must be considered to develop these competencies.

Given the above, the objective was to describe the perception of Nursing students about the teaching-learning process of clinical periods and delivery mechanisms.

METHODS

This is a descriptive research with a qualitative approach. The study population consisted of 133 nursing students from the Universidade Regional do Cariri- Advanced Campus of Iguatu, located in the urban area of Iguatu, Ceará, Brazil.

Students from the eighth to the tenth semester, regularly enrolled in the undergraduate nursing course and who had completed the nursing discipline in the process of caring for women's health, were included, 16 academics were approached, and four were excluded due to unavailability for collection after two scheduling attempts. Thus, 12 nursing students participated in the study.

The snowball technique was used to select the students who corresponded to the research participants during the period of availability for collection. The snowball technique or snowball sampling is characterized by the initial choice of a participant (one of the three representatives of the classes that had already attended the discipline was drawn by lot). This indicates a new participant, who indicates again and so on until reaching the research objective11. After identifying and approaching the participant and informing the research objectives and procedures for data collection, it was waited up to 48 hours to schedule the interviews at a time favourable to the student.

Data collection took place from March to June 2020. Considering the recommendations for social isolation resulting from the pandemic related to Coronavirus Disease 2019 (COVID-19) in force at the time, data collection was carried out through the Skype® application.

A semi-structured interview was used for data collection, containing data on the characterization of the participants (marital status, color/ethnicity, sex, sexual orientation, education, professional status, profession, domicile, and monthly family income), followed by a script of questions previously structured regarding the teaching-learning process on clinical periods and mechanisms of childbirth: 1. What do you understand by labor and delivery? 2. What do you understand by clinical periods of childbirth? Which ones are they? 3. What is the concept of birth mechanisms? Which ones are they? 4. What is the difference between clinical periods and delivery mechanisms? 5. Tell me how the themes of clinical periods and childbirth mechanisms were approached in nursing graduation? 6. Tell me about how you consider your learning concerning the themes of clinical periods and delivery mechanisms. 7. Tell me about intervening factors (positive and negative) in the teaching-learning process concerning thematic clinical periods and delivery mechanisms.8. What suggestions to improve the assimilation of the content?

The interview was recorded using a smartphone brand Samsung® model A10 and through the technology of the Skype® application that allows free video and voice calls between users. Afterward, the speeches were transcribed in full, being transposed to Microsoft Office Word® version 2010. The participants were informed about the procedures for data collection and electronically signed the Free and Informed Consent Term and the Post-Informed Consent Term, as well as the authorization term for the use of voice and image.

Data collection was terminated using the theoretical data saturation criterion. The data obtained were analyzed according to the thematic categorical analysis technique12. The content of the speeches was gathered and grouped based on the identification of similarities and differences, and later, the description and interpretation of the collected data were carried out. In this process, from the patterns of recurrence of information, empirically emerged the three thematic categories presented in the results in which excerpts from the participants' speeches were presented. To check the participants' anonymity, they were identified by the letter "A," referring to the word "Academic," followed by a number corresponding to the interview order.

The research was submitted to the Research Ethics Committee (CEP) and complied with the ethical principles of resolution 466/12 of the National Health Council of the Ministry of Health, respecting all recommendations concerning research involving human beings, being approved with an opinion no. 3,895,905 and CAAE:28640420.5.0000.5055.

RESULTS

The 12 participants are all females. The age ranged from 20 to 25 years old, with a mean of 22.2 years. Most self-declared as brown (n=09), single (n=10) and heterosexual (n=10). There was a predominance of academics enrolled in the 9th semester (n=07), none of the participants worked, and only three received a scholarship and/or institutional financial aid.

Category 1- The teaching-learning process about clinical periods and childbirth mechanisms in nursing graduation

The teaching-learning process on clinical periods and delivery mechanisms from the perspective of nursing students were carried out through lectures and interactive strategies with theoretical-practical articulation, as mentioned by the participants:

Through an expository class, the teacher had images and videos, and we had contact in the internships. (A3)

This theme was addressed through theoretical classes, the didactics of oratory slides, and only. (A4)

They were explained in an explanatory way through slides, some videos, and [...] there was a demonstration with the anatomical puppets. (A8)

[...] (the teachers) take videos and slides, texts, we go to the laboratory, there is all that anatomical part [...]. (A5)

Although considered well designed for using dynamic approaches with the inclusion of active methodologies, the teaching was characterized by extensive content taught in a short period of time, resulting in learning difficulties.

In addition, over time, the academics reported difficulties in rescuing the acquired knowledge because it was specific:

It was clear and complete, and we ended up not remembering after the course (discipline), and, unfortunately, teachers have little time to talk about everything. (TO 1)

[...] they were approached excellently, but I think that as there are many subjects [...] in a short period [...], there was a lot to study [...]. (A10)

It was approached in a very dynamic way because the subject teachers liked active methodologies, so it was very dynamic and noticeable, but over time we see other things, and we forget about them. We have to keep reviewing them. (A2)

[...] this course (discipline) was the one we paid (coursed) the best [...] we saw the content and then saw these active methodologies and fixed it more in our minds (the content) [...]. (A11)

Look, to be honest, I liked it. It was one of my best subjects. I think the best of the undergraduate course was women's health, and despite being a little complicated to learn these technical names, we fixed the main idea [...] is already very important. The teachers managed to do it dynamically so we could understand it well. (A7)

[...] I managed to absorb a lot. But over time we don't study and forget some particular things [...]. We got lost, but the approach was excellent. I liked. (A5)

The academics considered the methodological approaches as applicable to favor the teaching-learning process. However, this did not occur in a significant way as the students reported difficulties in distinguishing the concepts, clinical periods and delivery mechanisms:

They were approached in a way [...] of active methodology. There were both theoretical classes with slides, as well as the availability of books, there were gymkhanas, and team games [...] It's just that there are so many issues of women's health, and it was approached excellently, but I don't particularly remember many of these concepts. (A10)

So the class was well taught, an explanatory approach, there were active methodologies, but I don't remember, just a few things [...]. (A11)

The teachers had a good time (the content), they used several themes and active methodologies, and it was possible to understand the clinical period and the delivery period. Still, we forget because it's been a long time. (A12)

The academics recognized that part of this non-assimilation of content stemmed from their weaknesses in the process of co-responsibility/commitment during teaching-learning and emphasized the need to include a study review routine:

I consider it (teaching-learning) to be positive, but on my part, it is negative [...] as I said, they (the teachers) explain well, they are highly regarded, and they are willing. I think time is short. There should be more time and what weighs more is the question of us reviewing it ourselves at home and in our free time. Because the teacher does his part, however, little time explains all the content, and we have to take responsibility for studying that. (TO 1)

It was good, but I forgot much due to not reviewing the content. (A3)

I believe that I have some knowledge, but I need to go deeper. It is an area that I like and that I intend to follow. (A4)

[...] I managed to absorb a lot [...] it's just that when we don't exercise [...] don't read [...] we end up forgetting something, that flash comes, but we never remember to remember everything [...]. (A5)

[...] I have to review it. What I know I didn't learn in graduation, but because now in this period of quarantine I'm studying a little [...] on this subject, but during graduation, we don't see that much, we don't feel very prepared, do not know. (A9)

Of course, every semester, we have to be revising and we have to be studying. That's why we forget some things, but it was well passed on. (A12)

Learning was referred to as weakened as the participants showed a relative understanding of the theory but could not articulate the knowledge in practice.

Due to the reported learning difficulty, they pointed out the need to expand knowledge on the subject of clinical periods and delivery mechanisms during practices in stages from an approach that considered not only the technical but subjective aspects inherent to obstetric care:

[...] It's very superficial [...] I'm already in the 9th semester, but I've already seen delivery in person during the internships. But when we are faced with reality, I think we are very unprepared for what the theory says [...]. Regarding the theory [...], we even see the issue of clinical periods. We know that there are latent, active, and transition phases, but when it is there at the time, in reality, everyone feels very unprepared. I think this should be worked on more at graduation [...]. (A9)

[...] I still have a lot to learn. It's a subject that I'm also interested in, especially learning and putting into practice, which we don't see so much in care and working well with this mother's emotions, and it's not just linked to the terms technical. (A7)

I consider it fragile since we see it in theory, but in practice, we cannot associate it often [...]. We don't have a concise phase of this mechanism teaching how it happens, and we don't even see this teaching process in the internships. (A8)

In this category, the participants pointed out how the teaching-learning process took place and recognized their difficulties, emphasizing aspects related to commitment, organization, and co-responsibility concerning studies on the subject.

Category 2- Facilities and difficulties in the teaching-learning process about clinical periods and delivery mechanisms in nursing graduation

The academics reported that the potentiating aspects of the teaching-learning process were related to the way the content was taught (a clear, accessible, detailed language with theoretical-practical articulation and emphasized the mastery of the content, the detailed explanation and the disposition of the teachers for teaching and clarification of doubts:

Teachers are willing to talk about it and explain it clearly. (TO 1)

We managed to clear all doubts [...]. (A3)

[...] the teachers have mastery of the subject [...] in the classroom. (A4)

[...] the classes were well explained [...] there was also a theoretical-practical approach [...] in the laboratory, we saw how the mechanisms were [...] many images, videos [...] (A5)

[...] we had a teacher who showed all aspects of the theme at all times. (A6)

[...] they (the teachers) applied it dynamically so that we could fix the content well. (A7)

[...] a detailed explanation, both of the periods and mechanisms of delivery. (A8)

The students also positively mentioned using active methodologies in the teaching-learning process as a strategy that facilitated understanding the content.

[...] these active methodologies were excellent. They encouraged us to study even extra materials [...] I tried to be learning and read other things. So I think that's good. (A10)

[...] the positive is that they used a lot of active methodologies, and the type of class varied a lot. (A12)

On the other hand, the academics reported that the negative aspects were mainly related to the difficulty in articulating theory and practice and the few opportunities for practical experiences during the internships in the discipline:

But we haven't had much training. (A3)

However, what is lacking is a practice of understanding better and consolidating learning. (A4)

The negative is more the issue of not having seen more in internship [...], but concerning the class itself, the theoretical point was well explained [...]. (A5)

Negative point joining theory to practice. There was little of it. We knew a lot in theory, how to talk, the time of labor, and the mechanisms, but when we would attend, we couldn't. So I think it's a failure in the teaching-learning process. (A8)

The negative is that there could be more practice on this subject, which we didn't have much. (A11)

The negative is that we had little practice. (A12)

Another aspect that negatively influenced teaching-learning refers to organizational issues related to the academic semester, as the provision and extensive amount of content were insufficient to be taught in short periods:

Time is short because women's health has a lot, and our semester is short. It's been four months and a long time, but it was good. (A2)

[...] it was a short period to work on many subjects because women's health is a vast world, so, sometimes, you had a class to work on and try to solve your doubts about a pervasive subject. (A10)

[...] it's such an extensive subject that needs to be discussed more. I didn't think the semester was enough to discuss these subjects because they still had much to discuss. (A7)

Negative aspects related to the way the contents were taught also mentioned, which were centered on a traditional teaching approach:

The negative is not being so didactic, being more on slides, the same things as always. (TO 1)

The negative is that active methods were lacking. (A6)

But a negative factor is that they speak in a very superficial and mechanized way and are rarely discussed. It's a slide, something thrown at the students, and I think this makes learning very difficult that when we go to reality, there's something that doesn't match very well, and we feel a lot of doubt. It has a deficit regarding these matters, labor and newborn care. People feel too unprepared. (A9)

In this category, the intervening factors in the teaching-learning process of the students about clinical periods and delivery mechanisms were mentioned, emphasizing the use of active methodologies as a potentiality and the disarticulation between theory and practice as the main limitation.

Category 3: Needs to be discussed in the teaching-learning process about clinical periods and delivery mechanisms in nursing graduation

Nursing students pointed out suggestions to improve the teaching-learning process about clinical periods and mechanisms of childbirth, predominantly referring to the need for theoretical-practical articulation:

I believe in bringing more practical classes on the birthing process. (A3)

[...] is to practice, go to internships and be able to follow the labor and have the teacher's help. It made him explain and provide more significant learning. I believe it is [...] going from theory to practice, an internship field. (A4)

I see the issue of joining theory to practice [...] so that we, as students, can understand. Because it is elementary for you to understand and learn the mechanisms, but in practice (it is difficult) to identify them, as well as in the internship fields. [...] It would be of great value during labor and delivery (the teacher) to explain what is happening at that moment. (A8)

[...] it should be divided better how these subjects are given [...] various contents in a class or two ends up being a thing played to finish soon [...], a lot of slides, one on top of the other [...]. It's a lot of information that, if it's not worked more dynamically, it's difficult for you to assimilate. So, the suggestion would be that they teach some class that is not so much linked to theory but more a practical thing because, in the laboratory, there are even some things for them to take to the classroom, but the teachers don't even care. (A9)

The academics suggest intensifying the use of strategies that allow practical contextualization, referring to classes with simulation, use of laboratory resources, discussion of problem situations, and active methodologies as strategies to facilitate learning. The expansion of practical experiences during the internships and indications of complementary readings of classic books on women's health were also suggested:

Always use problem-solving to stimulate critical thinking, align scientific knowledge with situations, and use active methodologies, dynamics, and games. (A2)

I think applying more simulations as studies of some cases, only simulating. (A12)

[...] review activities and book recommendations because I still have all the slides, there are some PDF files, but for example, I don't remember any essential book for the course (discipline) [...]. I missed that in women's health. (A10)

In addition, they would suggest expanding and stimulating the debate about vaginal delivery and subjective aspects related to obstetric care to the detriment of technical characteristics:

Well, it is essential that this be worked on more and that there is another incentive for us to study this issue of childbirth, labor, and women's health more (A9)

[...] there was a lack of active, more practical, and professional methods that embraced the cause of normal birth [...] how beautiful normal delivery is, how much better it can be [...] (A6)

[...] it must associate, train the nurse, health professional with the technical terms, but connected, at the same time, with the patient, with the inspirational words, with the feeling that that woman is bringing [...] this is very important, it has to be learned together. (A7)

This category showed that the needs identified by the academics were mainly aimed at meeting the theoretical-practical articulation, expanding the topics covered, and didactic changes in the resources and strategies used to favor learning and contribute to the provision of obstetric care.

DISCUSSION

In the teaching-learning process, dialogued expository classes carried out by professors allow the exposition of contents. However, there is little encouragement for participating and sharing students' opinions and previous knowledge about the theme and dynamism during classes¹³.

The study identified the need for inclusion and new strategies in the teaching-learning process. This aspect shows that traditional teaching approaches are increasingly not so attractive today, as they do not favor meaningful learning¹⁴.

Because of this, when teaching technologies are combined with active methodologies, classes become more attractive, dynamic, and interactive for students and transform the way of learning and teaching, contributing to positive experiences by providing students with active participation in their teaching-learning process^13-14.

In the study, there were difficulties in retrieving knowledge related to the discipline related to non-significant learning. We emphasize the need for continuing education that articulates theory and practice based on technical and scientific knowledge of epidemiological, clinical, and humanistic bases and evidence necessary for professional performance in obstetric nursing⁷.

The need to reorient/overcome traditional pedagogical practices becomes evident, where teachers can plan and develop innovative actions centered on emancipatory, critical, reflective, autonomous, and humanistic pedagogy so that the teaching-learning process occurs significantly¹⁵.

The findings emphasize the need for student co-responsibility for meaningful learning. During health education, students need to assume an active, responsible and autonomous role in the search for knowledge, with emancipatory pedagogical approaches as mediators of changes in teaching and student posture for the development of critical, reflective, committed, creative, sensitive, and ethical and civic responsibility to act in different scenarios and social contexts^16-17.

In the results of this study, time was referred to as a limitation for learning. Corroborating this perspective, a study states that the curriculum of some courses has extensive activities with little free time available, which leads to difficulties for students and a deficiency in the adequate performance of academic assignments¹⁸.

In addition, in the classroom, students report tiredness and drowsiness due to bad sleep habits, as they are often dispersed and have difficulty concentrating. On the other hand, outside the university environment, they do not have good study habits and a structured environment to carry out their academic activities and invest insufficient time to obtain learning¹⁹.

In the findings of this research, despite new methods in the teaching-learning process, the simultaneous articulation between theory and practice is configured as a weakened aspect of nurses' health education on clinical periods and delivery mechanisms.

This fragmentation between theory and practice in nursing education presents itself to the student in the form of difficulties in mobilizing theoretical knowledge and connecting it to the care needs evidenced in practical experiences, whose overcoming requires that the teaching-learning experiences are centered on the perspective of teaching-service-community integration and in multi-professional and interdisciplinary practice, helping to break with the dissociation between theory and practice and for the development of competences, abilities, and attitudes¹⁶.

In this way, the urgent need to think about how to articulate theory and practice throughout the training of nurses is reinforced, and the search for and inclusion of innovative models can favor the teaching-learning processes²⁰.

Students deal with complex problems, situations, and activities of technical, personal, or emotional dimensions during internships. However, they count on the presence of teachers providing support²¹. These activities require formal educational processes that guarantee short, medium, and long-term learning to train qualified professionals through the development of skills that can result in effective performance in the performance of professional practice²².

Using Problem-Based Learning in training processes can favor the development of competencies by encouraging active participation based on autonomy and dialogic, developing critical-reflective thinking, and encouraging teamwork to act in different practice scenarios²³.

To qualify the nursing care offered to users, the need for constant changes in the teaching-learning pedagogical approaches used during the training of nurses is highlighted in order to reorient their understanding of their work object by making it possible to transpose the dimension of technical and operational assistance for a broader understanding of the human being and the subjective aspects inherent to care²⁴.

In the context of obstetric care, it is evident the importance of encouraging vaginal delivery, especially with the work of nurses. In contrast, the presence of these professionals in care settings is associated with reducing unnecessary interventions and encouraging good practices in care at delivery and birth²⁵.

The students pointed out aspects that affect curricular fragmentation. The inclusion of practical simulation scenarios, in addition to strengthening the articulation between the disciplines of women's and children's health, favors significant learning by promoting theoretical-practical articulation, promoting the development of competencies, and providing the active participation of students in care to parturition and humanization of care⁹.

In this way, in opposition to the fragmented and disciplinary curricula inherent to the traditional educational system, it is suggested that the structuring of integrated and transdisciplinary curricula that allow the development of innovative actions so that the teaching-learning process takes place in a significant way and results in a critical, reflective, active, autonomous and emancipated graduate profile¹⁵.

A study²⁶ carried out with nursing professors showed that the integrated curriculum represents a curricular modality favorable to developing competencies during academic training. However, they emphasize that its implementation is still a challenge as it requires the creation of favorable environments for the instrumentalization of teachers for the exercise of their practices, as well as a continuous deepening of discussions and reflections aimed at (re)orientation in the field of macropolitics, national curriculum guidelines and the Unified Health System²⁶.

FINAL CONSIDERATIONS

The nursing students' perception analysis showed that the teaching-learning process about clinical periods and delivery mechanisms is weakened by the approach and difficulties in assimilating the contents, theoretical-practical dissociation, and difficulties in organizing the study routine, which can affect the development of skills to work in childbirth care.

Thus, the study raises the need, through analysis of the difficulties presented by students, to (re)think pedagogical strategies for meaningful learning from the inclusion of active and problematizing methodologies and reorganization of political-pedagogical projects with an emphasis on curricular integration with a view to impact on the student's profile.

One of the limitations was the possibility of participants' memory bias resulting from the investigation of facts experienced before the data collection period, which may underestimate the teaching-learning processes experienced. However, when linked to the teaching-learning process, the retrospective approach allows a better understanding of meaningful learning.

Although the investigation from the student perspective makes it possible to highlight weaknesses and the need for changes in the teaching-learning process on the subject, the transversal and unidirectional approach can limit the broad understanding of the phenomenon. Thus, longitudinal research on the subject is suggested, encompassing all those involved in the teaching-learning process.

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25 Nicaretta JC, Cortêz DT. Centros de parto normal: revisão integrativa. Revista Saúde e Pesquisa [Internet]. 2015[acesso em 09 maio 2022];8(2):345-53. Doi: https://doi.org/10.17765/1983-1870.2015v8n2p345-353

26 Franco ECD, Soares AN, Bethony MFG. Currículo integrado no ensino superior em enfermagem: o que dizem os enfermeiros docentes. Enferm. Foco [Internet]. 2016 [acesso em 09 maio 2022];7(1):33-6. Doi: https://doi.org/10.21675/2357-707X.2016.v7.n1.662

Submission: 11-05-2022

Approval: 25-07-2022