Implantation of the Kangaroo Mother Method in the perception of nurses in a university hospital

Abstracts

OBJETIVO: Compreender a percepção de enfermeiras de uma Unidade Neonatal, acerca da implantação do Método Mãe-Canguru. MÉTODOS: Trata-se de um estudo exploratório-descritivo, de abordagem qualitativa, realizado na Unidade Neonatal do Hospital das Clínicas da Universidade de São Paulo, do qual participaram cinco enfermeiras. A coleta de dados foi realizada através de entrevistas, as quais foram transformadas em narrativas e categorizadas. RESULTADOS: Das narrativas foram extraídas três categorias interpretadas à luz da mudança planejada, a saber: o processo de tomada de decisão e de sensibilização da equipe de saúde, os fatores intervenientes e as crenças e sentimentos relacionados a implantação do Método Mãe-Canguru. CONCLUSÃO: O estudo permitiu verificar a importância do envolvimento dos colaboradores da instituição nos processos de mudança e a necessidade de adequação dos recursos humanos e físicos para a efetiva implantação do método. Dessa forma, forneceu subsídios para a reorganização das atividades assistenciais e gerenciais no referido serviço.

Avaliação de programa de enfermagem; Mudança organizacional; Enfermagem neonatal; Recém-nascido de baixo peso; Cuidadodo lactente

ORIGINAL ARTICLE

Implantation of the Kangaroo Mother Method in the perception of nurses in a university hospital^*

Implantación del Método Madre canguro en la percepción de enfermeras de un hospital universitario

Thaís Cristina de Hollanda Parisi^I; Eliane Regina Berti Coelho^II; Marta Maria Melleiro^III

^IRN, Neonatologist at Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – USP – São Paulo (SP), Brazil

^IIRN, Neonatologist at the Neonatal Unit at Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – USP – São Paulo (SP), Brazil

^IIIPh.D, Professor at the Professional Orientation Department at Escola de Enfermagem da Universidade de São Paulo – USP – São Paulo (SP), Brasil

Corresponding Author

ABSTRACT

OBJECTIVE: To understand the perception of nurses in a Neonatal Unit about the implantation of the Kangaroo Mother Method.

METHODS: This is an exploratory-descriptive, qualitative study, performed at the Neonatal Unit at Hospital das Clínicas, Universidade de São Paulo, with the participation of five nurses. Data collection occurred through interviews, which were transformed into narratives and then categorized.

RESULTS: Three categories were extracted from the narratives and interpreted according to the planned changes: the decision-making and awareness processes of the healthcare team, the intervenient factors and the beliefs and feelings associated to the implantation of the Kangaroo Mother Method.

CONCLUSION: This study showed the importance of the involvement of the collaborators at the institution during the processes of change and the need to adequate the human and physical resources for the effective implantation of the method. Therefore, it yielded subsidies for the reorganization of the healthcare and managerial activities of the service.

Keywords: Nursing evaluation research; Organizational innovation; Neonatal nursing; Low birth weight; Infant care/methods

RESUMEN

OBJETIVO: Comprender la percepción de enfermeras de una Unidad Neonatal, respecto a la implantación del Método Madre canguro.

MÉTODOS: Se trata de un estudio exploratorio-descriptivo, de abordaje cualitativo, realizado en la Unidad Neonatal del Hospital de las Clínicas de la Universidad de Sao Paulo, en la que participaron cinco enfermeras. La recolección de los datos fue realizada a través de entrevistas, las mismas que fueron transformadas en narrativas y luego categorizadas.

RESULTADOS: De las narrativas fueron extraídas tres categorías interpretadas a la luz del cambio planificado, a saber: el proceso de toma de decisión y sensibilización del equipo de salud, los factores intervinientes y las creencias y sentimientos relacionados a la implantación del Método Madre Canguro.

CONCLUSIÓN: El estudio permitió verificar la importancia del involucramiento de los colaboradores de la institución, en los procesos de cambio y la necesidad de adecuación de los recursos humanos y físicos para la implantación efectiva del método. De esta forma, dio subsidios para la reorganización de las actividades asistenciales y gerenciales en el referido servicio.

Descriptores: Investigación en evaluación de enfermería; Innovación organizacional; Enfermería neonatal, Recién nacido de bajo peso; Cuidado del lactante/métodos

INTRODUCTION

Low weight at birth is one of the main problems observed in the maternal-neonatal area, since it damages both the social network in which this newborn will be inserted and the hospital institutions, by causing serious consequences to the neonate's health.

The high amount of low-weight preterm children (under 2,500g) born every year reaches 20 million, of which nearly one third dies before one year of life, usually due to respiratory problems, asphyxia at birth and infections⁽¹⁾.

As such, governmental actions and programs focusing on maternal-neonatal healthcare have been establishing a new paradigm, aiming at promoting the humanization of care, through the implementation of initiatives and projects of healthcare humanization and improvement of the quality of the bond established between the healthcare professionals and the users of the healthcare services.

Regulation #693/00 establishes the Norms for Humanized Care to Low-weight Newborns, known as Kangaroo Mother Method – Método Mãe-Canguru (MMC), issued by the Ministry of Health⁽¹⁾. This is a healthcare proposal that, among other humanizing measures for neonate care, states that the newborn must be placed in skin-to-skin contact, in the vertical position and prone against the chest of an adult in order to promote bonding, encouraging breastfeeding and aid in the newborn's recovery.

In this perspective, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) started the necessary changes to implement the first two stages of the MMC in 2005: the presence of the parents at the Neonatal Unit in order to share care for the newborn and the execution of the aforementioned kangaroo position.

Every change in an organization represents some modification in the working relations, in the responsibilities, everyday attitudes, habits and behaviors of people that are members of said organization⁽²⁾. In this context, the implementation of change must be carefully idealized, so that the innovation can be guaranteed to be compatible with the necessities of the workers and the organization, so as it will provide observable advantages and benefits⁽³⁾.

As such, it is fundamental that the situation be analyzed by everybody involved in the future changes, so that after the comprehension of a situational diagnosis, feasible solutions and strategies for the implantation of the change can arise, resulting from teamwork adapted to the conditions of the organization⁽⁴⁾.

By believing in these assumptions and working at the Neonatal Unit of HCFMUSP as an intern of the Neonatology Specialization Course, I proposed this study, as a term paper for the aforementioned course and aiming at understanding the perception of the nurses of a Neonatal Unit about the implantation of the MMC. As such, I chose a group of nurses at that same unit as subjects, since they were the professionals most involved in this process.

METHODS

This is an exploratory-descriptive, qualitative study.

The setting for this study was the Neonatal Unit of Instituto da Criança at HCFMUSP, which provides tertiary care to newborns and currently has 63 beds distributed in four sectors: low risk (23 beds), medium risk (15 beds), high risk (9 beds) and intensive care (16 beds). Therefore, every neonate is sent to the Neonatal Unit immediately after birth and distributed by the sectors according to the level of complexity of their clinical condition.

In order to meet this demand, the staff at this unit has 79 professionals, with 19 nurses (two of them managers), 50 nursing auxiliaries and 10 nursing attendants, responsible only for indirect care provided to the neonates.

The research project for this study was submitted to the Review Board of the institution, with data collection being started after the project was approved.

The collaborators of the research were five nurses working in the aforementioned Neonatal Unit, who effectively participated of the process of MMC implantation, as it is important that the subjects selected for a qualitative study experience the investigated phenomenon.

The number of collaborators was not previously determined, since the numeric criterion is not applicable to the qualitative research sample. In this type of investigation, the concerns lie in delving deeper and the comprehensive coverage of the social group portrayed in the study. However, basic criteria were proposed in order to delimit the sample, such as: clearly defining the most relevant social group for the interviews, not finishing them while the empirical base of the research is not defined, predicting a progressive inclusion process guided by the discoveries in the field and its confrontation with the theory⁽⁵⁾.

As such, the study collaborators were informed about the goals of the research, received and signed the term of consent, which was elaborated according to the norms of Resolution 196/96⁽⁶⁾, which covers the ethical aspects of research involving human beings.

Data collection occurred from August to November, 2006, through semi-structured interviews, scheduled according to the availability of the study collaborators.

The guiding questions of the interview were:

– How do you see the implantation of the Kangaroo Mother Method in your professional activity?

– Describe how this method has been executed in the Neonatal Unit.

The transcription stage followed. This stage includes transposing the oral recordings to written documents, involving also texting and transcription. Texting was performed with the definition of keywords that are used to show the incidence of the emphasis placed in certain situations and the transcription is supposed to be a wholly recreated text, corresponding to its finalization⁽⁷⁾.

After this stage, dates were scheduled with the study collaborators so that their narratives could be checked. Then, some changes were made, so that the narratives could be confirmed and used in the research. In this occasion, fictitious names were suggested for each research collaborator, as follows: Ruby, Emerald, Sapphire, Amethyst and Opal.

The data from this study were collected and analyzed simultaneously, looking for significant events extracted from the collaborators' narratives.

Data analysis obeyed to the following stages⁽⁸⁾: it was focused on the personal experience reported, phrases or statements directly related to the study phenomenon; the meanings of these phrases or core themes were interpreted as an informed reader would; the collaborators also provided their interpretation, whenever it was necessary; the meanings were investigated so that we could verify what they unveiled about the essential and recurrent characteristics of the study phenomenon, and finally, the analysis was concluded by elaborating probable definitions or statements about the studied object.

RESULTS

The interpretative analysis of the narrative allowed for the construction of three categories, which are described next.

The decision-making and the awareness processes of the healthcare team

Participative management provides people with real possibilities of taking part in management, with freedom to question, discuss, suggest and change a decision. This happens because, when there is an atmosphere of mutual trust between groups, people are involved, made aware of and encouraged to contribute of their own will. When this does not occur, there are reportedly difficulties for the team to accept the new, and it can perceive the proposal as an imposition from the upper echelons, as stated in Ruby's testimony. Therefore, it is important to maintain a participative process, where spaces are provided for discussions with the team involved in the process of change⁽⁹⁾.

"When they presented the proposal of implanting the MMC to us, this proposal was not very explicit, they didn't say look, let's implant it because of such and such, it was a bit obscure, some people were even resistant to accept it and were forced to take the course [referring to the training course for the implantation], simply so that their image in the institution would not be damaged". [Ruby]

A successful process of change assumes the permanent awareness and education of the people involved^(10-12). However, in the testimonies of the respondents, this qualification was linked, mainly, to the technical-scientific dimension, leaving the ethical-politic and social-educational dimensions, where the awareness of the team would happen, in the background.

The intervenient factors for the implantation of the MMC

The analysis of the narratives allowed for the observation of the description of factors considered intervenient in the implantation of MMC. These factors refer to the infra-structural aspects, the type of institution, inadequate supervision, work overload and lack of teamwork.

Overall, management tends to concentrate its attention on managing organizational resources, which allow the institution to reach the goals it has assumed, provided that the resources are well-managed⁽¹³⁾.

In MMC, the necessity of offering the caregivers a space that allows physical contact is imperative, since it will allow them to gradually trust their own ability to care and protect the neonate⁽¹⁴⁾.

The following testimonies highlight the necessity of resizing human, material and physical resources of the Neonatal Unit, the setting of this study, in order to execute the proposal in this institution.

"I believe that we will need physical resources, material resources, financial resources and especially human resources to implant the proposal of humanized care for low-weight neonates, otherwise it won't be possible to have it effectively implanted". [Emerald]

"When you have an adequate infrastructure and sufficient human resources to comply with the proposal you can observe the advantages that the method offers, such as: strengthening the bond between mother and child, faster weight gain, lower hospital costs and lower hospital stays, since it is possible to discharge a 1,800g child". [Amethyst]

HCFMUSP is an organ that has, besides providing high complexity hospital services, education and research as its attributions. That said, this institution is expected to receive interns from every healthcare area. Therefore, it was highlighted that the turnover of such students interferes in the implantation of MMC, as mentioned below:

"Another intervenient factor for the implantation of this healthcare proposal is the fact that this institution is a school hospital. It is different from a private institution, where the multidisciplinary team is always the same, the same people will always be inserted in the project as a whole. Here in this institution the change of residents is frequent, and each group that comes in thinks in a different way, so you have to orient new groups constantly". [Ruby]

The high healthcare demand at the Neonatal Unit was also clearly identified in the narratives of the collaborators as another aggravating factor for the implantation of the healthcare proposal. According to the nurses, such fact is a consequence of the low number of human resources, particularly nurses, which damages the quality of healthcare activities provided in this unit and their inadequate supervision.

Since MMC is a strategy of healthcare humanization, and integrality of care means that it should not only be focused on the newborn, but also on the family⁽¹⁵⁾. This corroborates the testimonies of the collaborators, as seen in Opal's statement.

"Besides material resources, there is still the human resources factor as a limiter for the execution of the healthcare proposal, we have few professionals to supervise the actions provided to the mother-child binomial adequately, especially on weekends when we work with a reduced staff, and still we have the managerial activities that take up a large share of our time". [Opal]

Another aspect considered a difficulty, which emerged from the collaborators' speeches frequently, involves the issues of work overload due to the scarcity of human resources and the educational demand, consequence of the institution being a school hospital. This is evident in Amethyst's statement:

"We, nurses, are assigned only to the sectors of higher complexity, where are the children in graver states, with the other sectors remaining under the supervision of the head nurse, who has several other things to do. However, on weekends, when we don't have a head nurse, this supervision is the responsibility of the other nurses, which overburdens our work even more". [Amethyst]

Regarding teamwork, the professionals were perceived to be partially cohesive as to the implantation of the MMC measures, contrary to the premise that this must be a collective working modality, where a given task is shared among the various members of said team, and they have a common goal to achieve in this task⁽¹⁶⁾.

"The mother is more a partner of ours than of the medical team, surely this doesn't mean all the doctors. The impression I have is that the doctors give the orders and we have to accomplish it, when everybody should actually be inserted in the situation. It's necessary to decide together the best form and the best moment to perform the technique, so as not to do it carelessly". [Ruby]

Beliefs and feelings regarding the implantation of MMC

Change is an inherent process of the human being – therefore, inevitably an emotional process. This is a sign that the main targets of emotional manifestations in a process of change are the human beings that participate in this experience⁽¹⁷⁾. The following makes evident the idiosyncrasy of one of the collaborators, and the conflict generated with the implantation of the changes.

"I feel that the team is not motivated. At first everybody was excited with the implantation of the MMC, but now I see that it's falling into oblivion". [Sapphire]

Change makes what is known to be exchanged by ambiguity and uncertainty. However, such feelings and behaviors do not constitute a negative aspect in the process of change, instead suggesting the necessity of more clarification about the goals and the intended results⁽¹⁸⁾.

In this sense, the collaborators also showed dissonant expectations about the effective implementation of the MMC after the change of the Neonatal Unit's physical area for the new building belonging to the HCFMUSP complex, named Instituto Doutor Arnaldo, as mentioned by Opal and Emerald.

"Soon we'll be moving into the new building that will be a part of the Hospital das Clínicas Complex, "Instituto Doutor Arnaldo". We expect to have a larger physical space that will allow the implantation of the Kangaroo Mother Method integrally". [Opal]

"If nowadays we have a management that defends the implantation of MMC and wants our unit to be a reference for this method, maybe, when we move into the new building, management won't be the same and the new bosses may not want to implement this proposal." [Emerald]

DISCUSSION

During the implantation of MMC-related measures at the studied Neonatal Unit, it was observed that these measures were implanted without being fully adequate to the items mentioned by Regulation # 693/00 established by the Ministry of Health⁽¹⁾. However, it was noticed that team involvement in the process of implanting such measures started when they were performed, not at the moment when the decision to adopt the healthcare proposal was made.

Successful changes, before their execution and incorporation by the organization must undergo three different changes⁽¹⁹⁾. The first stage of the process of change corresponds to defrosting. This stage aims at generating the motivation of the individuals, as well as preparing them to recognize the inefficiency of the current model. The agent of change, i.e., the one who leads it, attempts to create a feeling of necessity for change in the involved individuals. Therefore, people will become unsatisfied with their current situation, and become aware of their necessities. It was also noticed in the testimonies of the interviewees that some team members were resistant to comply with the method due to failures in the process of communication prior to the implantation of the aforementioned measures of the MMC.

The second stage of this process corresponds to movement. In this stage, the agent of change identifies, plans and implements appropriate strategies, guaranteeing that the propelling forces overcome the repressing forces. In this study, the implantation of MMC-related measures was observed to be preceded of technical-scientific qualification, offered to all the professionals of the institution. However, it was also observed that the socio-educational and ethical-political dimensions were at risk.

The last stage of planned change is re-freezing. At this stage, the recently-acquired behavior is integrated to standard behaviors. In order for re-freezing to occur, it is fundamental that the agent of change supports and reinforces, continuously or intermittently, the individual adaptation efforts of the people affected by the change. This will avoid the extinction of the acquired behavior.

Another aspect made evident in the process of implantation of the MMC is teamwork, characterized as the reciprocal relation of two complementary dimensions: work and interaction. The articulation of technical intervention happens through communication⁽²⁰⁾. However, the process of communication between the team members was perceived to have some noise, since compliance, as well as the implantation process for this proposal, had not been widely discussed or practiced by the whole multidisciplinary healthcare team.

Still in the teamwork perspective, it is known that all healthcare professionals perform their actions within a given sphere of autonomy and responsibility, which correspond to their working field. However, in order for the team to articulate their work, it is necessary that their members take the interdependence of their actions and the professional autonomy of the other into consideration⁽¹⁶⁾.

In view of these considerations, and believing that the participative management must be the foundation for the progress of an organization, it was verified that this study shows the necessity of more participation of people directly involved in the processes of change, since it was observed that the collaborators believe and comply with changes when these become significant to them. Besides, they highlight the necessity of some alterations in order to fully implement the MMC, according to the norms of the Ministry of Health.

FINAL CONSIDERATIONS

The study allowed for the comprehension of the perception of a group of nurses about the implantation of MMC. It was seen that the measures recommended by the proposal of humanized healthcare for low-weight newborns are not being executed integrally as of yet. Some of them are being instituted and others await the move to a new area at Insituto Doutor Arnaldo.

Therefore, said unit is in process of reorganization of activities, aiming at completing all the necessary stages to fulfill the proposal, since the first two stages of the method are still under implantation.

It was also verified that the awareness of the healthcare team about the MMC implantation was partial, because, in the respondents' perspective, they resent not having been more involved in the decision-making process.

Regarding the implantation process of the MMC measures, some factors certifiably make it difficult to fully establish the recommendations for this proposal, such as the need to adequate human, physical and material resources. The collaborators also highlighted the importance of teamwork for effective implementation.

It is worth noting that, for a change to be successful, it is necessary to monitor and evaluate it continuously, foreseeing later improvements to the change. Thus, it is believed that the result of this study allows for this evaluation and contributes for the reorganization of the actions developed within the aforementioned service.

Another aspect worth of note is that change is necessary and important for healthcare institutions, and that the nurse, in this sense, must take the role of agent of the process of change. This study led us to believe that it is indispensable for the nurses involved in the implantation of the MMC to act as challengers in view of change, understanding it as an opportunity for growth and development.

It is also believed that the results of this study can contribute for the comprehension of the process of change that has been occurring in this service, providing subsidies for the reorganization of healthcare, management, educational and research activities. Besides, it is expected to contribute for the success of humanized and high quality neonatal healthcare in view of this comprehension.

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*

Monografia de conclusão do Curso de Especialização em Neonatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – USP – São Paulo (SP), Brasil

Publication Dates

• Publication in this collection
  13 Jan 2009
• Date of issue
  2008

History

• Accepted
  08 Aug 2007
• Received
  09 May 2007