Potentialities and limitations of nurses ’ performance in the Normal Birth

Objective: To know the potentialities and limitations of the nurse’s performance in the Center for Normal Birth (CPN). Method: Qualitative approach, exploratory-descriptive type, carried out in 2018, with six nurses working in public intra-hospital CPN in the metropolitan region of Fortaleza, Ceará, Brazil. The collection of information occurred through individual interview, with analysis from the assumptions of the sociology of professions, focusing on the themes: knowledge and autonomy; credentialism; division of labor; labor market and value chart. Result: The nurse’s performance in the Center for Normal Birth (CPN)enhances good practices for childbirth and birth, as well as increases the importance and visibility of this professional in maternal and child care. Clinical care and management emerge as the focus of the nurse’s action in the CPN. However, even with the induction of the State to this action, there is still the need for recognition of the competencies and autonomy of the nurse in obstetric care by other professionals. Conclusion and implications for practice: There are challenges that need to be overcome such as the expansion of autonomy and respect for the accreditation of the nurse to work in the CPN and the harmonization between the management of the work process and management of clinical care by this professional.


INTRODUCTION
The scenario of care for women in childbirth has been influenced by changes taking place in Brazil, 1 especially the mobilization of both pregnant women and health care institutions and professionals in search of less interventionist care and a humanized birth.
Care geared to the needs of the parturient woman is enhanced by raising women's awareness in the fight for their rights and in calling for improvements in living conditions. In this regard, the World Health Organization (WHO) and the United Nations Population Fund recommend the leadership and involvement of a midwife or nurse with prenatal obstetric skills, as well as for the management of vaginal delivery. 2,3 This is because the model of interventionist care, although justified by the use of technology to improve the efficiency of labor and the safety of the pregnant woman and the newborn, is correlated with worse maternal and neonatal outcomes on the national and international scene. This circumstance has prompted the mobilization of public health professionals in the search for changes in the standards of Brazilian obstetric care. [4][5][6][7] In view of this, the creation of the Stork Network is important for the implementation of this new model of obstetric care. It is a network of care that aims to ensure women's right to reproductive planning and humanized attention to pregnancy, childbirth and puerperium, as well as the right to safe birth, growth and development of the child until the age of two. 8 In this context, in search of a more humanized assistance to women, focused on the needs of the mother and the reduction of mortality rate, the Ministry of Health has established guidelines for the implementation and qualification of the Center for Normal Birth (CPN) under the Single Health System (SUS). 9 However, because it is a new scenario of practices in the health system, the performance of the nurse is still in a field of construction and disputes.
The inclusion of obstetric nurse in confronting the adversities presented from the induction of the state, with financing for training in the area, construction and costing of new health equipment such as the CPN, appears as an important action in the Brazilian obstetric scenario. This makes it possible to strengthen the profession in the scene of habitual risk childbirth. 10 New areas of nursing arise from the socially constructed changes, often driven by the State, since they have a leading role in public service. The continuous reorganization of the health system to provide answers to social demands requires the adaptation of nursing to the new realities and can be seen as important and necessary professional evolution. 11,12 Thus, the CPN has an autonomous role of the obstetric nurses in situations considered of habitual risk, besides being responsible for the valorization of the natural childbirth, allowing the woman to participate actively in the process. It emphasizes the importance of obstetric nurse's role in the scenario of childbirth care and births at habitual risk, due to the less interventionist care inherent in their training, as well as in the promotion of the use of evidence-based good practices and awareness of women's role in the process of parturition. [8][9][10] In this context, the question is: how does the nurse act in the CPN? What care and management practices have been developed by nurses on this health equipment? Based on that, this study aimed to know the potentialities and limitations of the performance of nurses in the Normal Birth Center.

METHOD
A qualitative, exploratory and descriptive study, 13 conducted in 2018, with the participation of six nurses working in intrahospital CPN, located in a public institution in the metropolitan region of Fortaleza, Ceará, chosen because it was the first center authorized by the Ministry of Health in the state. All nurses from the team participated in the research, based on the inclusion criteria: working in CPN for at least six months. Although they were used as exclusion criteria to be on holiday or leave at the time of information collection, there were no nurses in these conditions.
Health equipment is an important point of attention, offering care during childbirth at normal risk to the eight municipalities that make up their respective health region. It performs an average of 300 deliveries per month with three pre-delivery, delivery and post-partum rooms and is a field for practical experiences of nursing undergraduate course and residence in obstetric nursing of public universities.
The information was collected between July and August 2018, by means of an in-depth individual interview lasting 30 minutes on average, conducted by one of the researchers in a room made available for this purpose, with registration on a voice recorder, from the authorization of the participants. The interview addressed, in open questions, the perception of nurses on aspects of professional practices at CPN, including their routine, the performance as part of the team, the actions of care and management of nurses at CPN, the meaning of care for these professionals, the difficulties and facilities for implementing good practices at birth and delivery, as well as the changes needed to facilitate the implementation of these practices.
Thematic analysis 13 was used for the organization of information, from the construction of a table with the participants' narratives, extraction of the units of meaning and, later, the units of context, considering the themes listed in the sociology of professions, 14 which theoretically guided the analysis. It should be noted that all the researchers participated in this stage. The results will be divided into the following themes: Knowledge and Autonomy; Credentialism; Division of Labor; Labor Market and Value Framework.

Nurses´ performance in the Normal Birth Center
Ferreira Júnior AR, Brandão LCS, Teixeira ACMF, Cardoso AMR The sociology of professions consists of analyzing and understanding the manifestations of professionalism in the emergence and development of professions and occupational groups that are marked by the diversity of organization models, internal heterogeneity, the imprecision of the borders that separate them, the diversity of unification criteria and other specificities arising from historical and geopolitical contexts associated with their genesis. 14 In the perspective of this study, it is used as a basis for discussing the professional practices of nurses in Normal Birth Center, health equipment inserted in the public system and regulated by the Ministry of Health in the year 2013. 9 It should be noted that the instrumental Consolidated Criteria for Reporting Qualitative Research (COREQ) was used in order to provide transparency to the process carried out in the research. 15

RESULTS
The participants were female, with working time at CPN between one and 10 years, age range from 26 to 59 years, five of whom had a specialization in obstetric nursing and one completed the uniprofessional residence in obstetric nursing.
In the theme Knowledge and autonomy, the following reports were presented:

But there is a lot here, it is a very rich field, it is very pleasant, it is very good, we have a lot of autonomy, but there is also the question of having a lot of responsibility. (E6)
In the CPN

DISCUSSION
The first theme Knowledge and Autonomy involves the types of professional activities, control and occupational autonomy, as well as the types of knowledge and skills. 14 In this perspective, it is emphasized that for the nurse to have autonomy in the CPN it is essential to have a broad knowledge of the care of the mother and child and dexterity in the practice of care.
The actions of the obstetric nurse at CPN fortify the valorization of humanized assistance, since these professionals collaborate with the promotion of the health of the woman and the newborn from a vaginal birth. This facilitates the process of labor and results in several benefits for both. 7 In this scope, the nurse has an important role in the obstetric scenario, especially as an enhancer of healthy practices for childbirth and birth, based on scientific evidence. 2 For this, the professional needs constant improvement, since only through knowledge is it possible to obtain social respect and consequent autonomy for the development of work activities. 14 It is worth pointing out that in view of his ethical-humanistic training, the nurse has a welcoming conduct with assistance based not only on techniques but also on practices related to dialogues between professionals and users. This shows a singular care integrated by qualities such as affection, respect and security towards women, valuing their protagonist in childbirth. 7 The importance of the theoretical and reflective constructions that have been developed during the formative process in obstetrics for nurses is stressed, since this makes it possible to transform thoughts and practices that contribute to the qualification of the services provided in the health system. 17 On the other hand, attention should be paid to the need for continuous improvement of nurses' knowledge, since new practices are constantly implemented in obstetric nursing. This requires dedication to professional updating in an environment that presents various difficulties in daily life. 18 The performance of the nurse in the CPN allows the application of the knowledge learned during his training process, which may result in the extension of his autonomy in the development of activities. However, it also requires greater effort from the professionals to encompass the various responsibilities resulting from this process.
The theme of Credentialism aims to identify the degree of openness and closure of credentials and requirements for access to training, evolution and comparison. 14 Nurses, especially midwifery specialists, strive for autonomy and recognition of their skills in assisting labor and birth, but they must be aware of their responsibilities and assume the results of their care in the same way as medical professionals; discussion on this issue, setting out preventive care and the legal consequences, must be essential. 19 It should be noted that the Law on the Professional Practice of Nursing, passed in 1986, confirms the role of obstetric nurses in the integral care of labor/partum, emphasizing their autonomy and competence in offering care to the process of parturition. 20 Moreover, for better social recognition of this professional category, it is necessary to add value to care during the act of partaking, without forgetting the gender issues involved in the process. Generally, these are women nurses caring for other women in parturition, in an environment of old male domination. 21 It is also necessary to build relationships of trust among professionals, with the use of clear and respectful communications, as well as the development of teams that promote interprofessional Nurses´ performance in the Normal Birth Center Ferreira Júnior AR, Brandão LCS, Teixeira ACMF, Cardoso AMR collaboration. 22 However, the narrative highlights the fragile bond between the team as a difficulty in implementing the practices recommended by the WHO, since there is still a devaluation of the nurse's skills on the part of the medical team; the importance of humanized care needs to be further disseminated.
This interprofessional relationship poses a challenge to be overcome by the nurses for the qualification of the work developed at CPN. It also emerges as a possibility of expanding the importance of the professional category for the development of activities in the field of obstetrics.
In this sense, the development of maternal and child health care by professionals qualified for teamwork emerges as an important challenge in several countries. Positive experiences of collaboration should be leveraged as a guide for health systems to replicate. 23 The collective act, based on current norms, enhances the social recognition of a profession in a given activity, especially in those carried out in part by another category. 14 Therefore, CPN nurses must understand the importance of their training and of the norms that govern their professional performance, since this accredits them to develop the activities of qualification of childbirth and birth in this health equipment.
The Division of Labor theme involves position in the official socio-professional classification, the evolution and comparison in the scope of work. 14 As presented in the previous axis it is possible to perceive the space of dispute between obstetric nurses and doctors.
The nurse has as assignments, tasks directly related to care and others, which involve leadership of the nursing team and the management of resources, whether physical, material, human, financial, political, or information. 24 The accumulation of activities of a professional category can be seen in a negative way by the requirements that this entails. However, it can also be viewed as an opportunity to expand the professional domain of this category in a specific area of activity. 14 In addition to care assistance, the nurse is responsible for the administrative management of the CPN, having numerous responsibilities associated with the bureaucratic part, making his work extensive.
As a manager of nursing care, this professional needs knowledge, skills and attitudes to perform his work effectively. 24 Participants report on practices they consider part of the management: filling out paperwork, partogram, taking notes, recording occurrences, admission to medical records, and organizing the sector as administrative actions. In addition, they cite the question of sizing of nursing staff, delegation of activities and checking of materials among their management attributions.
In the care area, however, participants report on the importance of their work for the woman, the newborn and family members in the childbirth follow-up process. This involves all the stages in this situation and should be carried out with patience and organization.
The managerial attributions of nurses are indispensable for health services in the world, and there should be a consensus on these managerial competencies and stimulus to awake discussions on the subject, so that the debate promotes the knowledge and definition of the administrative actions of the nurse and, mainly, awakens the managerial development in these professionals. 24 However, it must be stressed that health systems should prioritize obstetric care by trained professionals over purely administrative areas. Reconciling the two issues can greatly enhance the quality of services offered to the population. 25 Obstetric nurses have important responsibilities not only in welfare practices but also in administrative matters, which are prioritized by health institutions. In management, nurses are recognized by the supervision of nursing staff and the provision of resources necessary for the unit, making the assistance provided effective, but this assignment requires greater demand for time and dedication to service, often causing the nurse's distance from humanized practices. 26 This reality, it seems, is one of the challenges that needs to be addressed. Assistance and administrative practices are concatenated, but in the division of labor, management activities take up an important amount of time that could be made available for the direct care of the mother. The search for harmony in these actions is necessary to optimize the performance of the nurse in the CPN.
The Labor Market theme presents the context of the evolution and characterization of labor market access requirements and career typologies or other professional development mechanisms. 14 It should be noted that adequate training for the obstetric care process can enhance the quality of service and user satisfaction. The practice of care focused on women in labor, but with an understanding of professional weaknesses and potential, is responsible for significant improvements in care. The development of practices in obstetrics should be built on formative work that emphasizes the demands of those involved in the situation. 27,28 Moreover, midwifery training for nursing should use tools based on constantly discussed theoretical concepts. From this, everyday practices tend to be carried out with greater technical precision, which adds confidence and security to the practitioner and the woman during the care provided. 29,30 In addition, specific training in obstetrics is presented in the participants' narratives as essential to qualify the activities developed at the CPN. This factor delimits it as a space conquered by those who have credentials in a nursing niche: obstetrics.
In this perspective, the professional identity of midwifery nursing is strengthened in its aggregation with the CPN, because the link with this public institution allows nurses to broaden their social visibility, being one of the benefits caused by this Nurses´ performance in the Normal Birth Center Ferreira Júnior AR, Brandão LCS, Teixeira ACMF, Cardoso AMR situation. In counterpoint with this issue, due to the approximation between category and institution, it is necessary that the actions developed in the CPN produce positive outcomes, otherwise, obstetric nursing may be held responsible for the possible fragilities found in the daily routine of the services.
It should be noted that the CPN as a point of attention recently implemented in the SUS, provided the opportunity to open a broad field of action for Brazilian nursing. Unlike the obstetric center, the CPN has the nurse as responsible for the line of maternal-infant care, expanding the social importance of this professional 31 .According to Rodrigues,14 this may denote the demarcation of professional space reached by a category, by influence in the State, which induces expansion of the labor market in this group of individuals.
The last theme dealing with the Framework of Values presents the perceptions of members of the profession and representative institutions on occupational autonomy and control, working conditions and employment, criteria for assessing the quality of services, the skills of members of the profession, the defense of the public interest, responsibility and altruism. 14 The interviewees emphasize, in their statements, the importance of the CPN regulations for obstetric nursing, since this delimits the field of action, with organization of the activities developed in daily life. However, there is reported weakness in monitoring the activities of this health service, which hinders the implementation of the actions described in the rules that govern it.
Monitoring and evaluation at the SUS are essential for the qualification of the services offered to the population. And nursing has always played an important role for this to occur in the country, providing continuous improvement of the system. 11 When this does not occur, it produces limitations to the actions of the nurse, as described by participants.
The standardization being used as a basis for the actions implemented in the CPN, is capable of safeguarding the potential of obstetric nurses for maternal and childcare and management activities. On the contrary, when norms are not considered, there is the possibility of hindering the development of the work that the nurse can legally perform. The denial of the signature by nurses of the Hospital Admissions Authorization is an example cited by the participants.
This action is based on the norms of the Ministry of Health 9 and may not be practiced because of disputes with other professional categories, which do not allow the occupation of this space by obstetric nurses. This limits their performance in the CPN, because it does not allow them to be officially responsible for hospitalization, monitoring and discharge of women and newborns, as determined by the SUS regulation.
The recognition of the activities inherent to the members of the occupational group responsible for the work is essential for the construction of the professional aspects that foster the continuous development of the actions of that collective.
Knowing and recognizing their limitations and potential enables the expansion of social interest and visibility of the profession. 14

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
The Normal Birth Center is not the exclusive domain of a professional, and it emerges as a setting for discussions to improve maternal and childcare, as well as giving greater visibility to obstetric nursing in the public health system. In addition, it denotes the influence of this category on the State for the expansion of the labor market and the insertion of obstetric nurse in the scenario of childbirth, something that should be better explored.
This point of attention is relevant because it broadens the area of operation of midwifery nursing and guarantees through regulations the labor autonomy of these professionals. However, in disrespect to the current norms this autonomy is not yet total, caused, possibly, by disputes with other categories, because it is observed the need for greater recognition of the competencies of the nurse by other professionals.
It should be noted that specific training in the area, with enhancement of scientific evidence, increases the potential for qualification of the care provided. Also, the concatenation of care and management actions in the maternal-infant area can be used to obtain greater social recognition of the obstetric nurse. However, bureaucratic work exacerbated to the detriment of direct care may limit this process.
The study is limited to equipment with specific contextual characteristics. However, as part of the maternal and childcare network, they follow guidelines listed by the health system management, thus presenting a reality that may be similar to those found in other scenarios.
Although public policies are supporting the insertion of obstetric nurses in childbirth and birth care, especially in the CPN, the transformation of the care model continues to be considered a challenge that demands efforts from management, health professionals and society.

FINANCIAL SUPPORT
National Council for Scientific and Technological Development. Granting of Scholarship for Scientific Initiation PIBIC/CNPq to Ana Carolina de Melo Farias Teixeira, in 2018.

AUTHOR'S CONTRIBUTIONS
Conception of the study design: Antonio Rodrigues Ferreira Júnior.