Nurses' adherence to the Kangaroo Care Method: support for nursing care management1

OBJECTIVE: construct an explanatory theoretical model about nurses' adherence to the Kangaroo Care Method at the Neonatal Intensive Care Unit, based on the meanings and interactions for care management. METHOD: qualitative research, based on the reference framework of the Grounded Theory. Eight nurses were interviewed at a Neonatal Intensive Care Unit in the city of Rio de Janeiro. The comparative analysis of the data comprised the phases of open, axial and selective coding. A theoretical conditional-causal model was constructed. RESULTS: four main categories emerged that composed the analytic paradigm: Giving one's best to the Kangaroo Method; Working with the complexity of the Kangaroo Method; Finding (de)motivation to apply the Kangaroo Method; and Facing the challenges for the adherence to and application of the Kangaroo Method. CONCLUSIONS: the central phenomenon revealed that each nurse and team professional has a role of multiplying values and practices that may or may not be constructive, potentially influencing the (dis)continuity of the Kangaroo Method at the Neonatal Intensive Care Unit. The findings can be used to outline management strategies that go beyond the courses and training and guarantee the strengthening of the care model.


Introduction
Professional adherence does not involve watertight, preprogrammed behaviors to comply with normative requirements, but is directly related to the professional's insertion in the world, in society, in work and potential to transform him/herself, the practices and the context. The need to investigate this phenomenon derives from the immense challenge to make the recommended conducts, which are considered as scientifically protective and beneficial (to the patient and/or professional), permeate the practice as intensely as they are theoretically accepted.
In the context of the Neonatal Intensive Care Unit (NICU), nursing care management should not only meet the technological and infrastructural advances, but also the integrality of care, as a guiding axis of the work processes. Within this logic, the workers, managers and infants/relatives should be considered as protagonists in the production of health (1) .
What the search for quality in neonatal care is concerned, the Kangaroo Method is highlighted, which involves new forms of practicing and thinking care at the NICU, demanding a transformation of the care model in place and of the professionals' conceptions.
The adoption of the Kangaroo Method essentially aims to change attitudes towards care and handling the baby and towards the family's participation. This objective, in turn, encompasses some aspects of professional knowledge/actions, like the communicative and creative approach, the opening of spaces and the relation established for care (2) .
The nurse plays a fundamental role in the management of welcoming care, comfort, stimulation and environmental interventions, so as to promote skin-to-skin contact, the infant's development and the strengthening of affective bonds in the family (3) .

Method
This study is part of the interpretative epistemological branch of qualitative research. The theoretical framework was Symbolic Interactionism, which permitted exploring the nurses' compliance with the Kangaroo Method as a phenomenon related to the meanings their interactive activities produce in care. In function of the symbol, the human being does not respond passively to the reality, but actively and creatively, always recreating the world of action (4) .
Grounded Theory was the methodological framework selected because of its high level of systemization in the interpretation of the data, which aims to produce constructs or theoretical models, explaining the action in the social context. Due to the intensity of its analytic rigor, it demands theoretical sensitivity, creative attitude and determination from the researcher (5)(6) . The interviews were closed off based on theoretical saturation, which was made possible by the simultaneous data collection and comparative analysis. The representativeness of the subjects and the information quality were used as criteria for analytic density in the theoretical sampling process (7) .

Results
All (8) participants were female, with ages ranging between 20 and 45 years and a mean age of 39 years.

Working with the complexity of the Kangaroo Method
The characterization of the complexity involved in the subjects' discourse refers to the multiplicity and dynamic behavior of the care and management demands in this care model at the NICU. It involves broad and interlinked issues, such as care, citizenship and affection, which occupy a singular place in the concreteness of care, as each person has his/her history.

Finding (de)motivation to apply the Kangaroo Method
One important aspect linked to the compliance process is the professionals' motivation to apply the Kangaroo Method. The discourse appointed the need to value the nursing professionals' individual preferences and aptitudes for work at the NICU. would need to happen in that sense of stimulating people to put the Method in practice So, you doing it, saying: look, we're gonna do it now with that mother and so…, really insist (Nurse AM1).

The theoretical model
In the Grounded Theory, the central phenomenon is The link among the categories in this research was based on the Conditional/Consequential Paradigm or Model, which offers an organization scheme to join and order the data, so as to integrate structure and process (5) . The diagram ( Figure 1

Discussion
From the perspective of symbolic interactionism, not only the individual and the influence of the social structure or his/her personality on individual behavior is focused on, but the nature of the interactions and the dynamic social activities between the people in a society (4) . Thus, the adherence to the Kangaroo Method can be conceived as a result of the interactions among the professionals at the NICU, being therefore dynamic, social and intersubjective.
In the application context of the humanizing practices, there is a distance among prescriptive, institutionally established and truly executed work. This contradiction happens in the face of a hierarchical and generally centralizing work structure, where the professionals are more valued for their mastery of the technological environment, for the execution of standardized and routine tasks than for relational actions (10) .  (11)(12)(13) .

Sporadic and inconsistent actions, deficiencies in
The predominant values in education and practice derive from the hegemonic medical model and influence both the public work process and each worker's private practice. Health work cannot be fully controlled, as it is put in practice continuously through the relation between people, being therefore subject to the way the professionals develop their practice. Hence, within their autonomous space, the professionals act with intentions that are based on their values and conceptions (14) .
The way each person feels, thinks and acts is permeated by that person's intentions and interests.
This private universe composes the organization's psychosocial dimension, which is dynamic because people continuously change when interacting, also modifying the reality (15) . Therefore, it is important to establish a collaborative procedure change, in which the leaders and their subordinates jointly constitute a new individual and collective culture, actively participating in the process and acknowledging the presence of tensions. One of these tensions is the dynamics of work at the NICU as a source of pleasure and burnout for professionals (16) .  (17)(18) .
In view of this reality, the central role of management in nursing care as a process should be acknowledged, with great potential to lever changes.
Improvement actions in care fully depend on the nurses' better performance in service and team management, adopting postures of leadership and commitment to the profession and to the work practice (19) .
Management is a powerful instrument to trigger a critical reflection process on daily practice in the teams, favoring the professionals' compliance and commitment to a better care production process, beyond fragmented tasks and procedures (20) .
With a view to the dissemination, implementation or strengthening of the Kangaroo Method, managers and leaders need to understand the importance of (individual and organizational) core competences that will permit advances in the achievement of targets and outcomes. Management practice needs to be directly related to staff development in the job world, promoting an organizational culture that values qualities beyond the technical competences. This is a constructive and positive culture, based on conquests and the encouragement of humanism, with a special place for creativity, emotion and relationship (21)(22) .
For the changes in nursing practice to happen, a strategy needs to be established for the preparation of leaderships who assume innovative ideas, enhance creative environments and break with the barriers that impede organizational changes (23) .

Conclusion
The understanding that emerged from this study is that the professionals' compliance process is dynamic and These strategies will guarantee the continuity of these care practices, so that the operation of the Method is not limited to some few professionals' choice, but is part of a comprehensive care framework involving the teams.
Further research is recommended to understand the relation between the profile of the professionals who work in neonatal intensive care and competency development for humanization practices, as well as the design of management and training strategies that strengthen the Kangaroo Method.