Nursing intervention identification in rooming-in

Abstracts

Diante da escassez de parâmetros que possibilitem conhecer a carga de trabalho existente no Sistema de Alojamento Conjunto (SAC), torna-se necessário identificar as atividades de enfermagem na assistência ao binômio mãe-filho. O estudo teve como objetivos: identificar as atividades de enfermagem realizadas no Alojamento Conjunto do HU-USP; classificar as atividades em intervenções de enfermagem, segundo a Nursing Intervention Classification (NIC), e validar as intervenções. O levantamento das atividades foi realizado por meio dos registros e da observação direta da assistência de enfermagem, em todos os turnos. O conteúdo das intervenções foi validado com as enfermeiras da unidade, por meio da técnica de oficina de trabalho. Identificaram-se 43 intervenções diretas e indiretas de enfermagem, atividades associadas e atividades pessoais da equipe. O instrumento construído com as intervenções/atividades possibilitará, em futuros estudos, correlacionar o tempo despendido na execução dessas intervenções e, assim, propor parâmetros no dimensionamento de profissionais de enfermagem necessários ao SAC.

Alojamento conjunto; Cuidados de enfermagem; Carga de trabalho; Recursos humanos de enfermagem no hospital

ORIGINAL ARTICLE

Nursing intervention identification in rooming-in^*

Identificación de las intervenciones de enfermería en sistema de alojamiento conjunto

Alda Valéria Neves Soares^I; Raquel Rapone Gaidzinski^II; Michelli Oliveira Vani Cirico^III

^INurse. PhD in Nursing. Escola de Enfermagem da Universidade de São Paulo. Director of the Divisão Materno Infantil of the Hospital Universitário of the Universidade de São Paulo. São Paulo, SP, Brazil. [e-mail]

^IINurse. Free Lecturer. Escola de Enfermagem da Universidade de São Paulo. São Paulo, SP, Brazil. [e-mail]

^IIINurse. Escola de Enfermagem da Universidade de São Paulo. São Paulo, SP, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

Considering the need of parameters to know the workload existent in Rooming-in (RI), it is imperative to identify nursing activities in the mother-child binomial. The objectives of the study are: to identify nursing activities in the Rooming-In Unit of the HU-USP; to classify activities in nursing interventions according to the Nursing Intervention Classification (NIC), and to validate the interventions. A survey of all activities was carried out by means of clinical records and direct observation of nursing assistance in all the shifts. The content of interventions was validated with the nurses of unit, by means of the workshop technique. It was identified 43 direct and indirect nursing interventions; activities associated and personal activities of the staff. The instrument built with the number of these interventions/activities will permit to, in further studies, correlate the time expended to perform these interventions/activities and thus to propose parameters to measure the need of nursing professionals in RI.

Key words: Rooming-in care. Nursing care. Workload. Nursing staff, hospital.

RESUMEN

Ante la falta de parámetros que posibiliten conocer la carga de trabajo existente en el Sistema de Alojamiento Conjunto (SAC), se vuelve necesario identificar las actividades de enfermería en la atención del binomio madre-hijo. El estudio tuvo como objetivos: identificar las actividades de enfermería efectuadas en la unidad Alojamiento Conjunto del HU-USP, clasificar las actividades en intervenciones de enfermería, de acuerdo con el Nursing Intervention Classification NIC y validar las intervenciones. El relevamiento de las actividades fue realizado a través de los registros y de la observación directa de la atención de enfermería en todos los turnos. El contenido de las atenciones fue validado con las enfermeras de la unidad, utilizándose la técnica de oficina de trabajo. Fueron identificadas 43 intervenciones directas e indirectas de enfermería, actividades asociadas y actividades personales del equipo. El instrumento construido con las intervenciones/actividades permitirá, en estudios futuros, correlacionar el tiempo consumido en la ejecución de tales intervenciones y así proponer parámetros para el dimensionamiento de profesionales de enfermería necesarios en el SAC.

Descriptores: Alojamiento conjunto. Atención de enfermería. Carga de trabajo. Personal de enfermería en hospital.

INTRODUCTION

In Brazil the healthcare model adopted to assist the mother-child binomial is the Rooming-In System (RIS) which according to the Ministry of the Health⁽¹⁾ is defined as a hospital system where a healthy baby soon after childbirth stays next to its mother 24 hours a day in the same hospital environment until both are discharged. This type of continuous stay allows parents to be given guidance to care for their child, stimulates breastfeeding and favors family binding, in addition to contributing to decrease hospital infection indexes.

The significant difference in a RIS is the role of care providers in situations when they remain available to help mothers take care of themselves⁽²⁾.

Women during the puerperium period feel accepted through the nursing actions that show attention to their needs. When a healthcare provider shows interest in patients' wellbeing, it leads to an effective interaction. On the other hand, if they are not assisted, they feel that as despise, lack of attention and humiliation.

Thus, unqualified assistance is perceived by women when there is lack of tenderness, of patience, physical distance and no regard for their complaints, which are attributes being studied by several authors ^(2-5)_.

To assist women during this period in full healthcare providers should pay attention to their actual needs, focusing on the human relationship between healthcare provider and patient, but that would only be effective if there are qualitative and quantitative human resources adequate to provide such assistance.

The objective of the RIS is not to overload physical or emotionally those women. In this type of system women during the puerperium are stimulated to take care of themselves and to take care of their child, but that does not mean that women during this period has to, or even are responsible for taking over the care for their child and for themselves.

The main assistance approach of healthcare providers in this system is related to providing healthcare education and guidance so that women acquire confidence and tranquility to take over their role as mothers. This patient profile does not require sophisticated equipment or major procedures, which leads some administrators to classify this assistance as minimum nursing care. However, it demands from healthcare providers significant communication skills, availability, monitoring, assessment and an accepting stance which unarguably takes time and professional competence.

In this sense, the correct number of nursing personnel for this assistance model is relevant in order to ensure the proposal founding the RIS.

The number of nursing personnel is defined as a

systematic process to determine the number of healthcare providers and professional qualification required to providing nursing care enough to guaranty the quality previously set for a group of patients/clients according to the organization's philosophy and structure and to the uniqueness of each service⁽⁶⁾.

This process

[...] depends on knowing the workload existing in the assistance units. The workload, on its turn, depends on the needs of assistance to be provided to patients and on the standard of care intended⁽⁷⁾.

In the Brazilian regulations there is the Administrative Rule n. 1016 of the Ministry of the Health of August 26^th, 1993⁽¹⁾ which disposes on rules to implement the Rooming-In system and it recommends that the minimum number of human resources in the nursing team should be one nurse for 30 mother-child binomials and one assistant nurse for 8 binomials.

Considering the shortage of specific parameters able to determine the number of people for the RIS, this study proposes, in order to contribute to outlining an instrument able to quantify and qualify more reliably the nursing human resources required to providing nursing care to the mother-child binomial.

For those purposes we have to know the workload in the RIS by bearing in mind that said load is expressed in the quantity and type of nursing interventions/activities conducted by the nursing team and the time spent in making those interventions.

Therefore, identifying and validating nursing interventions/activities are the first step towards a more efficient planning of human resources and then, later, to plan the time to be spent in those interventions, which will allow knowing the workload in the RIS.

The study is a subproject of the research: Methods to calculate the number of healthcare providers: developing an application program subsidized by the CNPq inserted in the research line: Management of Human Resources in Healthcare and Nursing of the Post-Graduation Program in Nursing of the USP School of Nursing.

OBJECTIVES

• To identify the activities carried out by the nursing team;

• To classify those activities according to the Nursing Intervention Classification⁽⁸⁾;

• To validate the list of nursing activities/ interventions conducted at the RIS.

METHOD

This is a case-study, quantitative research whose object is to identify, classify and validate the activities conducted by the nursing team in the RIS.

The research was conducted in the Rooming-In unit of Hospital Universitário of University of São Paulo (HU-USP) whose priority is to provide full assistance to women and newly-born babies from childbirth to hospital discharge.

The unit has 47 beds for the mother-child binomials, the average number of patients assisted is 300 a month and occupation rate is about 80%. The minimum time patients remain in the unit is 48 hours after childbirth.

The nursing team is composed of a head nurse, 12 assisting nurses, 34 nursing technicians/ assistants, one material technician and two clerks.

This assistance environment enables adequate conditions for teaching and researching in the Obstetric and Neonatal Nursing area.

The subjects of the study were all nursing professionals working at the Rooming-In unit from June 15^th to August 4^th, 2007.

The project was approved by the Chamber of Research and the Committee of Ethics in Research of the HU-USP, protocol no. 0020.0.198.196-07.

The nursing professionals present during the period of the study were approached and asked whether they would like to participate in this investigative proposal and their consent was requested. The procedures followed the guidelines disposed in resolution no. 196/96 of the Brazilian Health Council⁽⁹⁾.

The research was conducted in four methodological phases, with different collection strategies and data analysis.

First phase: identifying nursing interventions/activities carried out to assist the mother-child binomial.

The data referring to the identification of the activities done by nursing professionals for the binomial were collected from the records of nursing assistance and from the medical charts of the mother and newborn baby from admission to discharge. The data were completed through direct observation of the assistance provided by nursing professionals in order to capture activities that are done, but not recorded.

The records of the activities were collected by the researcher and a student of the Nursing Graduation Course of the School of Nursing of University of Paulo who has a PIBIC-CNPq scholarship in Scientific Initiation, in a random, statistically determined sample of 68 medical charts from September 22^nd, 2006 to May 10^th, 2007.

That same undergraduate student observed the subjects directly after they had given their Free and Informed Consent.

To do that, a nurse and a nursing technician/assistant working in the morning, afternoon and night shifts were randomly chosen and were observed during their shifts while they did their activities. Five collection days for each shift were set in order to include possible activities and how they were done by different professionals.

Eight assisting nurses, eleven nursing technicians/assistants were observed in six afternoon shifts and five night shifts. Due to the selection technique adopted, some professionals were observed more than once.

Second phase: classifying activities in a standardized language of nursing interventions.

The list of activities done by nursing professionals for the mother-child binomial was classified in nursing interventions according to the Classification of Nursing Interventions (NIC)⁽⁸⁾.

The NIC⁽⁸⁾ is a comprehensive, standardized classification of the interventions made by nurses; some positive aspects should be highlighted, such as: to be based on researches, to mirror clinical practice and current researches, to have a user-friendly organization structure, to speak in clear and clinically significant language and to be associated to the diagnoses of NANDA I, North American Nursing Diagnosis Association-International, diagnoses that have already been implemented in the RIS of the HU-USP, the field of this investigation, since 2004.

The NIC⁽⁸⁾ defines intervention as

any treatment based on clinical judgment and knowledge made by a nurse to increase the results to be obtained by patient/client,

and activity is defined as

specific behavior or actions taken by nurses to implement an intervention which helps patients/clients obtain the result expected. Nursing activities are located at the concrete level of an action. A number of activities are required to implement an intervention.

Every activity identified in the patients' medical charts and observed during the work shift of the nursing team was fitted in the most pertinent intervention through an analysis of the many possibilities by bearing in mind that in the NIC⁽⁸⁾ selecting a nursing intervention for a certain patient is part of a nurse's decision-making process and that the standardization of the Classification is in the titles and definitions of the interventions. However, the care provided is individualized through the activities. Thus, any changes or additions to the activities should be consistent with the definition of the intervention. Activities were grouped by the researchers during six meetings which lasted approximately four hours each until the completion of a list to be validated by the nurses.

The activities that had no correspondence in the taxonomy of the NIC were grouped in activities related to the nursing work and personal activities of nursing professionals.

Associated or additional nursing activities that could be done by other professionals, but are done by the nursing team were taken into consideration. The activities classified as personal refer to the breaks required in the daily work to meet physiological needs and those of communication with nursing professionals.

Third phase: validation of the instrument of nursing interventions/activities

The instrument built in the previous phase was submitted to the analysis of the nurses working in the Rooming-In unit of the HU-USP to validate the contents as to properness, understanding and comprehension of the intervention/activities carried out by the nursing professionals.

The validity of the contents of an instrument is necessarily based on judgment and it represents the whole context of the contents ⁽¹⁰⁾.

A subtype of content validity is the face validity where it is checked whether the instrument seems to measure the concept. It consists of an intuitive type of validation where one asks colleagues in the research to evaluate the contents and analyze whether the instrument mirrors what the researcher intends to measure⁽¹¹⁾.

To validate the contents of the instrument proposed according to the face validity the Workshop technique was used,

which is a process structured with groups, regardless the number of meetings, focused around a core question that the group proposes to prepare within a social context. In its application, the Workshop is not limited to a rational reflection; rather, it involves the subjects in full, their ways of thinking, feeling and acting⁽¹²⁾.

Authors⁽¹³⁾ have pointed out that this technique allows a horizontal relation between interviewer and interviewee once it favors a space of discussion and its objective is to recover existing knowledge, to allow the manifestation of feelings related to the experience lived, to ease inter-group expression and communication added to motivation to discuss contents.

The instrument was validated by the nurses who worked in the Rooming-In unit and the Workshop was structured in two meetings. The first meeting lasted two hours and a half and the second, two hours.

Seven nurses of the Rooming-In unit participated in the first workshop, and in the second, five. Two nurses of the group were taking their post-graduation degree; two, their master's degree and the other three were specialized in obstetrics.

For the group discussion a presentation on the research's objective was prepared, contents on the NIC (definition, possibilities of use, domains and classes) and each nurse received a copy of the instrument with a list of interventions/activities identified in the Rooming-In unit.

After the construction of the nursing interventions/activities instrument was explained, each intervention/activity was read and discussed. The following item was only read after the previous one had been agreed upon or an alteration had been consensually accepted.

The fourth phase was the measurement of the quantity and the time spent in the nursing interventions/activities related to the mother-child binomial, which will be approached hereinafter.

RESULTS

The data from the records collected from the 68 patients' medical charts reporting the nursing activities allowed us to assess 83 activities related to the care provided to mothers and newborn babies. Among them, nurses' specific activities, such as care planning and evaluation, in addition to the activities prescribed, which mirrored the activities done by the nursing team, such as: orientation, controls, procedures, activities involving help offered to patients both related to self-care and to the newborn baby and to the documentation referring to several records involving monitoring the baby's clinical and behavioral status.

Direct observation of the activities done by the nurses and nursing technicians/assistants allowed identifying indirect care provided to patients related to documenting the care; supply of materials and equipment; using computers and telephone sets; cleaning the patient's unit; teaching activities both to students as training activities and professional development; and personal activities, such as food, hydration and socialization, totaling 192 activities done by the nursing team.

The instrument containing domains, classes, interventions and activities resulting from this phase of the research was presented for validation to the nurses working in the Rooming-In unit.

The contents of the instrument with the list of direct, indirect, associated and personal interventions/activities were validated in the two workshops at the Rooming-In unit. Some modifications were made to the instrument referring to the wording of certain activities and the nurses also suggested that some activities should change interventions because they would fit in better in other intervention already proposed.

At the end of the discussion the group stated that the interventions proposed mirrored the workload of the nursing team of the Rooming-In System, and validated the list of interventions/activities by means of an individual judgment and collective consensus.

The classification validated by the nurses of the Rooming-In unit had, according to the NIC taxonomy: 6 domains, 17 classes, 43 interventions and 155 activities, which can be seen properly summarized in Tables 1 and 2.

DISCUSSION

The objective presentation of the activities/interventions of the nursing team shows the Rooming-In unit's assistance approach and objectives leading to another way of dimensioning human resources in this healthcare model.

The validated list of activities of the nursing team in the Rooming-In unit allowed us to verify that the team performs in educational aspects oriented towards the development of maternal skills for the purposes of giving a woman tools to take care of her child. There are also interventions involving the organization of the unit's physical structure, planning the care to be provided to patients and coordinating the nursing team focused on providing quality and humane care.

The World Health Organization (WHO) published in 1998 a guide for post-childbirth care for mothers and newborn babies. There it is written that post-childbirth care should respond to mother and baby's special needs. As to the woman, care should contain information/advice on: taking care of the baby, breastfeeding, self-care, hygiene, signs of possible problems in that period, sexual activity, contraception, among others, and related to the baby, the needs refer to a safe environment, adequate food, observation of body's signs, safe room temperature, and it mentions that the main objective of post-childbirth care should be setting and maintaining breastfeeding⁽¹⁴⁾.

Therefore, the interventions/activities found in this study validate the main objective of the care provided in a Rooming-In unit by encompassing educational actions, developing maternal skills and promoting more family integration.

The strengths of the Rooming-In unit are the orientations given to parents, when they have an opportunity, in addition to solving their doubts, to learn how to take care of their child properly⁽¹⁵⁾, an aspect contemplated in several interventions, such as: Guidance to PARENTS: baby, Assistance in BREASTFEEDING, Promoting BINDING and other direct interventions.

Some authors⁽¹⁶⁾ state that several researches point out the mother as a co-participant in the assistance because the system allows training her to take care of her child and breastfeeding, acknowledging her child's needs and fully satisfying them, thus becoming a healthcare multiplier agent within the family and the social and ecological environment. The contents are worked at the RIS of the HU-USP and are present in several interventions, mainly in the "Family" and "Behavioral" domains.

Direct cares to the mother and newborn baby are essential and valued by the team and they are represented in several interventions in the Physiological - Basic, Physiological - Complex and Family domains. Other interventions are related to safety and to the healthcare system, characterizing the hospital where the RIS has been implemented, in addition to interventions related to the management of the unit, indirect care, such as: Documentation, Delegation, Employees Supervision, among others.

The NIC⁽⁸⁾ has the following domains in its taxonomic structure: Physiologic - Basic, Physiologic - Complex, Behavioral, Safety, Family, Healthcare System and Community. In this study interventions belonging to the seven domains were identified. The Community domain did not come out in the records included in the forms of the mothers and newborn babies and, so, a future study could check whether or not this domain is approached in the activities in the RIS.

The list of interventions/activities, a prototype of an instrument to identify workload, will help measuring the time spent providing care to the mother/child binomial.

CONCLUSION

Nursing should be sensitive enough to detect and respect the needs of every binomial and family, not being limited to the hospital routines and, thus, able to individualize the care through nursing diagnostics and prescriptions prepared in an ethical and conscious way, and the activities assessed here are just the most prevailing.

This study is limited because other hospitals where there is a RIS may do some activities different from those found in the AC of the HU-USP, and others may be done just at the site where this study was conducted. So, the list of interventions/activities should be validated within different contexts.

However, the list of interventions/activities validated allows knowing a significant part of the interventions made in the RIS and, thus, it can contribute to outline an instrument able to quantify more reliably the workload of a nursing team.

Identifying and validating the contents of the list of interventions/activities were the first step to dimension the personnel in a RIS and, should this research be continued, it will allow future studies to correlate the interventions/activities listed in the instrument and to measure the time spent in doing them and, thus, to help nursing managers plan efficiently the number of care providers required to assisting the mother/child binomial.

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• ¹
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• 16. Sochi CGS, Melo DF, Javorski M, Menossi MJ. O Alojamento Conjunto em Hospitais-Maternidades do Município de Ribeirão Preto: análise da assistência. Acta Paul Enferm. 1996;9 (3):15-23.

Correspondência:

Alda Valéria Neves Soares

Rua José Telles da Conceição, 44 - Lauzane Paulista

CEP 02441-020 São Paulo - SP, Brasil

*

Extraído da tese "Carga de trabalho de enfermagem no sistema de alojamento conjunto", Escola de Enfermagem, Universidade de São Paulo, 2009.

Publication Dates

• Publication in this collection
  01 July 2010
• Date of issue
  June 2010

History

• Received
  12 Mar 2009
• Accepted
  25 May 2009