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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.5 São Paulo Oct. 2011
Prenatal care protocol: actions and the easy and difficult aspects dealt by Family Health Strategy nurses*
Protocolo de atención prenatal: acciones, facilidades y dificultades de los enfermeros de la Estrategia de Salud de la Familia
Edilene Matos RodriguesI; Rafaella Gontijo do NascimentoII; Alisson AraújoIII
graduated from Fundação Educacional de Divinópolis, Associated
with Universidade do Estado de Minas Gerais. Divinópolis, MG, Brazil.
IIRN, graduated from Fundação Educacional de Divinópolis, Associated with Universidade do Estado de Minas Gerais. Divinópolis, MG, Brazil. firstname.lastname@example.org
IIIRN. M.Sc. Ph.D. in Health Sciences, Faculdade de Medicina, Universidade Federal de Minas Gerais. Assistant Professor I, Universidade Federal de São João Del Rei, Campus Centro Oeste Dona Lindu. Divinópolis, MG, Brazil. email@example.com
The objective of this study was to learn the perception that nurses have about the protocol of their attributions in prenatal care, identifying the health actions they develop, as well as the easy and difficult aspects in using the referred protocol. This qualitative study was developed with Family Health Strategy nurses in Divinópolis, Minas Gerais. The data survey was performed through interviews with five nurses. The data was submitted to thematic content analysis. Results showed the need for investments in professional qualification for women's health care in the pregnancy-postpartum cycle, as well as to create and implement protocols that promote a better interaction between the medical and nursing work.
DESCRIPTORS: Prenatal care; Maternal-child nursing; Family Health Program; Primary Health Care.
Este estudio tuvo como objetivo conocer la percepción de los enfermeros acerca del uso del protocolo de sus atribuciones en la atención prenatal, identificando las acciones de salud desarrolladas por estos profesionales, así como los puntos que facilitan o dificultan el uso del referido protocolo. Se trata de n estudio cualitativo, desarrollado junto a los enfermeros de la estrategia de salud de la familia del municipio de Divinópolis-MG. Para la recolección de datos se realizaron entrevistas con cinco enfermeros. Los datos fueron sometidos a análisis de contenido, en la modalidad temática. Los resultados demuestran la necesidad de inversiones en la formación de personal calificado para la atención de la mujer en el ciclo gravídico-puerperal, así como la creación e incorporación de protocolos que promuevan una mejor interacción del trabajo médico y de enfermería.
DESCRIPTORES: Atención prenatal; Enfermería maternoinfantil; Programa de Salud Familiar; Atención Primaria de Salud.
Pregnancy is a vitally important experience in the lives of women and their families. Across pregnancy, physiological changes occur that involve all organic systems, arousing expectations, emotions, anxieties, fears and discoveries, demanding profound knowledge on all changes that occurred during this period, with a view to adequate care delivery to pregnant women's health(1).
In this context, prenatal care comprises care, conducts and procedures for pregnant women and their fetuses. This care ranges from conception to the start of labor, preventively, and also aims to identify, treat or control illnesses; prevent complications during pregnancy and delivery; guarantee good maternal health; enhance good fetal development; reduce maternal and fetal morbidity and mortality rates; prepare the couple for parenthood(2).
According to the Ministry of Health (MH):
Qualified and humanized prenatal care is delivered through the incorporation of welcoming conducts and without unnecessary interventions; easy access to high-quality health services, comprising actions that integrate all care levels: health promotion, prevention and care delivery to pregnant women and newborns, ranging from basic outpatient care to high-risk hospital care(3).
Among the professional categories working in prenatal care, nurses occupy a paramount place in the team, as they are qualified for women's health care, play a very important role in health education, promotion and prevention, and also serve as humanization agents(4).
To organize and regulate nursing professionals' actions in primary health care, including prenatal care, in the last decade, Municipal Health Secretaries (MHS) in Brazilian cities have been elaborating protocols according to theoretical frameworks and service and population needs/demands.
As nursing students, the two authors had the opportunity to participate in a curricular practicum in primary health care, which took place in three distinct cities in the Central-West of Minas Gerais, where they could observe that each of these had a distinguished way of organizing prenatal nursing care. Among the three experiences, this care practice in Divinópolis attracted the authors' attention due to the family health team nurses' incipient participation in prenatal care. The importance of nurses' participation aroused the authors' strong interest in understanding these professionals' perception of the municipal protocol that supports and organizes these professionals' care.
In Divinópolis/MG, since mid-2006, municipal public health network nurses have been participating in prenatal care, based on a Regulation and Legislation Protocol for Nursing Professional Actions, elaborated by the Municipal Health Secretary, Division Head, Basic Action Management and by Nurses who were Public Health Specialists.
Thus, a field research among family health team nurses in Divinópolis/MG was proposed. This study is justified by its importance in the management of health services and the professional Nursing category, as this study will permit a better understanding of the professionals' work and the advances, limits and challenges in using this protocol.
To get to know nurses' perception on the use of the task protocol in prenatal care, to identify the health actions nurses in the Family Health Strategy develop and to investigate what points facilitate and hamper the use of this protocol.
In 1984, in response to a range of demands, the Ministry of Health elaborated the Comprehensive Women's Health Care Program (PAISM)(5), which marked a conceptual rupture with the principles of the women's health policy and the criteria for choosing priorities in this field. The PAISM incorporated the service decentralization, hierarchization and regionalization proposals, as well as care comprehensiveness and equity, including education, prevention, diagnosis, treatment and recovery, covering women's health care in gynecology, prenatal, delivery, post-partum, menopause, family planning, STD, uterine colon and breast cancer, besides seeing to other needs identified based on women's population profile(5).
The main goal of the PAISM was to attend to women in all phases of life, respecting the needs and characteristics of each. Since its elaboration, the pregnancy-postpartum cycle was and continues being one of the main priority areas in this program. The functioning of the PAISM, mainly prenatal care, requires the availability of trained human resources, an adequate and equipped physical area, laboratory support and recording instrument, data processing and analysis, structuring of a referral and counter-referral system to permit care delivery to pregnant women at the three complexity levels of the health system, as well as permanent assessment of the actions developed(5).
Then, in the year 2000, the Ministry of Health launched a technical manual with references for the organization of the care network, professional training and standardization of prenatal care practices(6). In the same year, the Ministry also launched the Delivery and Birth Humanization Program (PHPN) and SISPRENATAL (Information System of the Delivery and Birth Humanization Program)(7).
The PHPN was elaborated based on the need for change in the care model, in which humanization and rights appeared as the structuring principle. The goal of SISPRENATAL was to permit the adequate monitoring of the pregnant women inserted in the PHPN. This information system is part of DATASUS and defines the minimum list of procedures for adequate prenatal care(6-7).
Another important point that marked the development of prenatal care was the implantation of the Family Health Program (FHP), which today is called the Family Health Strategy. This strategy is presented as a reorientation proposal of the care model, developed based on primary health care, as the structuring axis of this health organization level. Prenatal care should take place at primary health care units, characterized as the entry door into the system, where the sector's bonds with the community are closed. Since it was established, pregnant women's increasing participation in prenatal care consultations has been perceived(6).
The prenatal period precedes the child's birth, when a set of actions is applied to pregnant women's individual and collective health(8). When the health team has contact with a pregnant woman, it should know how to understand the multiple meanings of pregnancy for that woman and her family. The history of each pregnancy is determinant for a good development of that human being and, therefore, should be welcomed comprehensively, based on the report of the pregnant woman and her companions. The main goal of prenatal care is to welcome women since the start of their pregnancy, when they will go through physical and emotional changes. Each woman will deal with these changes differently. Some of these transformations can arouse fears, doubts, anguish, phantasies or mere curiosities about what happens inside them(9).
Nevertheless, prenatal consultations involve simple procedures, so that health professionals can dedicate themselves to listening to the women's demands, transmitting trust to conduct the pregnancy and delivery autonomously. Professionals need to clarify any doubts that arise very clearly, so that the woman feels safe(8).
Prenatal care is often the client's first contact with the health system. Therefore, the team should be concerned with giving the pregnant woman the best possible impression(9).
For the Brazilian Federation of Gynecology and Obstetrics Societies (FEBRASGO), prenatal care consists in preventing, identifying and correcting maternal or fetal abnormalities; orienting the patient about pregnancy, delivery and care to the newborn and promoting psychological support for her to be able to adapt to the pregnancy(10).
The following are fundamental factors in this care: service organization, professional training and use of adequate and available resources, guaranteeing comprehensive care and the basic requisites for promoting and preventing the main diseases though(9).
Health professionals are responsible for many of the aspects needed to guarantee adequate quality of life to the population. The reorder the nursing care strategy, health protocols are elaborated. These are instruments created for health professionals to practice their profession according to the rules for professional practice. Through these, professionals will be regulated and supported to exert their functions, watching over the quality of service delivery(11).
Another important aspect of protocols is the reorganization of the work process, so that its central focus is a multiprofessional team. Interdisciplinarity permits knowledge exchange, professional enrichment, so as to reach a broader perspective of the patient, with a view to offering more qualified and effective care(12).
It is important to note that, besides using all of their technical knowledge, through the reorganization of the work process, nurses receive greater autonomy. Rethinking prenatal care involving professionals presupposes a new look on the health work and service organization process in which, through the establishment of protocols, each multiprofessional team member's technical-scientific competence is valued, thus offering qualified and humanized care to pregnant women(13-14).
Interested in going deeper into nurses' subjective, genuine and particular field when they use their prenatal care task protocol, qualitative research was chosen as the ideal scientific method for this study, as it is capable of answering very particular questions and, yet, at a level of reality that contains many meanings, beliefs, values and attitudes that cannot be reduced to operational variables(15).
In compliance with Resolution 196/1996 on research involving human beings, the Municipal Health Secretary - responsible for the institution - assessed and authorized the research, as well as the competent Institutional Review Board(16).
The study context comprised the 15 primary family health care units in Divinópolis/MG. The study subjects were the nurses allocated to these units. Nurses who accepted to participate in the research were eligible. It should be highlighted that the family health strategy covers approximately 25% of the population in Divinoópolis, while the remained is attended by traditional health centers.
Data were collected through an open interview and guided by a semistructured script with the following questions: 1. What prenatal care actions do you perform? 2. What points facilitate the use of the prenatal nursing care task protocol at your health unit? 3. And what points hamper the use?
These interviews were held with the nurses at prescheduled times, according to the interviewees' availability. The interviews took place at the primary family health care units where these professionals were allocated, and all interviewees had previously signed the Informed Consent Term.
To finish data collection, discourse repetition was used. Thus, data collection finished when the researchers perceived that statements were repeated, which happened after five interviews, i.e. five subjects were interviewed. With a view to protecting the nurses' identity, each research subject received capital letter "e", followed by a number from 1 to 5, according to the chronological order in which the interviews were held.
The interviews were recorded and then transcribed, and the collected material was submitted to Thematic Analysis. This analysis consists in the valuation of the theme, which is the unit of meaning that naturally gets out of a text analyzed according to criteria related to the theory that guides reading(15).
Next, the results are presented based on the three research foci: The nurse's perception of prenatal care actions; Facilities in using the prenatal care protocol and Difficulties in using the prenatal care protocol.
RESULTS AND DISCUSSION
The nurse's perception of prenatal care actions
Regarding the description of the prenatal care actions the nurses develop, the testimonies reveal that the professionals under analysis perform most of the procedures recommended in the Nursing Task Protocol.
I do a pre-consultation, the pregnancy diagnosis through the pregnosticon or beta HCG tests, registration in SISPRENATAL. I also fill out the pregnancy card with the necessary identification data and assess the vaccination status because, in case of delays, we also administer vaccines. I do the pregnancy group, home visits, active search for women who do not attend. I also calculate the gestational age on the card, weighing and measuring the height for the SISVAN, as well as some orientations about the dental consultation. In case the generalist physician is absent from the unit, I request some routine tests. When the mother comes for the heel prick test, either I or the physician already schedule the post-partum consultation and, on the same day, if necessary, we vaccinate against measles (E1).
The woman arrives here with a suspected pregnancy, I request the pregnosticon or beta HCG test. She returns with the result and, if positive, I already make an appointment with the physician. Before the consultation I already do a screening, I weigh everything correctly and then the physician requests the other tests (E2).
I do the pregnancy groups. If a pregnant woman arrives complaining of a delayed period I even request the diagnostic test. If requested I also visit the pregnant woman at home (E4).
I do pregnosticon and vaccination. I also do visits and orientations... but it's not prenatal, I don't do prenatal, I do the nursing consultation.(E5)
Some nurses' lack of knowledge on prenatal care was evidenced, as they did not considered the actions they performed for pregnant women as part of this type of care. They believed that only the medical consultation during the pregnancy period characterized prenatal care.
Look, I do all of this I said, but I do not take responsibility for prenatal care. I don't get involved in something I don't know well(E2).
Only the physician does the prenatal care actually. If the result of the test I requested was positive, from that point onwards the physician follows the pregnant woman... (E4).
What I do is not prenatal, I don't do prenatal. I do the nursing consultation (E5).
Prenatal care is not just limited to the procedures performed inside the physician's consultation room. According to the Ministry of Health's Technical Prenatal Care Manual, high-quality prenatal care includes both simple actions (orientation, pregnancy groups, request for diagnostic tests, home visits, among others) and common risk procedures the physician or nurse performs during the prenatal consultation(6).
Facilities in the use of the prenatal care protocol
The protocol used in prenatal care at the primary health care services in Divinópolis offers the nurses care organization because it establishes conducts and procedures that optimize the health work process and benefit management, health professionals and users. It is also essential to guide and support high quality care practice.
Performing tasks according to established protocols is important, as these enable professionals to deliver a high quality service. Competency development according to the protocols is the support base for adequate health care. It is important for protocols to be constructed based on Consensus, Technical Standards, Manuals, Protocols and other documents the Ministry of Health and the State Health Secretary issue, observing the application to local realities with a view to producing positive impacts on the quality of life of the population the team attends when using the protocol(13).
What makes it easier is to be able to request the tests that detect pregnancy early, routine prenatal tests, as well as the availability of a referral service (E1).
For me, the protocol facilitates the autonomy to be able to request tests, forward(E2).
The nurses see the municipal protocol as a document that regulates, supports, sustains and guides the activities that need to be performed. Thus, the protocol grants the nurses security in practicing their functions.
The protocol is a standardizing instrument that guides professionals in the accomplishment of their functions. It is based on scientific and practical knowledge on daily health work, according to an extremely dynamic reality, which makes its permanent assessment obligatory, as well as modifications according to the circumstances involved(11).
What makes it easier for me is the certainty that I have support. If I do prenatal care it's written here, standardized (E3).
It's a document that supports me to practice my activities at the unit. The protocol supports us (E4).
Only one nurse among the interviewees has a different opinion.
There is no facilitator for me, because I don't do the prenatal (laughs)... To tell you the truth, this protocol and nothing mean the same thing to me. I don't even use it, for me this protocol is very... ah I don't know, I didn't even read it (E5).
Difficulties in the use of the prenatal care protocol
As for difficulties in the use of the nursing task protocol in prenatal care, the interviewees mention the lack of theoretical and practical training for care delivery to pregnant women. It is definitely fundamental for health professionals to be prepared and trained, as this is a fundamental factor for qualified care. Also, professionals are unprepared for or neglect the adoption of care technologies in prenatal follow-up(8). An educative process that enables professionals to gain practical competencies and problem-solving, critical thinking and decision-making skills is essential.
What makes it difficult for me is the lack of specific training for prenatal consultations, for nurses to act with more security (E1).
I could even get a lot of books and read a lot about prenatal care. But, in practice, it's different. So, what I feel is that the health unit, the municipal health secretary does not give me support. I'm not confident to do prenatal care. This protocol is very succinct (E4).
Two nurses explained that they did not do prenatal consultations at their unit due to a lack of time and the large number of inhabitants in their coverage area.
In fact, we don't do it because of a lack of time. I only do it if there's no physician (E3).
Our FHP attends almost 6 thousand inhabitants, we can't do prenatal consultations (E4).
It is known that planning is needed, which demands the determination of nursing actions through the use of a work method with a view to attending to the clients' needs. Care planning is one of nurses' functions, which permits nursing care management in a global, coherent and responsible way(17). Thus, nurses could deliver care to women during pregnancy if care were planned without impairing work at the unit.
Lack of teamwork is another point that hampers prenatal care. Difficulties in this context range from the team physician's resistance to collaborate with the nurse in prenatal care to better interaction between the nurse's and the physician's work process. A health unit team is expected to do its work as a group. If not, it will go against the proposal of comprehensive care delivery to users.
Teamwork results from professionals' articulated actions and interaction. An integrated team is marked by a set of characteristics, which are: enhancing a flexible work division; questioning of inequality in the valuation of distinct activities and their respective agents; preserving technical differences among specialized activities; exerting professional autonomy, in view of interdependence among different professional areas: decentralizing decision making in the work team; and constructing a common care project(18-19).
The problem is that we work alone a lot, as I don't do the prenatal consultations I can't take responsibility for them because, afterwards, nobody will want to take responsibility in case of complications (E2).
For me, the difficulty is the lack of greater direction, of a flow chart, for example, indicating forwarding, what to do, how to do it, that is, in which all professionals will follow the same course (E3).
When answering questions about difficulties, one nurse demonstrated great resistance in the use of the protocol, alleging that the instrument is a copy of the manuals the Ministry of Health has created and a document that cannot be used in her care practice.
I think that it is a big farce, a big lie. We use practically nothing of it. I think the Ministry has already recommended things and you don't need to invent anything new, look here (shows the Ministry books on her table), they're all mine. There's no need to make protocols, no, it's already regulated in the resolution. I bet that nobody read this protocol unless the students. I never read it to tell you the truth. I don't even know what's written there. I only use the things the Ministry mentions, I do everything the Ministry says here. What it doesn't say I don't do and what it says I do. The protocol is a copy. There's a lot of people who'll say that it's marvelous and how many times have they read it?! None (laughs) (E5).
It should be highlighted once more that the protocols are important management instruments that need to be adopted and that their use is fundamental for service organization. They are not neutral instruments, but follow guidelines that are sometimes prescribed by scientific evidence, sometimes by SUS standards or both. In general, the use of a protocol at a health unit is directly related with the definition of the care model and the construction of the work process one wants to set up(13).
Therefore, performing activities based on protocols is a complex issue that involves many organizational, social and behavioral factors. Most health professionals may not be familiar with the standards recommended for good professional practice due to different reasons, including lack of knowledge and lack of clarity about the recommendations(19).
The study about how family health team nurses perceive the Prenatal Nursing Care Task protocol demonstrated that it is a powerful instrument to reflect on the care delivered to pregnant women and identified the points that enhance and impair the protocol's use in daily nursing work.
Although the nurses do not understand that the actions they reported are not part of prenatal care, this research contributed to verify the important of these professionals' participation in maternal-infant health care in the city.
If, on the one hand, it was proven that most interviewees perceive the great value of using the protocol and possible modifications that should be made, on the other, resistance against its use is also observed among the nurses themselves and physicians in the service network.
Out of five nurses under analysis, however, three showed to participate in prenatal care. It should be underlined that, among these three, one more closely approximated the actions the protocol recommends. Despite flaws in the instrument, it should be clarified that this does not prevent professionals from offering high-quality care.
Some points were also evidenced which impeded nurses from delivering prenatal care, whose solution demands investments. These investments include the following: development of specific theoretical-practical training, provision of information and clarifications about the importance of incorporating and using care protocols and creation of protocols that enhance interaction between medical and nursing work with a view to improving service quality.
Thus, it is perceived that gaps exist in prenatal care at the units under analysis, which strongly influence health management with a view to the organization of care delivery to pregnant women in municipal primary health care. This demands joint efforts by the different entities involved in maternal-infant care (health management, health professionals and users), so that this protocol is truly effective and so that errors can be corrected.
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Received: 06/09/2009 *Taken
from the Course Conclusion monograph "O protocolo das atribuições
do enfermeiro na assistência pré-natal: a percepção
dos enfermeiros das equipes de saúde da família", Undergraduate
Nursing Program, Fundação Educacional de Divinópolis, Associated
with Universidade do Estado de Minas Gerais, 2009.
*Taken from the Course Conclusion monograph "O protocolo das atribuições do enfermeiro na assistência pré-natal: a percepção dos enfermeiros das equipes de saúde da família", Undergraduate Nursing Program, Fundação Educacional de Divinópolis, Associated with Universidade do Estado de Minas Gerais, 2009.