Obstetric/neonatal care: expansion of nurses’ clinical practice in Primary Care

Abstract

Objective

To understand the meaning of the expansion of nurses’ clinical practice in obstetric and neonatal care in the primary care context.

Methods

Qualitative study in which were adopted the theoretical-philosophical reference of Edgar Morin’s Complex Thought and the methodological framework of the Grounded Theory. The stages of collection, analysis and construction of the theory occurred in alternating sequences between September 2016 and September 2017. The theoretical saturation of data was reached after including 11 individual interviews with primary care nurses and four participant observations. Data were organized using the NVIVO10^® software and analyzed in three steps: open, axial and integration coding.

Results

The central phenomenon “Provoking changes in the performance of primary care nurses” and three categories emerged: Understanding the meanings of nursing care management in primary care; Dealing with the antagonistic and regulating movement that influences quality; and Improving quality to promote the resolution of primary care.

Conclusion

The meanings of the leadership movement in favor of the expansion of nurses’ clinical practice in primary care are related to the resistant posture of some professionals, the inconstancy of human and material resources, but above all, the search for the care essence.

Primary health care; Health services accessibility; Professional autonomy; Nursing care; Obstetric nursing

Resumo

Objetivo

Compreender o significado da ampliação da prática clínica do enfermeiro na atenção obstétrica e neonatal no contexto da atenção primária.

Métodos

Pesquisa qualitativa, com o referencial teórico filosófico do Pensamento Complexo de Edgar Morin e com o referencial metodológico da Teoria Fundamentada nos Dados. As etapas de coleta, análise e construção da teoria ocorreram em sequências alternadas, entre setembro de 2016 a setembro de 2017. A saturação teórica dos dados ocorreu com a inclusão de 11 entrevistas individuais com enfermeiras da atenção primária e com quatro observações participantes. Os dados foram organizados por meio do software NVIVO10® e analisados em três etapas: codificação aberta, axial e integração.

Resultados

Emergiu o fenômeno central “Provocando mudanças na atuação do enfermeiro da atenção primária” e a três categorias: Compreendendo os significados da gestão do cuidado de Enfermagem na atenção primária; lidando com o movimento antagonista e regulador que influencia a qualidade e melhorando a qualidade para promover a resolutividade da atenção primária.

Conclusão

Os significados do movimento de liderança em prol da ampliação da prática clínica do enfermeiro na Atenção Primária relacionam-se com: as resistências na postura de alguns profissionais, a inconstância de recursos humanos e materiais, mas, sobretudo, com a busca pela essência do cuidar.

Atenção primária à saúde; Acesso aos serviços de saúde; Autonomia profissional; Cuidados de enfermagem; Enfermagem obstétrica

Resumen

Objetivo

comprender el significado de la ampliación de la práctica clínica del enfermero en la atención obstétrica y neonatal en el contexto de la atención primaria.

Métodos

investigación cualitativa, con base teórica filosófica del Pensamiento Complejo de Edgar Morin y base metodológica de la Teoría Fundamentada en los Datos. Las etapas de recolección, análisis y elaboración de la teoría se realizaron en secuencias alternadas, entre septiembre de 2016 y septiembre de 2017. La saturación teórica de los datos se realizó con la inclusión de 11 entrevistas individuales con enfermeras de atención primaria y con 4 observaciones participantes. Los datos fueron organizados por medio del software NVIVO10® y analizados en tres etapas: codificación abierta, axial e integración.

Resultados

surgió el fenómeno central “provocar cambios en la actuación del enfermero de la atención primaria” y las tres categorías: comprender los significados de la gestión del cuidado de enfermería en la atención primaria, lidiar con el movimiento antagonista y regulador que influye en la calidad, y mejorar la calidad para promover la resolutividad de la atención primaria.

Conclusión

los significados del movimiento de liderazgo a favor de la ampliación de la práctica clínica del enfermero en la atención primaria se relacionan con las resistencias en la postura de algunos profesionales, la inconstancia de recursos humanos y materiales, pero, sobre todo, con la búsqueda de la esencia del cuidar.

Atención primaria de salud; Accesibilidad a los servicios de salud; Autonomía profesional; Atención de enfermería; Enfermería obstétrica

Introduction

Obstetric and neonatal care is undergoing significant transformations. Contemporary challenges converge to the adoption of a humanized care model based on good pregnancy, childbirth and birth care practices.¹ Currently, the difficult access to health services is a contrary factor to the quality of obstetric care.² In this direction, nurses working in Primary Health Care (PHC) are key elements in the protection and promotion of women’s health, and the concepts of Newborn (RN) and companion/family member.³

Through nursing care management, PHC nurses can establish innovative care by articulating science and art for a critical analysis of the situation. In this context, the organization of available resources and evaluation of care guarantee the quality of health services.⁴

One of the available tools for nurses performing care management are the nursing clinical protocols (NCP). In this setting, NCP were created based on the best evidence and the needs of care nurses in their clinical practice by providing subsidies in a more directive and practical way. NCPs also provide legal support for nurses conduct and decision-making.⁵,⁶ In the implementation of NCPs, are faced institutional, human and material barriers that affect mainly professional autonomy,⁵ and it also involves understanding interactions/actions in order that NCP gains meaning for the expansion of nurses’ clinical practice in PHC.³-⁵

Reducing maternal and infant mortality related to fragilities in prenatal care is a challenge for public health that could be achieved through a better offer and access to health services.²,³ Therefore, understanding the actions, barriers and concerns that motivated a group of nurses to lead changes in clinical nursing practice is importance for inspiring new movements that benefit women, nursing and PHC.

The need to investigate the issue also justifies the performance of this study, since specific works on nursing care management for obstetric and neonatal care by PHC nurses have not been found, and this is a relevant theme in Brazilian reality.

This study is part of the Master’s Dissertation titled: “The meaning attributed to nursing care management for the quality of obstetric and neonatal care by primary health care nurses in Florianópolis”. The aim of this cut is to understand the meaning of the expansion of nurses’ clinical practice in obstetric and neonatal care in the context of primary care.

Methods

This is a qualitative study with the theoretical-methodological reference of the Grounded Theory (Strauss) and the theoretical-philosophical reference of Edgar Morin’s Complex Thought.⁷,⁸

The following were involved in the study: five Health Centers (HC) and the Municipal Health Department (Portuguese acronym: SMS) of Florianópolis/SC/Brazil, the implementation of the Child Capital Program⁹ and the Women’s Health Nursing Protocol.¹⁰ The PHC of Florianópolis has 100% coverage of Family Health Strategy (FHS) teams in its 50 (fifty) Health Centers.

The following were used as data collection instruments: participant observation; a closed questionnaire to identify the subjects’ expertise; and the semi-structured interview with the guiding question ‘What does Nursing care management mean for the quality of obstetric and neonatal care in PHC?’

The data collection period was between September 2016 and September 2017. Nurses were contacted via institutional email address, and 11 interviews were conducted with PHC nurses at their workplaces. Participant observation was also conducted in three different scenarios that included Pregnant Women Group meetings, Prenatal Nursing Consultations and PHC nurses’ meetings. These observations were recorded in field diaries.

Data analysis followed three steps: open, axial and integration coding. The emerging codes were systematically grouped, compared and ordered using the NVIVO^®10 software. In open coding, the analysis was extended to possible informants and places. The emerging codes of this analysis formed the categories and subcategories. In the axial step, data were encoded around the central category of the study. In this step, were used the components of the Paradigmatic Model of Corbin and Strauss: Conditions, Actions/interactions and Consequences.⁶ In the integration step, were connected the basic concepts of the constructed theory. The stages of collection, analysis and construction of the theory occurred in alternation. Data collection was concluded after achieving theoretical saturation of data, when participants repeated information about the phenomenon, and in absence of new relevant elements to the study objective.⁶

This study integrates a research macro project that was approved by the Research Ethics Committee under number 1,148,080 and CAEE number 43112415.5.0000.0121. The information contained in the Informed Consent form (IC) was explained to each participant before the term was signed. Subjects’ confidentiality was guaranteed with use of the letter “E” and a numeral from the interview order [E1... E11].

Results

Out of the 11 participants, five were Family Health Strategy nurses; three were unit coordinators; two were managers in the Municipal Health Department, and one had the roles of nursing assistant and coordinator of the unit. The substantive theory derived from the analytic process reveals the interrelated meanings of movements/interactions between woman-nurse-nursing care. The central phenomenon of the study, “Provoking changes in the performance of primary care nurses”, supports three categories: Understanding the meanings of nursing care management in primary care; Dealing with the antagonistic and regulating movement that influences quality; and Improving quality to promote the resolution of primary care. The Theoretical model (Figure 1) presents the central phenomenon integrated to the analytical components: Conditions, Actions/interactions and Consequences.⁶,⁷

Figure 1
Theoretical model “Provoking changes in the performance of primary care nurses”

Understanding the meanings of nursing care management in primary care

For a long time, the clinical performance of PHC nurses remained limited to health actions with low resolution. In the occurrence of health situations in practice that demanded clinical management, nurses did not have the support to meet the care demands of individuals.

“Basically, they thought primary care nurses only did meetings with health agents, health promotion, at most, prenatal care and preventive care. [...] When it came to having a little more clinical autonomy for nurses, we had some reservations”. E1

Conscious that these contradictions on the clinical practice of nurses represent an obstacle to the quality of care, some PHC nurses took the lead role in initiating a discussion movement on NCP that culminated in the creation of the Permanent Committee on Systematization of Nursing Care. In addition to implementing the Systematization of Nursing Care, the committee has the following objectives: to discuss nursing resolution and establish improvements in the clinical management of health care for PHC users.

In order to give life to this movement, was developed the NCP and implemented the Practical Approach to Care Kit (PACK). These two care management tools are aimed at nurses and physicians for decision making on the clinical conduct of care during pre-natal, puerperal and neonatal periods. According to interviewees, the essential condition for the expansion of clinical practice was understanding that the work process in PHC is multidisciplinary, interdisciplinary, intersectoral and comprehensive. The nurses’ performance had to be discussed within this context. In this leadership movement, were found barriers from some doctors and nurses who were against the proposal, whereas others expressed their support.

“There are medical colleagues who support us a lot and other medical colleagues who look at us cross-eyed. It is normal, we are breaking a traditional method that is more aimed at the doctor and we are now turning our eyes to the team itself. What the team can solve. What nurses can solve. And that’s great!” E4

“There were those who said [nurses] they were not going to open any Protocol. That this was the doctor’s job! But, nursing do not need the blessing from any category to do it. We assume the lead role of nursing”. E1

Regardless of our colleagues’ support, Nursing must understand we do not need the consent of other professional categories to act in the care setting.

Dealing with the antagonistic and regulating movement that influences quality

Participants mentioned the lack of a sufficient number of FHS teams, the greater work demands, the lack of care supplies, limited physical space of the Health Centers for organizing Pregnant Women Groups, and the moment of crisis and instability of Public Health as contrary movements to the quality of obstetric and neonatal care. However, there is a lot of desire to work and provide a quality service.

“People are sick of the shortage of doctors and lack of this and that, but they still want to make a change”. E5

The lack of communication between health services appeared as a fragility in the Health Care Network. Information on maternity care is available through reports of mothers and records in the Booklet of the Pregnant Woman and Child. Having the Child Capital Program was mentioned as positive, since it is a form of guarantee of the scheduled return for childcare consultations in Health Centers. For better dealing with these obstacles, some actions/interactions were agreed upon, such as: the reflection on the holistic view of nursing, i.e., the capacity to offer comprehensive and resolute care for women/family, the solidarity among the team, the consultation between doctor and nurse, and Team discussion.

Improving quality to promote the resolution of primary care

The implementation of CNP and the PACK strengthened nurses’ clinical competence. Professionals who were initially resistant to change their work process, empowered themselves and felt important in the care context. This impacted on nursing resolution and the expansion of users’ access.

“A protocol aimed at greater empowerment of nurses and quality in their care. This has a direct impact on obstetric care management”. E4

“This [Protocol] has given an extra boost and help because it includes the issue of resolving, mainly, in the matter of medicines and request for examinations”. E3

Users, on the other hand, respond favorably to the prenatal nursing consultation performed by nurses. They feel secure, which is linked to the bond, affection and care of nurses together with the promotion of empowerment and autonomy of the pregnant couple.

“Patients prefer a consultation with the nurse, because we already have autonomy for the issue of medications, requests for examinations. So, nursing care has a much longer time, is warmer, more affectionate!” E8

“The nurse is Severino ‘Fix-it Man’. The nurse is at the reception desk. We’re hanging something on the wall. We have to do ... We end up getting a bit lost because of the accumulation of roles”. E9

Interviewees shared ambiguous feelings of professional satisfaction with the care offered, both because they like to attend pregnant and postpartum women/newborns, and because they perceived the positive impact of the care provided on users’ lives. On the other hand, they needed strategies to manage the work overload.

Discussion

This study was based on the Grounded Theory⁷. It revealed the meanings of nurses’ experience in Nursing care management led by a group interested in improving the quality of PHC care. The implementation of CNP and the Systematization of Nursing Care strengthened and expanded the professional clinical practice, which consequently improved nursing resolution and expanded users’ access.

From 1997, with the implementation of the Child Capital Program, started the first Clinical Nursing Protocols aimed at women and children.⁹ In the municipality, the program mentioned by interviewees is a reference for the organization of actions to protect, promote and recover the health of pregnant women, puerperal women, newborns and children with Health Centers. One of these actions is the visit of Educating Agents to mothers still in the maternity (public and private). They receive immunizations and schedule the consultations of women and newborns between the fifth and seventh day of life of the NB, and consultations with the dentist for the 30^th day of life of the NB in the Health Center.⁹

The Protocol of Women’s Health Care published in 2010 and constantly updated since 2016, is an essential document for nurses’ work process. The development and update of CNP is based on scientific evidence, and guarantees professional autonomy for the clinical follow-up of pregnant women at normal risk, NB and child. Through NCP, nurses request prenatal (usual risk) exams, prescribe medications (when necessary) and nursing care according to Nursing interventions and diagnoses. Therefore, it is based on the Systematization of Nursing Care to support the planning, organization, coordination, evaluation and execution of Nursing care.¹⁰

The expansion of nurses’ clinical practice to another context has boosted the quality of health care for the population, reduced care costs, favored professional recognition, and improved users’ access to health systems.¹¹ The strengthening of prenatal care by following safety and resolution criteria has favored adherence to prenatal care.¹¹,¹² This is especially important to maintain the continuous support offered by nurses through the longitudinal bond built, while is performed nursing care focused on women in their social context.¹²-¹⁵

Feeling incapable or with limited professional autonomy is a challenge for nursing care management. Other challenges include coping with communication problems between health services and care teams, bureaucracy in services and lack of adequate human resources.¹³,¹⁵-¹⁷

The literature recommends building the nurse-woman bond, nursing care focused on the social context, and the expansion of nurses’ clinical practice through NCP and Systematization of Nursing Care as important factors to increase the quality of health care.²,¹³-¹⁶ Even with the benefits achieved after implementation of NCP, the municipal management should provide sufficient human and material resources for the expansion proposal, otherwise, the consequence may be work overload for nurses.¹⁴-¹⁷

The Clinical Nursing Protocols are aligned with the unprecedented Brazilian initiative of implementing the Practical Approach to Care Kit (PACK). This kit is a model of care in South Africa and presents recommendations for 40 symptoms and 20 chronic conditions seen in PHC by nurses and physicians, based on the best scientific evidence available. Together with the University of Cape Town (South Africa) and with support of the British Medical Journal of Brazil (BMJ), its content was adapted to the local reality by PHC professionals.¹⁸,¹⁹

Returning to the Theoretical Model, it must be understood in the light of Complex Thought, that is, beyond its structure. Results cannot be understood as cause-and-effect. In a leadership movement, the interactions have incomplete traits in constant evolution. Each action/interaction involves the reorganization of care and of those involved through principles of autonomy and morphogenesis in order to welcome social and practice transformations.⁷,⁸

Although the conditions/contradictions of nurses’ work process are produced by the cultural, social and economic scenario, some actions/interactions are moving components of this dynamic. In feedback, these inputs and outputs of information modulate the search for other actions/interactions needed to achieve a larger goal. As a consequence, outcomes for each condition and action/interaction involved in the process will vary.⁷,⁸

Conclusion

When rescuing the objective of the study, is understood that the meanings of a leadership movement in favor of the expansion of PHC nurses’ clinical practice are related to the resistant posture of some professionals, the inconstant material and human resources, but above all, to the quest for the care essence. Although there are movements against these actions/interactions, understanding the leadership aspect of nursing by focusing on PHC resolution, strengthening FHS teams and opening access to users is part of the role of nurses and the municipal management. In spite of initial tensions and contradictions, the development of clinical behaviors must be persistent by knowing they paradoxically regulate the action of greater strengthening of nursing. The benefits of this expansion of nurses’ clinical practice for users/companions were the following: expansion of access to health services and maternal empowerment. For nursing, the benefits were improvement in the resolution and professional autonomy with positive repercussions for obstetric/neonatal care in PHC. Hence the importance to perform other studies on the subject. The strength of this study was its performance in a municipality that is currently a model for the country. The limitation is that data cannot be generalized to the country as a whole.

Acknowledgements

To the National Council for Scientific and Technological Development (CNPq) for financing the research macro project coordinated by Marli Terezinha Stein Backes and to the Coordination for the Improvement of Higher Education Personnel (CAPES) for granting the Master’s scholarship for Tamiris Scoz Amorim.

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Publication Dates

• Publication in this collection
  12 Aug 2019
• Date of issue
  Jul-Aug 2019

History

• Received
  29 Aug 2018
• Accepted
  16 Apr 2019