Improvement course for obstetric nurses of the Apice On Project: an experience report

Abstract

Objective

to report the practical experience lived in the Obstetric Nurses Improvement Course of the Apice On project of the Ministry of Health.

Method

descriptive study in the experience report modality. The reports were collected from a guiding question in a virtual meeting of the authors.

Results

the reflections were grouped into two main themes: 1) The potential of obstetric nursing and 2) Care as the main element of care.

Conclusion an and Implications for practice

the course is a national strategy of great impact for empowerment visibility of the professional category of Obstetrical Nursing. The improvement enable the participating nurses to acquire practical skills and technical safety, and motivate them to build strategies to overcome obstetric models that are not in line with current scientific recommendations.

Keywords:
Obstetric Nursing; Professional training; Parturition; Nursing Care

Resumo

Objetivo

relatar as experiências práticas vivenciadas no Curso de Aprimoramento para Enfermeiros Obstetras do projeto Apice On do Ministério da Saúde.

Método

estudo descritivo na modalidade relato de experiência. Os relatos foram colhidos a partir de uma pergunta norteadora em um encontro virtual das autoras.

Resultados

as reflexões foram agrupadas em duas principais temáticas: 1) O potencial da Enfermagem Obstétrica e 2) O cuidado como elemento principal da assistência.

Conclusão e Implicações para a prática

o curso é uma estratégia nacional de grande impacto para o empoderamento e visibilidade da categoria profissional da Enfermagem Obstétrica. O aprimoramento possibilitou, às enfermeiras participantes, a aquisição de habilidades práticas e segurança técnica, além de motivá-las à construção de estratégias para a superação dos modelos obstétricos que não estão alinhados às atuais recomendações científicas.

Palavras-chave:
Enfermagem Obstétrica; Capacitação profissional; Parto; Cuidados de Enfermagem

Resumen

Objetivo

reportar las experiencias prácticas vividas en el Curso de Mejoramiento para Enfermeras Obstétricas del proyecto Apice On del Ministerio de Salud.

Método

estudio descriptivo en la modalidad de informe de experiencia. Los informes se recopilaron de una pregunta orientadora en una reunión virtual de los autores.

Resultados

las reflexiones se agruparon en dos temas principales: 1) El potencial de la enfermería obstétrica y 2) El cuidado como elemento principal de la atención.

Conclusión e Implicaciones para la Práctica

el curso es una estrategia nacional de gran impacto para el empoderamiento y la visibilidad de la categoría profesional de Enfermería Obstétrica. La mejora permitió a las enfermeras participantes adquirir habilidades prácticas y seguridad técnica, y motivarlas a desarrollar estrategias para superar los modelos obstétricos que no están en línea con las recomendaciones científicas actuales.

Palabras clave:
Enfermería Obstétrica; Capacitación Profesional; Parto; Atención de Enfermería

INTRODUCTION

The Obstetrics and Neonatology Care and Teaching Improvement and Innovation Project, called Apice On, was an initiative launched in 2017 by the Ministry of Health (MOH), in partnership with several institutions,¹ aimed at the technical qualification of professionals in the fields of care and care at childbirth and birth; reproductive planning; care to women in situations of violence; abortion and legal abortion.²

The program was developed at university and certified teaching hospitals that performed more than 1,000 deliveries between January and December 2015 and adhered to the “Rede Cegonha” strategy, totaling approximately 97 signatory hospitals, distributed in all states of the country and in the Federal District.²

Together with the Rede Cegonha, Adequate Childbirth, the Maternal, Infant and Fetal Death Surveillance Training Program, among others, the project represented one of the MOH initiatives aimed at changing the Brazilian obstetric scenario,³ which has been the target of national and international criticism in recent years due to the high rates of childbirth interventions, cesarean section surgery and obstetric violence.^3,4

Thus, the main objective of Apice On was the implementation and the capillarization of practices based on scientific evidence, among them, the insertion of the figure of the obstetric/obstetrician nurse in direct delivery care.

Within the scope of the Apice On, project, the Obstetric Nurses Improvement Course (CAEO), which has been held since 2013 by the strategy Rede Cegonha,⁵ and which was then funded by the MoH through the Department of Strategic Programmatic Actions (DAPES), Secretariat of Health Care (SAS) and General Coordination of Women's Health (CGSM), in a cooperative action between the MoH and the following Higher Education Institutions (HEIs): Nursing School of the Federal University of Minas Gerais (EE/UFMG); Aurora Afonso Costa Nursing School of the Fluminense Federal University (EEAAC/UFF) and Anna Nery Nursing School of the Federal University of Rio de Janeiro (EEAN/UFRJ), all with experience in conducting the Enhancement Courses for Obstetric Nurses.⁵

CAEO's main objective was to qualify obstetric nurses in care and management processes focusing on delivery and birth care. The course structure included the updating of the technical-scientific knowledge, skills and attitudes of the obstetric nurse for delivery and birth care in various scenarios, such as hospitals, maternities and normal delivery centers.

Therefore, the course represented a driving force for changes in the model of delivery and birth care in the country, to broaden the potential of these professionals performance, returning childbirth to women and their families and transforming the current model of care into a care that respects women's autonomy and protagonism and believes in the physiology of the birth process.²

In the context of the Apice On, ten editions of the referred improvement course were held, which was attended by approximately 80 Obstetric Nursing professionals from all over the country. The authors of this report participated in the 6th, 7th, 8th and 9th editions of the course, which took place between September 2018 and February 2019.

Through the learning acquired at CAEO, the authors felt the need to write this report to share with the academic community the reflections that emerged from this experience, giving visibility to the action-intervention modality of the program, which can serve as an example for other training programs in the health area. In addition, by reporting on the practical experiences of improvement, this report represents a way of propagate successful experiences of Obstetric Nursing, which meets one of the objectives of the project Apice On.Thus, this article aims to report the practical experiences lived in the Improvement Course for Obstetric Nurses of theApice On Project, of the Ministry of Health, which sought the improvement of obstetric and neonatal care by encouraging the qualification of Obstetric Nursing

METHOD

This is an experience report built after the participation of the authors in the Obstetric Nurses Improvement Course of the Apice On Project held at Sofia Feldman Hospital, located in Belo Horizonte-MG.

The experiences of each author during the improvement course, as well as the perceptions and reflections made were explained during a virtual meeting held in February 2019, as the authors are from different states of the country. All reports came from a single guiding question: How was it for you to participate in the Obstetrician Nursing Improvement Course of the Apice On Project?

From the reports, the authors defined two main themes that were named as: A) The potential of Obstetric Nursing and B) Care as the main element of assistance. Each of the themes will be discussed through the interlocution of the lived experiences from the perspective of the improvement course graduates with the respective present concepts of the current literature, in which it is intended to establish a critical and reflective dialogue on the most relevant points highlighted by the authors. Thus, the report of obstetric nurses was based mainly on the guidelines of the MoH, based on the framework of the humanization model of obstetric and neonatal care.

EXPERIENCE RESULTS

Before presenting the results emerging from this experience, the trajectory of the improvements until the effective beginning of the improvement course will be contextualized.

Each obstetric nurse chosen was punctually indicated by the management of their respective workplace and, as a prerequisite for course participation, presented proof of registration of the title of Obstetric Nurse of the Regional Nursing Council of their state. On the other hand, a letter of agreement was signed stating that, after the first stage of improvement, corresponding to the theoretical-practical course, the participating obstetric nurses should be integrated into the Local Strategic Group - GEL of the home institutions to think of ways to insert both good delivery and birth care practices, such as the obstetric nurse in care.

In addition, they made a commitment to hold a Apice On regional outreach seminar to disseminate to the community the experiences of the course and the prospects for changes in the local obstetric scenario, based on a collective construction. Both the participation of obstetric nurses in the GEL (Local Strategic Group) and the construction of the local seminar correspond to the second stage of the improvement, which was monitored in person and virtually through a digital platform by the EEUFMG and HSF (Sofia Feldman Hospital) teams. It is noteworthy that, only after the seminar was held, the participating obstetric nurses received the certificate of completion of the course.

Through all these methodological resources, the course aims at the organization of obstetric and neonatal care through the dialogical process of the exchange of successful experiences and the joint and horizontal reflection of care planning.

In structural terms, the course is held in the city of Belo Horizonte-MG, in a 14-day immersion period, and has a robust workload of 132 hours, with 96 hours of practical activities, distributed in 12-hour shifts at Sofia Feldman Hospital (HSF), and 32h of theoretical activities.⁵

The course's improving nurses performed shifts at HSF in the following sectors: Emergency Care Unit (ECU); Induction Prepartum (IPP); Normal Birth Inpatient Center Helena Greco; Peri-Hospital Normal Birth Center Doctor David Capistrano (Birth House); Pregnant Woman's House; Integrative Practice Center and Joint Accommodation Unit.

From the reports of the experiences lived by the authors, two main themes were designed to be presented below: 1) The potential of Obstetric Nursing and 2) Care as the main element of assistance.

A - The potential of Obstetric Nursing

Although there are still several obstacles to be overcome, Obstetric Nursing is a professional category that has been gaining visibility, gaining space and making great advances in recent decades. There are still few places in Brazil that recognize the impact, in terms of quality, of the insertion of the obstetric nurse in the care of women in the pregnancy-puerperal period, as occurs in Sofia Feldman Hospital, even with a vast national and international literary production to support this working model.^6-11

In HSF emergency care, for example, women are initially treated by a generalist nurse responsible for risk reception and assessment (R&A). The R&A in Obstetrics is governed by the principle of equity of the SUS (Unify Health System), favors the organization of the entrance doors of emergency services in Obstetrics through qualified listening and reception and represents a working process supporting the clinical decision to identify, as early as possible, of the critical or more severe pregnant woman, prioritizing their care.¹²

After going through the R&A with the generalist nurse, the woman is then attended by an obstetric nurse (ON), who conducts a full Nursing consultation, including anamnesis, physical and obstetric examination, clarification of doubts, exchange of knowledge and, finally, the decision regarding the outcome of the service: hospitalization, reevaluation or discharge from the service. According to the authors, this form of work is successful because it values the autonomy and potential of obstetric nurses, favors multi-professional work and, above all, responds to what the National Humanization Policy¹³ calls as a warm, resolute and human attention.

At the Helena Greco Normal Birth Center, which is configured as an in-hospital type II ANC,¹⁴ a solid use of good delivery and birth care practices by obstetric nurses was envisaged as recommended by current national and international guidelines,^15-17 such as: free ambulation; active participation of the companion during all stages of labor; massive use of non-pharmacological pain relief methods; freedom of position and encouragement of vertical positions to give birth; oral nutrition and hydration throughout the entire period of labor and immediate postpartum, as well as horizontal relationships between women and health professionals, dialogue and effective participation of women in the decisions to be taken.

Thus, the authors noted a strong alignment of the care offered by obstetric nurses with recent recommended scientific evidence, which translates into safe care and good maternal and neonatal outcomes. It was noticed that the alignment between practice and theory is fundamental to ensure solidity to the performance of obstetric nurses, as well as favoring a satisfactory experience of care for women and their families, as recommended by the World Health Organization.¹⁷

In addition to the excellent care offered by obstetric nurses to women during labor, delivery and postpartum, the authors observed a comprehensive and very sensitive attention to the newborn, which is taken care of by the same team that accompanied him throughout the birth process. Thus, obstetric nurses strive to ensure that the healthy newborn is always in direct skin-to-skin contact with its mother and, following the recommendations of the Brazilian Society of Pediatrics, to have the cord clamped in time, pass its period of alert inactivity in the womb, without external interference, and be encouraged to breastfeed in the first hour of life.¹⁸

Another prominent environment in the performance of obstetric nurses that could be observed by the authors during the course is the David Capistrano Normal Birth Center, which is classified as a peri-hospital ANC because it is located adjacent to the hospital.¹⁴ This unit is fully managed by the obstetric nurse, as regulated by Resolution COFEN No. 0478/2015, which regulates the performance and civil responsibility of the obstetric nurse and obstetrician in the Normal Birth Centers and/or Nursing Birth Houses.¹⁹ The number of activities that make up the scope of the obstetric nurse's work in this sector is a demonstration of the potential of this category, since all stages, such as admission, assistance to labor and delivery, puerperium and discharge of the mother and newborn are performed by this professional.

By following the work performed by obstetric nurses in the sectors mentioned above, it was possible to realize the multiplicity of actions that this category is qualified to perform and how much the service and society can benefit from this work.

In the case of HSF obstetric nurses, there was a wide clinical expertise to perform different activities, some still pioneering throughout the country, such as postpartum IUD insertion,²⁰ the performance of obstetric ultrasonography and the various clinical examinations of the newborn performed by other professionals in the authors' origin hospitals. In addition, there is safety in performing these activities among obstetric nurses, who demonstrate theoretical knowledge and adequate training to interpret clinical situations and make decisions in a timely manner, favoring an efficient, safe and resolute outcome.

This professional qualification observed, according to the authors, is one of the pillars to promote a solid insertion of obstetric nurses in the direct care at birth throughout the country and, consequently, contribute to the improvement of maternal and neonatal indicators, since the literature shows that evidence-based professional qualification, coupled with the appropriate use of technologies, has a strong impact on the promotion of effective, humanized and individualized care.⁸

In contrast, some studies demonstrate the difficulty of insertion and performance of obstetric nurses in care throughout the country related to various factors, such as the lack of theoretical knowledge, lack of practical experience and the dispute over space with the medical team.^21,22

In view of this aspect, it is questioned that the other pillar that facilitates the insertion of these professionals is related to the development of ethical-political competence, of great importance for obstetric nurses in facing care practice, which transcends technical skills.²²

This is because, when inserted in a traditional practice environment, obstetric nurses end up being disadvantaged in their care and are often obliged to reproduce an interventionist biomedical model of action, with the use of discouraged and/or harmful practices.²³

The literature shows that where there is effective performance of Obstetric Nursing in the care of women/family/companion at the moment of delivery and birth, there is greater adherence to best practices and based on scientific evidence, for both women and newborns,^9,24 and this aspect was observed during the enhancement course. These data converge with studies that affirm the impact of nurses' performance on the birth scenario, highlighting the differential of this category in facilitating the implementation of new working models²⁵ and implementation of the concepts present in the Childbirth Humanization National Policy, which also reiterates evidence-based practice.^{6-11,21-23,25}

According to the WHO, obstetric nurses are the most appropriate professionals for the monitoring of pregnancies and normal deliveries because they have less interventionist characteristics in their care.²⁵ The authors noted that they guide their practical activities from the physiology of childbirth and thus act by encouraging women to live this experience. In addition, a recent report by the Pan American Health Organization, in conjunction with WHO and the International Confederation of Midwives (ICM), on the “State of Obstetric Nursing in the World,” concluded that these professionals can exercise 90% of essential care for women and newborns and thus can contribute to reducing the number of maternal deaths by two thirds. According to the report, the inclusion of obstetric nurses in the services represents a key element for sexual, reproductive, maternal and neonatal health care.²⁶

It was also observed that, in addition to their technical capacity, obstetric nurses act in a proactive, committed posture, with strong involvement and responsibility with women and the community, which strengthens the safety of users in the institution. The results from this work model are proven by the good indicators that the institution presents and perceived by the satisfaction reported by the users and their companions during the daily meetings promoted by the HSF team and the voluntary ombudsman team. This finding is reaffirmed by the latest Cochrane review, which points out that the care model offered by obstetric nurses, besides having fewer interventions, raises a higher level of satisfaction from its users.⁶

B - Care as the main element of assistance

During the course, it was realized that the HSF seeks to maintain its working philosophy in its entirety even in the face of budgetary difficulties that are a major financial crisis facing the institution a few years ago. It was noted that the hospital facilities are simple and a large part of the furniture/equipment is in poor condition.

Although this situation is not appropriate for a health service, it was noted that the essence of care offered by obstetric nurses and other teams remains effective in daily life. During the course, it was possible to understand that, even in the face of structural adversities, what keeps the hospital running is the collective desire to keep it running, without harming the community.

Through the conversations and reflections promoted by the course, it was realized that both obstetric nurses and other professionals working at HSF believe and recognize the greatness of their work and the impact it has on society. Thus, it was observed that, despite the adverse working conditions, the care offered can remain excellent if care is the main element of the assistance offered.

An example of this is the HSF Center for Integrative and Complementary Practices, a pioneering service in the country whose goal is to provide extended care to traditional obstetric care that is offered to women. In this simple but innovative environment, the following services are offered: auriculotherapy; homeopathy; florals; reiki; reflexology; music therapy; aromatherapy; moxibustion; suckers; herbal tea and foot baths, among others. Pregnant women hospitalized for clinical treatment or parturient in early labor can move to the nucleus and receive one or more of the offered practices, favoring relaxation, decreased anxiety and natural stimulus to labor.

The core practices are also aimed at hospital health professionals and women who will not give birth at the HSF or who undergo prenatal care in the supplementary network, which shows that the hospital's philosophy seriously honors the SUS’s principle of universality.

The authors realized that, in this model of care, women feel more cared for and welcomed, overcoming the structural and aesthetic issue of the service.In addition, it is noted that obstetric nurses build horizontal relationships with woman/families based on respect, equality and affection. Thus, by prioritizing care as the main element of assistance, the quality of care remains, the role of the obstetric nurse is recognized and the hospital remains a national reference for humanized childbirth care services.

Another important aspect that praises care as the main element of obstetric assistance offered in this service could be glimpsed in the work process of the in-hospital ANC. In this place, obstetric nurses work in a 1:1 care model, that is, an obstetric nurse attending exclusively to a woman. Thus, a professional is not expected to enter the PPP of another woman she is not following, without express need.

It was noticed that this form of work ensures that care is provided by the same professional, allowing full monitoring of labor, in addition to establishing a true bond between woman/family/professional, which facilitates a relationship of trust, guarantees the right to privacy and, consequently, substantially impacts the quality of care offered.

Since HSF is an internship field for medical residency and Obstetric Nursing, students begin the practical activities inserted in this singular model of care, deconstructing two main conceptions of the present day: 1) that the quality of learning is directly related to the amount of procedures and deliveries they will attend and 2) that the practice of procedures solely for teaching purposes does not constitute human rights violence.²⁷

This quantitative conception of procedures to be performed by students of residency courses was not perceived by the authors in the HSF. However, the traditional teaching of Obstetrics in most institutionsin Brazil requires that the student perform a number of procedures in order to be assessed, which leads to a culture of teaching the uninformed and unenforceable use of parturient women, especially the most vulnerable women, such as those with lower incomes and SUS users, by medical students and other professions, to train their surgical skills.²⁷

In this context, the abuse is perpetuated through an institutional culture that does not recognize students as rights violators, promoting a teaching of skills detached from the teaching of users' values and rights,²⁷ which, according to the authors’ perspective, does not happen in the HSF.

Abuses committed against women in labor, as consistently presented in the literature,^4,27-30 reflect a society in which the normalization and impunity of abusive access to the female body persists, reproducing social hierarchies of gender, class and race/ethnicity.²⁷ It has been noted that this is not the reality of teaching in HSF medical residency and Obstetric Nursing courses, which is why these courses should gain broad visibility and serve as a reference for others educational institutions.

In addition, health services that already offer respectful maternal care, free from abuse, disrespect and mistreatment, wich promote the participation of women and communities, and have implemented processes to continuously monitor and improve respectful obstetricians care also need to be identified, researched and documented, according to WHO.³⁰

The authors realized that the full monitoring of the parturition process offered by obstetric nurses in the HSF, from its onset until its realization, is facilitated by the unique look to women. The professional, immersed in this context, is allowed to observe the behaviors/expressions of women in each phase of labor and delivery, in addition to identifying the emotional aspects and needs of the parturient and her family, which far exceeds the technical skills. This model of care, based on the concept of humanization,⁷ in which the rights of users are in the prime of all attention, exponentially qualifies the residency courses that are developed there as they promote teaching of skills in sync with the teaching of values, ethics and users' rights.²⁷

Finally, the authors understood that this teaching-care model denaturalizes the view that health professionals have the right to freely access women's bodies, without their informed consent, to perform any practice in obstetric care.²⁷ Thus, the course concluded with the clear conviction that a work model centered on comprehensive care, such as the one offered at HSF, is feasible even in teaching hospitals and/or with few structural resources.

To foster these discussions, an important work on WHO childbirth care was launched entitled WHO recommendations: intrapartum care for positive childbirth experience. This paper summarizes the model practiced by HSF obstetric nurses: childbirth and birth as a positive experience and permeated by a holistic approach based on human rights and supported by scientific evidence.¹⁷

FINAL CONSIDERATIONS

The experience of HSF during the improvement course offered by the initiative Apice On was very rich in contemplating several innovative aspects related to the care, management and model of work/care for labor practiced at this institution. In addition to the technical qualifications offered to participants, the course promotes a reflection on the current obstetric scenario and teaching in Obstetrics, which is reproduced when technicism is normalized and individual care is ignored as the main guiding element of care.

From the perspective of the authors, CAEO re-signifies and broadens the participants' view of the role of obstetric nurses in assisting women, especially in the delivery and birth component. The improvement experience favored the learning of a rich theoretical and practical collection, both absorbed from the in loco experience, participant observation and discussions, highlighting the potential of Obstetric Nursing and impact on the quality of care offered to women.

This experience represented an empowering tool for the participating nurses, who returned to the origin services more technically confident, and strengthened to suggest changes in the model previously established.

It is known that the institution in question is a model service for the respectful care of parturient women and that most maternal and child care services in the country still have to go a long way to approach the work and teaching process that is reproduced in HSF Therefore, it is assumed that this report may encourage other obstetric nurses, especially those professionals who are placed in precarious obstetric care units and who need a stimulus to believe that it is possible to offer respectful, loving, integral-care-centered care and sustained by the scientific evidences, as it was glimpsed in the institution that hosted the improvement course.

Thus, it is considered that the improvement course represented a tool that empowers the Obstetric Nursing category as it highlights the potential of these professionals to build a solid, safe, effective, resolute and clearly satisfactory work model to users. In addition, it raises, among its participants, reflections on the limiting/proscribed models that are in force in most hospitals and maternity hospitals in Brazil and stimulate the design of practical strategies to overcome them.

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Edited by

ASSOCIATED EDITOR

Rafael Celestino da Silva

Publication Dates

• Publication in this collection
  013 Mar 2020
• Date of issue
  2020

History

• Received
  19 July 2019
• Accepted
  18 Dec 2019