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Training in the obstetric nursing residency modality: a hermeneutic-dialectic analysisa a Article extracted from a doctoral thesis “A práxis da enfermeira obstétrica na assistência à mulher no processo parturitivo”, defended in the Stricto Sensu Graduate Program of the Escola de Enfermagem Anna Nery at Universidade Federal do Rio de Janeiro by the author Giuliana Fernandes e Silva, under the guidance of Ph.D. Professor Maria Aparecida Vasconcelos Moura in 2019.

ABSTRACT

Objective

To analyze the conceptions of post-graduate obstetric nurses from the residency course on the training and practice in normal childbirth care.

Method

Qualitative, descriptive and exploratory research with 13 obstetric nurses in two public maternity hospitals in Rio de Janeiro, Brazil. Data collected by individual, semi-structured interview and hermeneutic-dialectic analysis.

Results

Despite the contradictions and dichotomies present in the training process, it was found that there was a breakthrough in knowledge and professional practice, which enabled the constitution of an integrative obstetric praxis, aware of the humanized principles in normal childbirth care, supporting the creation of new paths for obstetric nurses.

Conclusion and implications for practice

Residency training generated security for nurses in their care praxis, contributing to the social, cultural and political reformulation of the interventionist obstetric model. Residency involves a new and challenging training modality for nursing care in this area, requiring specific and ethical knowledge. The study highlights the need for the inclusion of post-graduate obstetric nurses in the practice of usual risk childbirth care, expanding the field of action of these professionals.

Keywords:
Women’s health; Obstetric Nurses; Natural childbirth; Education in Nursing

RESUMO

Objetivo

Analisar as concepções das enfermeiras obstétricas egressas do curso de residência sobre a formação e prática na assistência ao parto normal.

Método

Pesquisa qualitativa, descritiva e exploratória, realizada com 13 enfermeiras obstétricas em duas maternidades públicas do Rio de Janeiro, Brasil. Os dados foram coletados por meio de entrevista individual, semiestruturada e análise hermenêutico-dialética.

Resultados

Apesar dos contrassensos e dicotomias presentes no processo de formação, verificou-se nos depoimentos que houve superação no conhecimento e na prática profissional, que possibilitou a constituição de uma práxis obstétrica integradora, consciente dos princípios humanizados na assistência ao parto normal, sustentando a construção de novos caminhos para a enfermagem obstétrica.

Conclusão e implicações para a prática

A formação na residência promoveu segurança às enfermeiras, em sua práxis assistencial, contribuindo para a reformulação social, cultural e política do modelo obstétrico intervencionista. A residência envolve uma nova e desafiadora modalidade de formação para o cuidado de enfermagem na área, exigindo conhecimento específico e ético. O estudo evidencia a necessidade de inserção das enfermeiras obstétricas egressas na prática da assistência ao parto de risco habitual, ampliando o espaço de atuação dessas profissionais.

Palavras-chave:
Saúde da Mulher; Enfermeiras obstétricas; Parto normal; Educação em Enfermagem

RESUMEN

Objetivo

Analizar las concepciones de las enfermeras obstétricas egresadas del curso de residencia sobre la formación y práctica en la asistencia al parto normal.

Método

Investigación cualitativa, descriptiva y exploratoria con 13 enfermeras obstétricas en dos maternidades públicas de Rio de Janeiro, Brasil. Datos recopilados por medio de entrevista individual, semiestructurada y análisis hermenéutico-dialéctico.

Resultados

A pesar de las contradicciones y dicotomías presentes en el proceso de formación, se verificó que hubo superación en el conocimiento y en la práctica profesional, lo que posibilitó la constitución de una praxis obstétrica integradora, consciente de los principios humanizados en la asistencia al parto normal, apoyando la construcción de nuevos caminos para la enfermería obstétrica.

Conclusión e implicaciones para la práctica

La formación en residencia fomentó seguridad a las enfermeras en su praxis asistencial, contribuyendo a la reformulación social, cultural y política del modelo obstétrico intervencionista. La residencia implica una nueva y desafiante modalidad de capacitación para el cuidado de enfermería en el área, y requiere un conocimiento específico y ético. El estudio destaca la necesidad de la inclusión de las enfermeras obstétricas egresadas en la práctica de la asistencia al parto de riesgo habitual, ampliando el espacio de actuación de estas profesionales.

Palabras clave:
Salud de la Mujer; Enfermeras obstetras; Parto normal; Educación en Enfermería

INTRODUCTION

The predominant interventionist model in hospitals of the Brazilian Unified Health System contributes to building the perception of labor and delivery as situations with potential risks to the health of the woman and the child11 Santos AHL, Nicácio MC, Pereira ALF, Oliveira TCM, Progianti JM. Las prácticas de asistencia al parto normal: formación en la modalidad de residência. Rev Enferm UFPE [Internet]. 2017; [citado 2018 set 10];11(1):1-9. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/11871/14318
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. Unnecessary interventions and technologies – with emphasis on amniotomy, intravenous infusion of synthetic oxytocin, intrapartum analgesia, episiotomy and Kristeller’s maneuver – are still constant procedures in health services for women with healthy pregnancies22 Vargens OMDC, Silva ACVD, Progianti JM. The contribution of nurse midwives to consolidating humanized childbirth in maternity hospitals in Rio de Janeiro-Brazil. Esc Anna Nery. 2017;21(1):1-8. http://dx.doi.org/10.5935/1414-8145.20170015.
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. Currently, more than half of the births that occur are the result of caesarean sections (55.4%), with only 15% of these women indicating surgical intervention. As a result, more than 40% of these cesarean sections could be avoided through actions recommended by health policies. Such a situation can result in a greater number of damages in relation to benefits, favoring the high rates of cesarean sections in the country33 Aquino EML. Reinventing delivery and childbirth in Brazil: back to the future. Cad Saude Publica. 2014;30(Supl 1):S1-3. PMid:25167193., since their possible discomforts and adverse effects are disregarded in the decision-making process about the type of delivery.44 Medeiros RMK, Teixeira RC, Nicolini AB, Alvares AS, Corrêa ACP, Martins DP. Humanized care: insertion of obstetric nurses in a teaching hospital. Rev Bras Enferm. 2016;69(6):1091-8. PMid:27925085.

In view of the above, the Ministries of Health and Education published normative documents in order to institute policies and programs to qualify obstetric care, encourage normal birth and female protagonism, stimulating the performance of obstetric nurses55 Pereira ALF, Guimarães JCN, Nicácio MC, Batista DBS, Mouta RJO, Prata JA. Perceptions of nurse-midwives of their residency training and professional practice. Rev Min Enferm. 2018;22:1-8. http://dx.doi.org/10.5935/1415-2762.20180035.
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. Within the scope of these actions and the policy of reorienting health workers – especially for the strategic areas of the UHS –, in 2012 the Ministry of Health promoted the training of obstetric nurses through the creation of the Programa Nacional de Residência em Enfermagem Obstétrica – PRONAENF (National Residency Program in Obstetric Nursing, in free translation), in partnership with the Ministry of Education and Culture (MEC). PRONAENF aims to train specialists in the residency modality, to work in women’s health care in the processes of reproductive health, prenatal care, childbirth and birth, the puerperium and the family, guided by the health policies in force in the UHS.55 Pereira ALF, Guimarães JCN, Nicácio MC, Batista DBS, Mouta RJO, Prata JA. Perceptions of nurse-midwives of their residency training and professional practice. Rev Min Enferm. 2018;22:1-8. http://dx.doi.org/10.5935/1415-2762.20180035.
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The residency modality is characterized by training through work as a teaching-learning strategy, and aims to train health professionals with a view to overcoming the segmentation of knowledge and care in health care. The motivations for its creation are related to health policies that attempt to modify the medicalized obstetric model in services, for the institution of humanized care, the encouragement of normal childbirth and better quality indicators in maternal and neonatal care55 Pereira ALF, Guimarães JCN, Nicácio MC, Batista DBS, Mouta RJO, Prata JA. Perceptions of nurse-midwives of their residency training and professional practice. Rev Min Enferm. 2018;22:1-8. http://dx.doi.org/10.5935/1415-2762.20180035.
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. Therefore, the training of the obstetric nurse in this modality seeks to contemplate the technical-scientific recommendations for the promotion of humanized care, and the training of professionals attentive to the rights to health and the needs of the clientele11 Santos AHL, Nicácio MC, Pereira ALF, Oliveira TCM, Progianti JM. Las prácticas de asistencia al parto normal: formación en la modalidad de residência. Rev Enferm UFPE [Internet]. 2017; [citado 2018 set 10];11(1):1-9. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/11871/14318
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. In this context, the obstetric nurse came to be recognized for reinventing relationships less unequal and adding demedicalized knowledge about the physiology of childbirth.22 Vargens OMDC, Silva ACVD, Progianti JM. The contribution of nurse midwives to consolidating humanized childbirth in maternity hospitals in Rio de Janeiro-Brazil. Esc Anna Nery. 2017;21(1):1-8. http://dx.doi.org/10.5935/1414-8145.20170015.
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Despite this incentive, one of the main challenges faced in the teaching of Obstetric Nursing occurs from the contradiction between the guiding paradigm of the curriculum based on the humanization of care and the dominant, interventionist and medicalized care paradigm. This conflict can interfere with the quality of training of the obstetric nurse, especially with regard to assistance to normal birth.66 Pereira ALF, Mouta RJO, Barbosa DSP. El proceso de creación del curso de especialización en Enfermería Obstétrica, modalidad de residencia, en la red municipal de salud de Rio de Janeiro, Brasil. Cul Cuid. 2018;22(51):114-23. http://dx.doi.org/10.14198/cuid.2018.51.13.
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Consequently, the challenges to overcome harmful interventions and practices and to consolidate the model of humanized assistance in the obstetric area persist77 Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Practices in childbirth care in maternity with inclusion of obstetric nurses in Belo Horizonte, Minas Gerais. Esc Anna Nery. 2016;20(2):324-31. http://dx.doi.org/10.5935/1414-8145.20160044.
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, as well as to achieve a care practice that contemplates women as the protagonist of childbirth, stimulates the physiological process of giving birth and being born, and understand the uniqueness of each woman, her rights, beliefs and values.

Studies88 Santana AT, Felzemburgh RDM, Couto TM, Pereira LP. Performance of resident nurses in obstetrics on childbirth care. Rev Bras Saúde Mater Infant. 2019;19(1):135-44. http://dx.doi.org/10.1590/1806-93042019000100008.
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,99 Edmonds JK, O’Hara M, Clarke SP, Shah NT. Variation in cesarean birth rates by labor and delivery nurses. J Obstet Gynecol Neonatal Nurs. 2017;46(4):486-93. http://dx.doi.org/10.1016/j.jogn.2017.03.009. PMid:28549612.
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on the practice of obstetric nurses in the care of normal childbirth are focused on the experiences of these professionals in health services and the rates of deliveries performed, presenting the impact of obstetric residency and the knowledge applied in a quantitative approach. Despite its importance, there is still a gap in qualitative research that links the knowledge acquired in the obstetric residency course to the professional practice of nurses in normal childbirth. This study aimed to analyze the conceptions of obstetric nurses who graduated from the residency course on the training and practice in assisting normal childbirth.

METHOD

Qualitative research, of analytical nature, whose data production took place from October 2016 to March 2017, with 13 nurses graduated from obstetric residency programs, who worked in public maternity hospitals located in the city of Rio de Janeiro, Brazil. The participants, at the time of the interview, reported having, on average, four years of training.

The choice of the research scenario being maternity hospitals considered the insertion and professional performance of these nurses in the assistance for childbirth of usual risk, and because they constitute a practical field of training for residency courses. Such scenarios present a movement that is characterized by the expansion of this experience in several units, requiring investment in the qualification and distribution of the professionals’ workforce, outlining a care network with the insertion of obstetric nurses who graduated from residency courses. These maternities are for high, medium and low complexity care.

In one of the maternity hospitals, with a universe of 20 professionals, distributed in the reception and delivery room sectors, nine were graduates of the specialization course in the residency modality. In the other maternity hospital, 10 professionals worked in the delivery room and had a direct link with the maternity hospital; and of these, four were graduates of the residency course and accepted to participate in the present investigation. The reception/risk classification sector was managed by a Social Organization and had a different workload and working hours than nurses working in the delivery room. It is worth clarifying that the care provided at the reception/emergency room where nurses performed their activities, also met the demand for urgent mobile transport, part of the Cegonha Carioca Program (Stork Program, in free translation). This transport refers to obstetric ambulances, which aim to remove pregnant women in labor, registered in the program, to the reference maternity.

The inclusion criteria were obstetric nurses who graduated from the residency course, trained after the creation and incentive from PRONAENF, in 2012, and worked as statutory public servants or private sector workers in the same field. As exclusion criteria, were established nurses who performed activities of head of the unit and/or were in a situation of leave from assistance activities. The recruitment process took place with the presentation of the researcher at all maternity service scales. The research proposal and the research objectives were presented, inviting nurses who met the established criteria. The determination for the end of data collection occurred when the list of all obstetric nurses graduated from the residency course, working in the two selected maternity hospitals, was finalized.

The collection of information took place in person, through an individual interview, at the Obstetric Inpatient Unit, in a private room and prior appointment with each participant. A semi-structured instrument was used, consisting of six closed questions regarding the characterization of the socio-professional profile, and four open questions about the process of training obstetric nurses and their care practice in childbirth care.

Data analysis occurred through the identification of the empirical material collected, with a fluctuating reading of the interviews. Subsequently, data were classified with identification of the central ideas and reading of each corpus of communication, forming the categories of analysis. Afterwards, there was a confrontation between the different groups and the construction of data based on the theoretical assumptions of the hermeneutic-dialectic analysis.

Hermeneutics is the basic discipline that deals with the art of understanding texts, seeks understanding and interpretation, while the dialectical method introduces the principle of conflict and contradiction as constitutive of reality essential for analytical understanding1010 Taquette SR, Minayo MC. An analysis of articles on qualitative studies conducted by doctors published in scientific journals in Brazil between 2004 and 2013. Physis. 2017;27(2):357-74. http://dx.doi.org/10.1590/s0103-73312017000200010.
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. The synthesis of comprehensive and critical processes was performed, the communication of professional life and daily practice and common sense were worked, from which two categories emerged.

The research was approved by the Research Ethics Committees of the Escola de Enfermagem Anna Nery (Nursing School) and Instituto de Atenção à Saúde São Francisco de Assis (Health Care Institute), Universidade Federal do Rio de Janeiro (CEP/EEAN/HESFA/UFRJ), and the Municipal Health Secretariat (SMS-RJ), by means of Opinions No. 1,472,357 and No. 1,506,514, in April 2016. The letter N (Nurse) was used to guarantee data confidentiality and the numerical number corresponding to the order of the interview, in order to identify the participants while preserving their anonymity.

RESULTS

The participants presented a profile in line with the period of greatest professional productivity. It is noteworthy that all were women, aged between 26 and 36 years, and most were married. They reported their insertion in the labor market right after residency in a service with assistance for normal childbirth. Investment was observed on the quality of care in their training for the health of women and children, through the search for specific qualifications, after professional training in obstetrics. Among these, eight took other training courses in the area in relation to labor and birth, emphasizing the search for knowledge and updating. These results enabled an analysis of the conceptions of obstetric nurses in relation to their practice in assisting normal childbirth, in the context of the training of residents, from which two categories emerged.

The dialectical relationship between theory and practice in the training of obstetric nurses in the residency modality

In the dialectical relationship between theory and practice in the training of obstetric nurses, the interviewees (N1 and N5) reported that the theoretical approach was centered on the humanization of care and on gender issues. They considered the focus of this training to be outdated, highlighting the need to seek greater evidence in extracurricular activities about care technologies and the physiology of childbirth.

I miss the classes on childbirth physiology, we learned from the preceptors about path, dilation, touch, shortening and we looked for theory in articles, courses and congresses, in addition to classes taught on gender and humanization. (N5)

It has a lot of practice, but the theory is outdated, that was a complaint from the whole class. New care technologies and scientific evidence are learned from the outside. (N1)

The tensions between theory and practice were recurrent during the training of nurses, considering the divergences between the theoretical and practical content, and the practical experiences of the units where they were allocated. In another register, the interviewee reinterpreted the theory as obsolete, and presented the transition between curricula as something negative to professional training.

I had no theory that would offer a basis for the practice, it was out dated. At the time, there was the matter of whether to learn episiotomy or not, because the curriculum was against teaching episiotomy. We were in the transition phase of scientific evidence and they did not teach the cut [the episiotomy] to our class. (N4)

In addition to internal tensions during training, nurses revealed an issue of territorial space, which involved the dispute over the scenario of training in normal childbirth care with medical residents, making it difficult to carry out the systematic plan of nursing care prescribed to the parturients. The difficulties in this relationship between knowledge and the care process, as well as the already established professional relationships, showed conflicts in the nurses’ daily practice.

We had problems in relation to the medical teams. I had to take certain precautions with the patient that we were monitoring, because, if I left, they [the doctors] would take measures without communicating. (N6)

The problem in the delivery room was medical residents; if we left the place for a little while, when someone came back, someone was already intervening in the parturient, and this affected our plan and assistance in our daily work. (N5)

Despite these tensions, it is noteworthy that four graduates assessed the diversity of professionals in the residency course as something that favored the awareness of their worldviews, to build a professional identity capable of applying theoretical knowledge to a divergent reality. They emphasized the number of practical hours as an enricher in the process of training developing, enabling the acquisition of greater experiences.

The good thing about the residency is that it shows the diversity of professionals that teach, you learn a lot with each one and take the best that each professional/tutor has and shape your assistance profile. (N7)

I consider my training to be rich because it was like a residency; we had the opportunity to acquire theoretical knowledge with the teachers; and the practical part, in maternity hospitals we were able to deal directly with reality. The large practical workload provided an opportunity to think and learn (N9)

The nurses pointed out the diversity of professionals and/or preceptors in the course, and also reported that they learned and explored each one of them, in teaching and training, taking their experience to the practice of assisting normal birth. They considered the training to be rich, sought the experiences of the reality of the practice scenario and the extension of the content, improving and qualifying their assistance in the process of labor and birth.

Contributions of the training of obstetric nurses graduated from the residency to the practice of the specialty

Above the occasional divergences, the testimonies converged on the importance of training in the residency modality and its performance, the contributions to the insertion in the labor market and the way to overcome the interventionist model. Despite the common confrontations in the training, the obstetric nurses emphasized the influence of this critical knowledge for the practice and the professional attitude, seeking the constitution of their praxis.

The residency opened doors, all the jobs I have were due to this training. It was the foundation of my knowledge; the rest I went shaping in practice. This base made it possible for me to exercise a practice based on the physiology of childbirth. (N2)

I had every basis of what I do today, which is humanized assistance in childbirth. Everything I learned at the residency I can apply in my life, and they were essential. (N3)

All my graduation and residency training culminated for the professional I am today; I achieved autonomy and security, reconciling residency and work. (N6)

Nurses highlighted the importance of the training modality in residency with the movement between theory and practice, providing a foundation for knowledge and sustaining practice in the concepts of childbirth physiology. They reinforced learning in childbirth care, enabling the different experiences lived in this scenario as essential to their autonomy and professional safety in the area. During the training, they also demonstrated new attitudes in the performance of assistance adhering to the humanized model.

A lot of work was done on gender and humanization, theoretical points and our way of thinking was modified so that the practice was different, and not the same as that of the other professionals on the team. The theory in the residence was guided by discussions to change the way of attending what is found in the maternity ward. (N7)

The training from the residency was essential, I learned midwifery, another post-graduation doesn’t give the practical and theoretical know-how that we have. They [teachers] taught the protocols in face of what the Ministry of Health advocated. We are not always able to put the acquired knowledge into practice, but we are bearers of humanized and demedicalized training. (N10)

We spent all the time there and managed to work with the woman, because we created a bond and stayed until the moment of giving birth. (N6)

This training contributed to an assistance that prioritizes the creation of bonds with the pregnant woman, respecting the particularity and individuality of each woman. The reports show the enthusiasm and satisfaction of how the content was worked – especially in terms of gender and humanization –, and point out how they contributed to changing the way of thinking and acting, seeking to exercise a differentiated practice. They emphasized that the discussions enabled changes in their concepts in the way of assisting, knowing/doing the practice of midwifery, considering the acquired knowledge responsible for humanized and demedicalized training. They emphasized that the basis of humanized and comprehensive care was the differential for comprehensive care for parturient women in the pregnancy-puerperal cycle.

DISCUSSION

The profile of the obstetric nurse trained in the residency modality is one of leadership, excels in the search for autonomy and commitment, in addition to scientific knowledge to support the practice sustained by scientific evidence. This movement occurred spontaneously and as they identified needs during the monitoring of labor and delivery, invested in the professional training received at the residency.

This profile is presented in a construction of new knowledge, with the purpose of demarcating a space of changes in the obstetric scenario, and makes it possible to rescue the humanization of assistance through the physiological process of giving birth and being born. In practice, it allows them to perform their actions responsibly, through professional practice in the praxis of care, in order to meet the demands of health policies and the reproductive demand of women in the Unified Health System.

When analyzing the testimonies, a dialectical unity was observed in the professional training of the obstetric nurse, in which the theoretical content guided by humanization was re-signified as fragility to the participants, immersed in the hegemonic paradigm centered on the basic science of biology. Such nurses, once inserted in the care for normal hospital birth, there were ambivalences and contradictions in the theoretical-practical relationship of their professional training.

The nurses established an analogy between the lack of specific content in the course and its impact on activities in the practical field even during professional training. This difficulty in integrating theory and practice may have been influenced by the distance between teachers and preceptors. However, such difficulty is multifactorial and involves a scenario of greater complexity in social, academic and professional structures.

The dissociation of theory and practice causes a paradox in the training process. It imprints that the pedagogical work in the residency presents difficulties to carry out teaching in service as a theoretical-practical activity, and suggests the need to establish integrating strategies between the service and academy scenarios. Health education must be based on a teaching project that promotes the development of skills to contribute to society’s health needs.

In addition, in-service education comprises a professional socialization process with repercussions on work and career retention. This fact means that the practice corresponds to a transitional period in which the professional works together with a teacher, preceptor or tutor in a real work environment, which promotes the acquisition of a large volume of learning from the interaction with professionals who develop diversified assistance practices.1111 Kramer M, Maguire P, Halfer D, Brewer B, Schmalenberg C. Impact of residency programs on professional socialization of newly licensed registered nurses. West J Nurs Res. 2013;35(4):459-96. http://dx.doi.org/10.1177/0193945911415555. PMid:21816962.
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In this understanding, the importance of this type of professional training and the need to implement the changes arising from the evaluation of the residency courses, which stimulate the improvement of the quality of care is highlighted.

On the other hand, the proposal to humanize childbirth comes to recognize the autonomy of women as human beings, and the need to treat this moment with practices that, in fact, have evidence and allow to increase the security and well-being of the binomial. The new proposal by the Ministry of Health of humanization in childbirth care establishes changes in relation to access, assistance, quality and resolution, and aims to make the experience of pregnancy more humanized and less technical1212 Pereira RM, Fonseca GO, Pereira ACCC, Gonçalves GA, Mafra RA. New childbirth practices and the challenges for the humanization of health care in southern and southeastern Brazil. Cien Saude Colet. 2018;23(11):3517-24. http://dx.doi.org/10.1590/1413-812320182311.07832016. PMid:30427425.
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. Humanized care makes it possible to articulate scientific and technical quality with an ethical stance of respect for the need and uniqueness of each person of care in action.55 Pereira ALF, Guimarães JCN, Nicácio MC, Batista DBS, Mouta RJO, Prata JA. Perceptions of nurse-midwives of their residency training and professional practice. Rev Min Enferm. 2018;22:1-8. http://dx.doi.org/10.5935/1415-2762.20180035.
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In this context, it is possible to analyze that some nurses, despite characterizing certain content as a gap, highlighted the gender and humanization approach emphasized in training. These approaches configure the specificity of this modality for training, which goes beyond the technical aspects and transcends the focus on the attitudes of a conscious and committed practice of knowledge and doing.

Recalling the expression of the deponent who manifested the curricular transition and the change in scientific evidence on theoretical and practical content for carrying out episiotomy, the WHO, in its Guide to Good Practices, recommends its performance around 10% in specific situations, such as fetal distress, insufficient childbirth progress and imminent third-degree injury to the perineum1313 Monguilhott JJC, Brüggemann OM, Freitas PF, D’Orsi E. Nascer no Brasil: the presence of a companion favors the use of best practices in delivery care in the South region of Brazil. Rev Saude Publica. 2018;52:1. http://dx.doi.org/10.11606/S1518-8787.2018052006258. PMid:29364356.
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. The routine or liberal use of episiotomy was again reinforced as not recommended for spontaneous vaginal delivery, regarding the care in relation to positive experiences.

Given that scientific evidence does not support the routine use of this procedure, episiotomy rates still are high in Brazil and worldwide1414 Santos RCS, Santos RG. Fatores relacionados com a prática da episiotomia no Brasil: revisão de literatura. Estação Científica. 2016 ago;6(2):43-52. http://dx.doi.org/10.18468/estcien.2016v6n2.p43-52.
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. This panorama reflects a concern about the intervention of such a procedure in specialization courses, since the routine use of episiotomy is classified as a practice that is often used inappropriately.1313 Monguilhott JJC, Brüggemann OM, Freitas PF, D’Orsi E. Nascer no Brasil: the presence of a companion favors the use of best practices in delivery care in the South region of Brazil. Rev Saude Publica. 2018;52:1. http://dx.doi.org/10.11606/S1518-8787.2018052006258. PMid:29364356.
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Despite these inadequacies, obstetric nursing care has shown advances in compliance with technical regulations, with the frequency of episiotomy around 2.0%.1515 Guida NFB, Pereira ALF, Lima GPV, Zveiter M, Araújo CLF, Moura MAV. Compliance of nursing care practices with technical recommendations for normal birth. Rev Rene. 2017;18(4):543-50. http://dx.doi.org/10.15253/2175-6783.2017000400017.
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Even with significant changes achieved in the field, the country still has, statistically, one of the highest rates of interventions in childbirth care; this situation reflects the impregnation of some professionals in the logic of the dominant and interventionist model. And, although it does not reveal itself in the nurse’s perception, the teacher’s conduct reaffirms the residency’s political-pedagogical position, committed to the training of professionals willing to abolish episiotomy, preserving the woman’s body integrality against the practices of obstetric violence.

The consonance in an analysis of nurses’ assistance, in accordance with the recommended ministerial protocols, portrays the investment in the training of these professionals and the successful experience, in which non-medical professionals are the primary health providers of healthy women during childbirth.1616 Pereda-Goikoetxea B, Marín-Fernández B, Liceaga-Otazu NE, Elorza-Puyadena MI. A qualitative study of hospital birth perceptions: the helix of priority needs. Midwifery. 2019;74:91-8. http://dx.doi.org/10.1016/j.midw.2019.03.018. PMid:30939335.
http://dx.doi.org/10.1016/j.midw.2019.03...

Some graduates of the residency criticized the difficulty in acting, due to the division of the practical field with other students, residents of medicine. This negative perception reflects on a threat to their work plan by another category of professional training, showing a space of conflict that, in the speeches about the practices in the daily care of normal childbirth, refer to it as a tension movement.1717 Breman RB, Iobst S, Paul J, Low LK. Clinicians’ perspectives on admission of pregnant women: a triad. MCN Am J Matern Child Nurs. 2019;44(5):260-8. http://dx.doi.org/10.1097/NMC.0000000000000550.
http://dx.doi.org/10.1097/NMC.0000000000...

This situation is considered to be against the order established in the hospital environment, where external and internal limits arise in the relationship between medical professionals and obstetric nurses with the clientele. Such limits are mediated by knowledge and conduct, which must be overcome, in the direction of an emerging model. This environment of professional dispute must be transformed in the sense of sharing the joint training spaces, aiming to collaborate in the integration and implementation of the interdisciplinary approach necessary for comprehensive, qualified, singular, human, dignified and respectful assistance.

For obstetric nurses, the discussion of clinical situations and conduct between professional categories allows for better management of care and work dynamics, in addition to favoring a unique care for each woman, newborn and assisted family.1818 Amaral APS, Cotta FM, Jardim DMB. A experiência na formação interdisciplinar dos residentes em obstetrícia do hospital Sofia Feldman. J Manag Prim Heal Care [Internet]. 2016; [citado 2018 set 10];7(1):1. Disponível em: http://www.jmphc.com.br/jmphc/article/view/349
http://www.jmphc.com.br/jmphc/article/vi...

When analyzing the ambivalences regarding the dialectical unity, theory and practice, the objective and subjective dimensions, the construction of the philosophy of praxis recreate, from top to bottom, the current system: science; culture; education; relations of individual and social powers, giving rise to the elaboration of an integral and original philosophy that surpasses the existing one.1919 Gómez Gutiérrez JJ. Filosofía de la praxis como crítica de la hegemonía en Antonio Gramsci. Ideas y Valores. 2018;67(166):93-114. http://dx.doi.org/10.15446/ideasyvalores.v67n166.56117.
http://dx.doi.org/10.15446/ideasyvalores...
The contradictions of the testimonies demonstrated a process of change in the care model, although the criticisms regarding the theoretical part in professional training are overcome by the specificity in practical modality that the residency has. Nurses acquire not only technical and scientific knowledge, but the management of the normal labor process, which they configure with the training received as satisfactory, determinants of their skills, attitudes, reception and humanization. These determine the consciousness of the active subject – as the protagonist of childbirth – in the practical process, evidenced in the product of his/her activity in the face of the scientific evidence experienced.

The formation of professional attitudes and skills, attentive to the rights to health and the demands of the clientele, are successively reinforced in the process of formation and raising of practical awareness. Consequently, the interviewees’ perception of the fragile dialectical relationship between theory and practice, does not reflect on the professional attitude, in which training and its interfaces with praxis favor in their entirety a knowledge elaborated materially at work, in order to implement a differentiated model. The effective qualification in this process aims to articulate a political project of social emancipation, a formation of scientific bases that allows the recognition of the laws of nature and society, formative practices guided by praxis, recognizing the need for capacities to think, produce and transform reality for the benefit of humanization.2020 Oliveira BLCA, Silva AM, Lima SF. Teekly workload for nurses in brazil: challenges to practice the profession. Trab Educ Saúde. 2018;16(3):1221-36. http://dx.doi.org/10.1590/1981-7746-sol00159.
http://dx.doi.org/10.1590/1981-7746-sol0...

In this perspective, it is emphasized that, seven graduates considered that the training allowed the acquisition of knowledge, translating into essential components to the perception of safety, qualification and competencies, especially in the relation of physiology and humanized assistance to normal childbirth. These results infer knowledge that enabled necessary skills for professional practice with autonomy and security.

The nurse, in the articulation of her knowledge since graduation, progressively builds her praxis. Theoretical activity provides an indispensable knowledge to transform reality and practical activity that is manifested in work or in creative praxis. The end of this activity is the real transformation to meet human needs, and the result is a new reality, a transformative praxis.77 Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Practices in childbirth care in maternity with inclusion of obstetric nurses in Belo Horizonte, Minas Gerais. Esc Anna Nery. 2016;20(2):324-31. http://dx.doi.org/10.5935/1414-8145.20160044.
http://dx.doi.org/10.5935/1414-8145.2016...

The predominance of participants in obstetric care has an important contribution to the care practice supported by the humanized model, such as the right to a companion, freedom of position and movement, the use of non-pharmacological methods of pain relief and the use of partogram.77 Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Practices in childbirth care in maternity with inclusion of obstetric nurses in Belo Horizonte, Minas Gerais. Esc Anna Nery. 2016;20(2):324-31. http://dx.doi.org/10.5935/1414-8145.20160044.
http://dx.doi.org/10.5935/1414-8145.2016...
These contribute for a creative professional praxis, which seeks to transform a proposal to change the interventionist obstetric model.

This training enables the development of specific professional knowledge, security in the development of work and satisfaction with the profession. Nurses choose the specialization course in the residency modality because it provides more practical experiences, which favors the acquisition of competencies and technical skills necessary for the exercise of the profession.2121 Lima GPV, Pereira ALF, Guida NFB, Progianti JM, Araújo CLF, Moura MAV. Expectations, motivations and perceptions of nurses on the nurse-midwifery specialization course in the residence modality. Esc Anna Nery. 2015;19(4):593-9. http://dx.doi.org/10.5935/1414-8145.20150079.
http://dx.doi.org/10.5935/1414-8145.2015...
This conscious and rationalized practice in the training of nurses is an attribute for obstetric praxis, as highlighted in previous fragments, the difference in the training due to the workload of practical knowledge, the scientific foundation of acquired knowledge, the plurality of practical experiences and recognition in the labor market. The emancipation of actions and practices is sought in order to revolutionize the current scenario in the obstetric area.

In this understanding, praxis involves not only the articulation between knowledge and practice, but the understanding that practice is a theory in action.2121 Lima GPV, Pereira ALF, Guida NFB, Progianti JM, Araújo CLF, Moura MAV. Expectations, motivations and perceptions of nurses on the nurse-midwifery specialization course in the residence modality. Esc Anna Nery. 2015;19(4):593-9. http://dx.doi.org/10.5935/1414-8145.20150079.
http://dx.doi.org/10.5935/1414-8145.2015...
This conscious practical activity, of not only interpreting but transforming, requires overcoming the reality adopted by common awareness of the social actors involved in this practice.77 Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Practices in childbirth care in maternity with inclusion of obstetric nurses in Belo Horizonte, Minas Gerais. Esc Anna Nery. 2016;20(2):324-31. http://dx.doi.org/10.5935/1414-8145.20160044.
http://dx.doi.org/10.5935/1414-8145.2016...
Nurses recognize themselves in their contribution to overcoming the reality of the Brazilian obstetric scenario, although this role still requires challenges that allow adding their cultural and social form, work and politics, and their manifestations in individual, group and collective activities.

Knowledge includes understanding the socio-political context of the professionals involved in the health care process and the socio-political context of Nursing, in addition to the understanding that the profession has of society and its policies. It also contemplates the political struggles for better health and living conditions for citizens, and the struggles for decent work conditions, wages and social justice.2020 Oliveira BLCA, Silva AM, Lima SF. Teekly workload for nurses in brazil: challenges to practice the profession. Trab Educ Saúde. 2018;16(3):1221-36. http://dx.doi.org/10.1590/1981-7746-sol00159.
http://dx.doi.org/10.1590/1981-7746-sol0...

It is understood that the experiences known by obstetric nurses are placed as a need for structural transformation in the care model, as major challenges that can lead to conformations for a demedicalized and humanized attention in the care of normal childbirth. This type of approach is congruent with PRONAENF, since the training contributed for nurses to approach childbirth with quality in the training of care, in addition to the care of the newborn and adherence to breastfeeding. The proposals presented aim to not only reduce the high prevalence of medicalization, the use of technologies without scientific evidence, but also interventions without the need or indications for cesarean sections. In this sense, PRONAENF has a direct impact on the quality of care for women throughout the process of pregnancy, childbirth and childbirth.88 Santana AT, Felzemburgh RDM, Couto TM, Pereira LP. Performance of resident nurses in obstetrics on childbirth care. Rev Bras Saúde Mater Infant. 2019;19(1):135-44. http://dx.doi.org/10.1590/1806-93042019000100008.
http://dx.doi.org/10.1590/1806-930420190...
,2222 Reis TR, Zamberlan C, Quadros JS, Grasel JT, Moro ASS. Enfermagem obstétrica: contribuições às metas dos objetivos de desenvolvimento do milênio. Rev Gaúcha Enferm. 2015;36(spe):94-101. http://dx.doi.org/10.1590/1983-1447.2015.esp.57393.
http://dx.doi.org/10.1590/1983-1447.2015...

Institutional support, managers’ commitment to public policies, qualified and autonomous training consistent with the insertion of obstetric nurses in health settings is essential, in order to implement care that promotes change in a model governed by ethical and legal precepts, in which it is possible to move more resolutely.

CONCLUSION

The results showed ambivalences about the training process of obstetric nurses that interfere in the perception about their professional praxis. They highlighted the dialectical relationship between theory and practice, presenting tensions between nurses’ common sense and scientific knowledge learned in the residency course, as well as disputes between professionals in the obstetric scenario as part of the challenge to be overcome.

In a cross-sectional analysis, convergence on the importance of the training modality in residency was highlighted, having the different experiences in the training process and their interfaces, as contributing factors to the knowledge of their professional practice transforming the obstetric nurse.

Considering that the knowledge of these nurses is built since the initial teaching process in their training and remains under construction in the exercise of work activities, their performance is constant and is combined with critical awareness in their involvement in deconstructing the interventionist obstetric model.

The praxis of nurses contributes to modifying the care paradigm of the interventionist obstetric model, which enables a qualitative transformation in the obstetric scenario with rescue of the physiology, humanization of attention, integrality of care, strengthening of bonds, empowerment of women as protagonists, re-signifying the moment of labor and birth. The specific obstacles portrayed result from an initiative to change in the face of alarming cesarean rates in maternity settings. In this investigation, the theoretical-practical relationship projects barriers, however, the construction of praxis overcomes the existing gaps, which, shaped since professional training, constitute a fundamental part in improving the quality of assistance to women during normal birth. This result converges with the principles of humanization, comprehensive care, good practices and safety in labor and birth.

This study strengthens scientific evidence in the research on the importance and insertion of obstetric nurses graduated from the residency, their training and influence on professional practice, in addition to highlighting the need for interdisciplinary integration in different obstetric scenarios. A limitation is the reduced number of participants in the field of maternities, even though the entire list of obstetric nurses who graduated from the Obstetric Nursing Residency Course at the two investigated institutions was considered.

  • FINANCIAL SUPPORT: This work was carried out with support from the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil – CAPES (Coordination for the Improvement of Higher Education Personnel, in free translation) – Financing Code 001. Author awarded with the scholarship: Giuliana Fernandes e Silva (Scholarship by the Academic Excellence Program and Internship Scholarship in doctoral research abroad conducted at the Universidad de Murcia, in Spain).
  • a
    Article extracted from a doctoral thesis “A práxis da enfermeira obstétrica na assistência à mulher no processo parturitivo”, defended in the Stricto Sensu Graduate Program of the Escola de Enfermagem Anna Nery at Universidade Federal do Rio de Janeiro by the author Giuliana Fernandes e Silva, under the guidance of Ph.D. Professor Maria Aparecida Vasconcelos Moura in 2019.

REFERÊNCIAS

  • 1
    Santos AHL, Nicácio MC, Pereira ALF, Oliveira TCM, Progianti JM. Las prácticas de asistencia al parto normal: formación en la modalidad de residência. Rev Enferm UFPE [Internet]. 2017; [citado 2018 set 10];11(1):1-9. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/11871/14318
    » https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/11871/14318
  • 2
    Vargens OMDC, Silva ACVD, Progianti JM. The contribution of nurse midwives to consolidating humanized childbirth in maternity hospitals in Rio de Janeiro-Brazil. Esc Anna Nery. 2017;21(1):1-8. http://dx.doi.org/10.5935/1414-8145.20170015
    » http://dx.doi.org/10.5935/1414-8145.20170015
  • 3
    Aquino EML. Reinventing delivery and childbirth in Brazil: back to the future. Cad Saude Publica. 2014;30(Supl 1):S1-3. PMid:25167193.
  • 4
    Medeiros RMK, Teixeira RC, Nicolini AB, Alvares AS, Corrêa ACP, Martins DP. Humanized care: insertion of obstetric nurses in a teaching hospital. Rev Bras Enferm. 2016;69(6):1091-8. PMid:27925085.
  • 5
    Pereira ALF, Guimarães JCN, Nicácio MC, Batista DBS, Mouta RJO, Prata JA. Perceptions of nurse-midwives of their residency training and professional practice. Rev Min Enferm. 2018;22:1-8. http://dx.doi.org/10.5935/1415-2762.20180035
    » http://dx.doi.org/10.5935/1415-2762.20180035
  • 6
    Pereira ALF, Mouta RJO, Barbosa DSP. El proceso de creación del curso de especialización en Enfermería Obstétrica, modalidad de residencia, en la red municipal de salud de Rio de Janeiro, Brasil. Cul Cuid. 2018;22(51):114-23. http://dx.doi.org/10.14198/cuid.2018.51.13
    » http://dx.doi.org/10.14198/cuid.2018.51.13
  • 7
    Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Practices in childbirth care in maternity with inclusion of obstetric nurses in Belo Horizonte, Minas Gerais. Esc Anna Nery. 2016;20(2):324-31. http://dx.doi.org/10.5935/1414-8145.20160044
    » http://dx.doi.org/10.5935/1414-8145.20160044
  • 8
    Santana AT, Felzemburgh RDM, Couto TM, Pereira LP. Performance of resident nurses in obstetrics on childbirth care. Rev Bras Saúde Mater Infant. 2019;19(1):135-44. http://dx.doi.org/10.1590/1806-93042019000100008
    » http://dx.doi.org/10.1590/1806-93042019000100008
  • 9
    Edmonds JK, O’Hara M, Clarke SP, Shah NT. Variation in cesarean birth rates by labor and delivery nurses. J Obstet Gynecol Neonatal Nurs. 2017;46(4):486-93. http://dx.doi.org/10.1016/j.jogn.2017.03.009 PMid:28549612.
    » http://dx.doi.org/10.1016/j.jogn.2017.03.009
  • 10
    Taquette SR, Minayo MC. An analysis of articles on qualitative studies conducted by doctors published in scientific journals in Brazil between 2004 and 2013. Physis. 2017;27(2):357-74. http://dx.doi.org/10.1590/s0103-73312017000200010
    » http://dx.doi.org/10.1590/s0103-73312017000200010
  • 11
    Kramer M, Maguire P, Halfer D, Brewer B, Schmalenberg C. Impact of residency programs on professional socialization of newly licensed registered nurses. West J Nurs Res. 2013;35(4):459-96. http://dx.doi.org/10.1177/0193945911415555 PMid:21816962.
    » http://dx.doi.org/10.1177/0193945911415555
  • 12
    Pereira RM, Fonseca GO, Pereira ACCC, Gonçalves GA, Mafra RA. New childbirth practices and the challenges for the humanization of health care in southern and southeastern Brazil. Cien Saude Colet. 2018;23(11):3517-24. http://dx.doi.org/10.1590/1413-812320182311.07832016 PMid:30427425.
    » http://dx.doi.org/10.1590/1413-812320182311.07832016
  • 13
    Monguilhott JJC, Brüggemann OM, Freitas PF, D’Orsi E. Nascer no Brasil: the presence of a companion favors the use of best practices in delivery care in the South region of Brazil. Rev Saude Publica. 2018;52:1. http://dx.doi.org/10.11606/S1518-8787.2018052006258 PMid:29364356.
    » http://dx.doi.org/10.11606/S1518-8787.2018052006258
  • 14
    Santos RCS, Santos RG. Fatores relacionados com a prática da episiotomia no Brasil: revisão de literatura. Estação Científica. 2016 ago;6(2):43-52. http://dx.doi.org/10.18468/estcien.2016v6n2.p43-52
    » http://dx.doi.org/10.18468/estcien.2016v6n2.p43-52
  • 15
    Guida NFB, Pereira ALF, Lima GPV, Zveiter M, Araújo CLF, Moura MAV. Compliance of nursing care practices with technical recommendations for normal birth. Rev Rene. 2017;18(4):543-50. http://dx.doi.org/10.15253/2175-6783.2017000400017
    » http://dx.doi.org/10.15253/2175-6783.2017000400017
  • 16
    Pereda-Goikoetxea B, Marín-Fernández B, Liceaga-Otazu NE, Elorza-Puyadena MI. A qualitative study of hospital birth perceptions: the helix of priority needs. Midwifery. 2019;74:91-8. http://dx.doi.org/10.1016/j.midw.2019.03.018 PMid:30939335.
    » http://dx.doi.org/10.1016/j.midw.2019.03.018
  • 17
    Breman RB, Iobst S, Paul J, Low LK. Clinicians’ perspectives on admission of pregnant women: a triad. MCN Am J Matern Child Nurs. 2019;44(5):260-8. http://dx.doi.org/10.1097/NMC.0000000000000550
    » http://dx.doi.org/10.1097/NMC.0000000000000550
  • 18
    Amaral APS, Cotta FM, Jardim DMB. A experiência na formação interdisciplinar dos residentes em obstetrícia do hospital Sofia Feldman. J Manag Prim Heal Care [Internet]. 2016; [citado 2018 set 10];7(1):1. Disponível em: http://www.jmphc.com.br/jmphc/article/view/349
    » http://www.jmphc.com.br/jmphc/article/view/349
  • 19
    Gómez Gutiérrez JJ. Filosofía de la praxis como crítica de la hegemonía en Antonio Gramsci. Ideas y Valores. 2018;67(166):93-114. http://dx.doi.org/10.15446/ideasyvalores.v67n166.56117
    » http://dx.doi.org/10.15446/ideasyvalores.v67n166.56117
  • 20
    Oliveira BLCA, Silva AM, Lima SF. Teekly workload for nurses in brazil: challenges to practice the profession. Trab Educ Saúde. 2018;16(3):1221-36. http://dx.doi.org/10.1590/1981-7746-sol00159
    » http://dx.doi.org/10.1590/1981-7746-sol00159
  • 21
    Lima GPV, Pereira ALF, Guida NFB, Progianti JM, Araújo CLF, Moura MAV. Expectations, motivations and perceptions of nurses on the nurse-midwifery specialization course in the residence modality. Esc Anna Nery. 2015;19(4):593-9. http://dx.doi.org/10.5935/1414-8145.20150079
    » http://dx.doi.org/10.5935/1414-8145.20150079
  • 22
    Reis TR, Zamberlan C, Quadros JS, Grasel JT, Moro ASS. Enfermagem obstétrica: contribuições às metas dos objetivos de desenvolvimento do milênio. Rev Gaúcha Enferm. 2015;36(spe):94-101. http://dx.doi.org/10.1590/1983-1447.2015.esp.57393
    » http://dx.doi.org/10.1590/1983-1447.2015.esp.57393

Edited by

ASSOCIATE EDITOR
Stella Maris de Mello Padoin

Publication Dates

  • Publication in this collection
    19 June 2020
  • Date of issue
    2020

History

  • Received
    23 Jan 2020
  • Accepted
    08 Apr 2020
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