THE PRENATAL NURSING CONSULTATION FROM THE PERSPECTIVE OF KRISTEN SWANSON’S THEORY OF CARE

ABSTRACT

Objective:

to understand the meanings attributed by Amazonian women regarding the prenatal nursing consultation.

Method:

descriptive, exploratory, and qualitative study, conducted through semi-structured interviews with the participation of 14 pregnant women in a basic health unit in the State of Pará, Brazil, between the months of August and November 2020. Data were transcribed and submitted to content analysis and supported based on the optics of Kristen Swanson’s Theory of Care.

Results:

prenatal care must be focused on creating a bond and the Amazonian woman’s singularity, allowing for her understanding to meet the women’s specificities, articulating integral health care, a relationship of knowing and being with the woman and her family, for relationships of exchange and involvement, providing a link to maternal health.

Conclusion:

concepts from the theory of care allow the nurse to be with the woman and provide individualized, singular, particularized care within the context of prenatal care.

DESCRIPTORS:
Nursing; Pregnancy; Prenatal Care; Maternal-Child Health Services; Nursing Theory.

RESUMO

Objetivo:

compreender os significados atribuídos pelas mulheres amazônidas quanto à consulta de Enfermagem pré-natal.

Método:

estudo descritivo, exploratório e qualitativo, realizado por meio de entrevista semiestruturada com a participação de 14 gestantes numa unidade básica de saúde do Estado do Pará, Brasil, entre os meses de agosto a novembro de 2020. Os dados foram transcritos e submetidos à análise de conteúdo e sustentados com base na ótica da Teoria do Cuidado de Kristen Swanson.

Resultados:

o pré-natal deve ser voltado para a criação de vínculo e da singularidade da mulher amazônica, permitindo a sua compreensão a fim de que atenda às especificidades das mulheres, articulando a atenção a saúde integral, uma relação de conhecer e estar com a mulher e família, para relações de troca e envolvimento, fornecendo um elo à saúde materna.

Conclusão:

conceitos da teoria do cuidado permitem que o enfermeiro esteja com a mulher e forneça um cuidado individualizado, singular, particularizado dentro do contexto no pré-natal.

DESCRITORES:
Enfermagem; Gravidez; Cuidado Pré-natal; Serviços de Saúde Materno-Infantil; Teoria de Enfermagem.

RESUMEN

Objetivo:

comprender los significados atribuidos por las mujeres amazónicas sobre la consulta de enfermería prenatal.

Método:

estudio descriptivo, exploratorio y cualitativo, realizado a través de entrevistas semiestructuradas con la participación de 14 gestantes en una unidad básica de salud del Estado de Pará, Brasil, entre los meses de agosto y noviembre de 2020. Los datos fueron transcritos y sometidos a un análisis de contenido y sustentados en la teoría del cuidado de Kristen Swanson.

Resultados:

la atención prenatal debe centrarse en la creación de un vínculo y la singularidad de la mujer amazónica, lo que permite su comprensión con el fin de satisfacer las especificidades de las mujeres, la articulación de la atención de salud integral, una relación de conocer y ser con la mujer y la familia, para las relaciones de intercambio y la participación, proporcionando un vínculo con la salud materna.

Conclusión:

los conceptos de la teoría del cuidado permiten a la enfermera estar con la mujer y proporcionarle un cuidado individualizado, singular y particularizado dentro del contexto en el cuidado prenatal.

DESCRIPTORES:
Enfermería; Embarazo; Atención Prenatal; Servicios de Salud Materno-Infantil; Teoría de Enfermería.

INTRODUCTION

The performance of nurses is supported by the Law of Professional Exercise - Law No. 7.498, of June 25, 1986, and regulated by Decree No. 94.406, June 8, 1987. Also, with the support of its exercise before Resolution No. 516 of June 24, 2016, of the Federal Council of Nursing, with the purpose of ensuring the realization of the Nursing consultation in prenatal care of usual risk, being one of its private activities, which should act in an integral, holistic, individualized, and humanized way¹. Prenatal care should occur with the offer of multi-professional care, in which the nurse and the doctor are the professionals responsible for performing this continuous, shared, and interprofessional care².

Prenatal care should be performed in a qualified, welcoming way, with bonding and empathy, access to information, mediated by the process of health education with a comprehensive care focused not only on the biological dimension, but also on the psychological, social, and cultural aspects³. Thus, the quality of prenatal care is an ongoing challenge in Brazil, mainly due to the poor quality of care in the country⁴, which has been shown to be associated with higher risks and complications in childbirth and puerperium, contributing to the increase in maternal and perinatal mortality rates⁵.

The Maternal Mortality Ratio (MMR) in Brazil is considered a serious public health problem, and reaches inequalities in Brazilian regions, especially in the North region, with the prevalence of women from social classes with lower access to health services, either by lack of structure and investment, or by the traditional culture of the region itself, which provides an intersection of health science and empirical health care produced in popular tradition. Such facts constitute a serious violation of human rights because it is an avoidable “tragedy” where 92% of maternal deaths occur in developing countries, such as Brazil. This factor was decisive for the country not to reach the fifth Millennium Development Goal, Improvement of the quality of maternal health, where it obtained an MMR of 107 deaths in 2021⁶, and thus establish new goals, especially as to the Sustainable Development Goals, considering indicators for the improvement of maternal health, for the decrease in up to 30 maternal deaths per 100,000 live births².

This scenario has enabled the search for strategies to ensure higher quality, with the realization of prenatal consultation, promoting important factors for the continuity of care, such as access to information, respect, autonomy. Also, the work on health indicators, such as the supply of medicines and inputs, the performance of basic procedures, and the access to, at least, six consultations, as recommended by the Ministry of Health (MH). In addition, to consider as one of the indicators of quality the needs of women with their meanings, valuing the respect for their expectations and wishes, to (re)think the practices in prenatal care⁷.

In line with the improvement of maternal health, Brazil has the possibility of ensuring comprehensive care. Studies¹,⁸-⁹ have shown the commitment established by nurses with the quality of prenatal care, providing greater satisfaction with empathy, effective listening, dialogue, respect, and care focused on their needs.

Therefore, this care should be directed to the singularity (which is own) and the particularities (peculiar) of Amazonian women who bring in their tradition the health care based on beliefs and values instituted in their life history. The population that lives in traditional communities in the Legal Amazon, historically, faces the negligence of the State in the face of contexts of vulnerability in the field of health, education and environment with riverine, extractive communities and traditional peoples, such as those of the forests, indigenous and quilombos’.

This particularity is eminent to the peoples of the Amazon, besides the fact related to the obstacles regarding access to health services, where there is a lack of investments for the promotion of maternal health. In addition, the care is traditionally based on traditional midwives, who use ancient practices, especially with the help of herbs for the women’s needs. With such specificities in the North region, these women need attention focused on these particularities, to ensure better indicators and positive evaluations in prenatal care.

In this sense, the American nurse Kristen M. Swanson stands out, who has the main concept about the Theory of Care and the processes that give meaning, from a theoretical-philosophical point of view and women’s well-being to the application of a Nursing Theory¹⁰-¹¹.

This theory is based on Nursing care in pregnancy, and in the present study, in prenatal care with its meanings that, according to its stages are described as: knowing (knowing people and their lives); being with (person as unique and individual); doing for (being emotionally with the other, as a process of helping their needs); holding beliefs (interaction of beliefs, experiences, skills, and knowledge for care practices and enabling people on the recommendations with their needs). This structure of care makes it possible to turn this look toward the nursing consultation in prenatal care¹⁰-¹¹, especially in the context of Amazonian women, where there is a need to expand studies focusing on the meanings of nursing care, since the studies related to pregnant women and prenatal care are focused on an evaluative relationship of prenatal care and not on the observance related only to the subjective data of this care¹²-¹³.

Thus, the study had as its guiding question: What are the meanings attributed by women to the prenatal nursing consultation? Thus, it aimed to understand the meanings attributed by Amazonian women to the prenatal nursing consultation.

METHOD

A descriptive-exploratory study with a qualitative approach and the participation of 14 pregnant women from the usual-risk prenatal program of the Amarino Almeida Basic Health Unit. This unit is in the municipality of Muaná, in Marajó Island, Pará, Brazil, being the fourth most populated municipality in Marajó, with almost 37 thousand inhabitants and 47% female population. The facility has: reception; screening; offices; and vaccination room.

Pregnant women are scheduled and referred by community health agents for prenatal care. The nurse performs the first consultation, following the MS protocol. The following consultations are interspersed between the doctor and the nurse.

The selection was made by convenience recruitment and met the following inclusion criteria: 1) over 18 years old; 2) accompanied by nurses; 3) who had at least three consultations. The exclusion criteria were limited to women with comorbidities or accompanied by a medical professional.

Data collection was conducted between August and October 2020 by means of semi-structured and recorded interviews with an average duration of 40 minutes during the waiting interval for the consultations. The interviews contemplated questions related to the prenatal nursing consultation. After being recorded and transcribed, the participants’ statements were identified by the letter P (Pregnant Women), followed by a continuous number (P1, ..., P14), to guarantee anonymity and the deponent’s confidentiality. The closure obeyed the saturation of the data when the understanding of the meanings occurred due to the similarities of the participants’ meanings¹⁴.

The material was fully transcribed by the main researcher and submitted to content analysis15 with the support of theATLAS.ti 8.0 software. The purpose of this analysis was to discover the content of the statements, and the following steps were taken: 1) pre-analysis (organization of the material with floating reading, choice of documents to be analyzed and the construction of the corpus based on exhaustiveness, representativeness, homogeneity, and hypothesis formulations).

In the second moment, 2) exploration of the material and treatment of the results (with the coding and categorization of the material - a cut made of the units of meaning, which can be words, theme, object, or referring to the event, and, to select the units, it is necessary to consider the pertinence, being able to obtain the occurrence, called contingency analysis; the categorization followed the semantic, syntactic, lexical, or expressive criteria)¹⁵-¹⁶.

In this stage, the functionality of ATLAS.ti 8.0 was objectified in the codification of the excerpts of the statements with the identification of the following meanings: information (54%), attentive listening (42%), doubts and fears (61%), confidence (37%), orientation (56%), prenatal (73%), nurse (75%), quality (47%), consultation (41%). And, in this final phase, that is: 3) treatment of the results, interference and interpretation, they became significant and valid with the presentation of the categories, constituting a type of controlled interpretation, which may be based on the constitutive elements - meaning and code and by the sender and the receiver)¹⁵.

The study was approved by the Research Ethics Committee of the Institute of Health Sciences of the Federal University of Pará, under opinion number 3,789,044.

RESULTS

Based on the non-aprioristic categorization, the following categories emerged: 1) The link in the prenatal consultation: the nurse being with the woman and the link for quality and safety; 2) The prenatal Nursing consultation: a relationship of being with and for singular care, which were related based on the thoughts of Kristen M. Swanson¹⁰-¹¹, who works on the meaning of meanings, of knowing and being with; and thus relate it to prenatal Nursing care.

The link in the prenatal consultation: the nurse being with the woman and the link for quality and safety

In the prenatal consultation, it is essential for the creation and maintenance of gestational care of pregnant women with a feeling of safety that a bond is established for the care of the health professional, eliminating obstacles to an unsafe pregnancy, reflecting concepts of knowing and being with.

[...] He keeps asking [nurse], sometimes we forget too [...] there are many questions [consultation] and the nurse gives all the attention, you are feeling this or that [...] We feel safe [...] (P1)

[...] For me the nurses in prenatal care have always been very good, and now it is no different, they follow up very well, take our doubts away, I can always count on them, we stay connected to them [...] I feel very good, they take care of me, it shows how the nurse is concerned, giving support [...] (P9)

The nurse’s guidance in the gestational process allows Amazonian women to feel safer and establish greater confidence in prenatal care. The bond is essential to ensure the safety and quality of prenatal care for women.

[...] He [nurse] explains what is normal to happen during pregnancy, but that it may last, it may be the entire pregnancy or it may be only a few weeks [...] he [nurse] says that if it continues depending on that week that he gave, look, it will go until such week, it will decrease, then he says if it is close [...] I feel very safe with him [nurse], he gives me the support I need, I even say that he is family, I say that because he takes care of me [...] (P1)

[...] I think it is a good relationship, the nurse who is taking care of me very well, she likes to know everything, if she is paying attention to everything like this, to talk, she worries about me [...]that total responsibility, she worries a lot and pays attention to me [...] (P3)

The doubts and concerns of prenatal women are constant, and the nurse is a link for clear and objective orientations for the understanding of the woman, enabling her knowledge through the bond related to the issue of understanding her subjectivities for a welcoming care:

[...] I am well assisted, when I arrived here to start prenatal care I had several questions, about this, you know, I asked and he [nurse] was good to explain right, you know, right, removing the doubts, everything I needed, he cared, very committed [...] (P3)

[...] He [the nurse] always took care of me in the best possible way, always orienting me that most symptoms were normal, he talked about some natural things that we could do, exercises, eat a few things to help improve [...] had a care that I don’t have with the other [other non-nurse professional], who doesn’t take care like that, I have affection for the nurse, who takes good care of me [...] (P6)

The prenatal nursing consultation: a relationship of being with and for the singular care

The meanings of Amazonian women point to the singularity of care for their particularities based on the beliefs and values of cultural tradition, with the nurse being present (being with) the woman, in a relationship of/with respect to the integrality and centrality of the care offered in the Nursing consultation.

[...] Look, from my point of view, it is just me and her (nurse), yes, always attentive, likes to talk to us [...] to know everything about us, what we are thinking, feeling, my fears, I think that is why I like her consultations, we always talk, I feel unique like the women who have health insurance [...] (P7)

[...] Look, regarding the consultations, I feel satisfied because the nurse is very friendly, she is polite, takes our doubts away, says that I am special [...] (P8)

The prenatal care is established to ensure a singular care that enables completeness, recognizing and being with her (woman), whose purpose is to identify changes in vital functions as well as the control of weight, blood pressure, measurement of uterine height, fetal auscultation, request for laboratory tests/imaging. Thus, expanding the singular care, attentive to their needs is paramount for nurses to provide sensitive and integral care:

[...] In the office, the first thing they do is talk, they are attentive, sensitive; after we talk, they check our blood pressure, the child’s heartbeat, ask how we are, if we are feeling well or not, they go to that part where they must listen to the baby [...] ask to touch the belly, I get all emotional during consultations, with my baby [...] (P2)

[...] If the child, if the heart is beating, they explain look, mommy, everything is fine, and they always say that the child is fine, don’t worry, don’t make any effort, so that is why I think it is very good [...] then they check the pressure, measure the belly, listen to the baby’s heart to see if everything is fine [...] always worried, and gives me support [...] (P9)

DISCUSSION

Prenatal care has been the object of study¹-³,⁵,⁷,⁹,¹⁷-¹⁸ and has shown the need to promote changes in care, either due to the organizational inability of health services or the presence of obstacles to quality assurance with an increase in the number of consultations. It presents, for the most part, less than six consultations; offer of exams; trained professionals; welcoming and risk classification; and linking the pregnant woman to the health network. These are some factors necessary to promote changes in prenatal care in the country.

As for the linking of the pregnant woman, in addition to the linking of the organizational sphere, which is established through the linking with the health unit and its maternity reference with the integration of prenatal care to the obstetric service in accordance with Law No. 11,634/2007. In this sense, the guidelines of the Stork Network come to ensure the reference and assistance, eliminating any situations of pilgrimage, still frequent in their daily lives¹⁹. For, linking the maternity with the regulation and flows constitutes one of the primary recommendations of the World Health Organization²⁰.

However, in addition to the organizational bond, the bond between the professional and the pregnant woman must be promoted, providing the sphere of being with the Amazon woman and her family, reflecting the basic processes of the Theory of Care by Kristen Swanson, who has, in this sense, the techniques of knowing and being with the other¹¹,²¹. The bond of care is established in constructive relationships between the pregnant woman and the professional, especially the nurse, and with respect for her meanings and subjectivity, thus guaranteeing this bond based on welcoming, empathy, and respect. These aspects are essential to guarantee the quality of prenatal care¹⁰-¹¹,²¹.

The framework of care suggested by the diligent theorist to maternal and child health cooperates not only to the elaboration of the method of care, but also to the provision of care, as an assistance program and strategy for the archetype of nursing care, concentrating the potentials of care in the parturient woman as physiological procedures, which can be noted as manifestations of the sexual and reproductive benefits to her health care¹¹.

In its similarity with health, this Theory constitutes the question of how to remain as a complemented procedure of care, which encompasses constituting original meanings, repairing the person in an integral way, renewing perfection, and reworking well-being. Space is included as a place, as it is accepted by the fact of the diverse contexts witnessed and that enthuse the subject throughout its elements in relation to cultural, biological, physical, and egalitarian perspectives¹¹.

It is worth pointing out that the Theory establishes that Nursing is centered on care with a fundamental link in the relationship with the woman and family and with the nurse, providing this support based on respect and on the integration of positive, subjective, and singular experiences in the prenatal consultation, since Nursing care and the family nucleus constitute the significant way for the adaptation process¹¹. Therefore, the prenatal consultation needs to establish an effective and qualified listening, in addition to the technical competence of the nurse, and establish a relationship of being with the other in his role as educator, to promote a care directed to their particularities with cultural aspects, such as riverside, quilombo, and indigenous people who value their beliefs and customs.

In the usual risk prenatal care, among the competencies of the nurse, according to the MH, are the orientation and health education regarding the transformations that occur in this period, besides emphasizing the importance of the periodicity of the consultations²²-²³, because the gestational period constitutes numerous biological/emotional/social transformations in pregnant women, requiring the real exercise as an educator during prenatal care; being with the woman becomes essential for the understanding of her integrality in prenatal care actions¹⁰-¹¹,²¹.

The theorist conceives an educational way of relating to a valued being, for which one feels a personal commitment and responsibility, allowing one to reflect on one’s worldview. The theory of care supports the assertion that caring is a central phenomenon of Nursing¹-³,¹⁰-¹¹. The interpersonal relationship between the woman/nurse is established with honesty, respect, understanding, wisdom, and reciprocity toward her, also incorporating elements that allow for effective communication and listening.

The metaparadigm emphasized by Kristen Swanson can be conceived under different aspects in Obstetric Nursing: the pregnant woman and her family nucleus as individuals in the modification procedure through childbirth and in the conception of the parental model; the extension of indicators of biopsychosocial and intellectual aspects in the adaptation of the originating element to benefit from the care, the connection and belief in the experiences of labor and birth and the perinatal well-being going towards the lack of diseases and complications, when understanding the importance of the actions in confrontation with the constitution of profitable people and collectivities, moderated in the potentials of existence and increase of citizenship¹¹.

However, first it is necessary for the nurse to involve his/her own experience to help him/her to become a genuine person within the interaction, being able to be perceived by the pregnant woman as a fully involved professional, thus, the bond for care in the prenatal consultation proves to be a link for safety and quality²⁴.

The being present of the nurse¹⁰-¹¹ in terms of listening and orientation becomes a highlight in the consultation with good and welcoming practices¹. Pregnant women emphasize one of the competencies of nurses in prenatal care in terms of holistic care and attentive listening to their doubts and questions. Information constitutes a link for the transforming care focused on her. Thus, self-knowledge is translated into quality care, as it satisfies the needs of the woman and her family.

The singularity of the nurse’s care is shown during prenatal care before the meanings of Amazonian women, evidencing a relationship of being with her that is based on her own relationship with pregnancy; They are from the riverside, quilombo, and indigenous communities, and have allowed the experience of this pregnancy for the guarantee of better indicators and needs of this population¹⁰-¹¹,²¹ because the lack of establishing a care for this look, an integral attention, of all the biopsychosociocultural aspects constitutes an agenda for understanding the particularities of these women and how they articulate with health professionals and services. At this moment, it is possible to get to know their lives and their demands that have a direct impact on the way of caring, which is only established in this relationship²⁵. Thus, these meanings must allow the woman to be the center of attention with the nurse in this relationship, and a singular care becomes real, mutual, and in the effective exchange for an effective prenatal care.

The singular care is established through the singularization of the pregnant woman’s needs, the integral to what is lived in her life contexts, where the biological, social, economic, family, and cultural aspects are considered²⁶. Each prenatal consultation is unique; exchanges, relations, and connections with the other and with the world are established only now of care. The nurse must promote this relationship with the meanings of Amazonian women in a full experience of relationships in prenatal care, with both as present and integral elements of this care²¹.

Prenatal care involves protocol determinations, which should be performed with the objective of reevaluating gestational risk¹-³,⁷,¹²-¹³ and working according to the needs of pregnant women. In the subsequent consultations, the main complaints are emphasized, the physical examination and weight control are performed, the vaccination schedule is checked, test results are analyzed, and the gestational age is calculated, besides checking blood pressure, fetal auscultation, and obstetric palpation¹-³,⁷,¹²-¹³, establishing a performance focused on perinatal health, with the valorization of the well-being and quality of pregnancy.

Pregnant women demonstrate their meanings both in the bond with the nurse during prenatal care and in their singularity, and consultations regarding conduct are considered important by women, because it is considered a time when they feel calmer for knowing their health conditions. And, when the nurse, through his/her consultation, acts in an effective, welcoming, integral, and unique way, his/her practice being directed to the scientific recommendations, with the intention of promoting a more effective attention during prenatal care. Even with more protocol actions, the nurse must be involved in care, because without knowing and being with the pregnant woman¹⁰-¹¹, care cannot be established.

Thus, prenatal care constitutes a primordial moment for perinatal health, and Amazonian women need the full support of nurses in consultations and directed activities. And, to guarantee Nursing care, the concepts in the light of Kristen Swanson’s Theory of Care support the nurses’ care in their search for knowing and being with the pregnant woman in a relationship of exchange, involvement, empathy, integrality, and singularity. These value dimensions allow the consultation not to be a mere routine meeting, but an occasion in which this caring relationship can be established with both, as supported by the Theory of Care.

As a limitation, the number of study participants in this investigation is emphasized, without generalizing, but rather, the singularity of prenatal care for Amazonian women.

CONCLUSION

The study evidenced the importance of nurses in prenatal care as a strategic link that strengthens the bond and uniqueness of living care that enables well-being through the presence of the nurse/pregnant woman based on the understanding of the meanings attributed by Amazonian pregnant women.

The realization of Nursing care in the light of Kristen Swanson’s Theory of Care provides subsidies for Nursing care in prenatal care, contributing to knowing and being with the Amazonian woman with a focus on her culturalism with meanings attributed by beliefs, values that will enable the creation of the bond for care and her prenatal singularity. For, when there is the nurse’s involvement, exchanges, affection, and relationship are established in a unique mutual relationship to promote perinatal quality.

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Edited by

Associate editor: Dra. Tatiane Trigueiro

Publication Dates

• Publication in this collection
  16 Dec 2022
• Date of issue
  2022

History

• Received
  31 Aug 2021
• Accepted
  12 July 2022