The implementation of Apice On Project in the Obstetric Residency Program: Nurses’ perceptions^a

Abstract

Objective

To describe the perception of graduates and the coordination of the Obstetric Nursing Program on the implementation of obstetric nurses in the delivery room of a Teaching, Research and Assistance Institution that is part of the Apice On Project.

Method

Descriptive, exploratory research with a qualitative approach carried out with five former residents in Obstetric Nursing and a Program Coordinator who experienced the execution of this health policy in 2019. A semi-structured interview was carried out between September and October 2021 and the data was submitted to content analysis.

Results

The obstetric nurse’s care and their professional training are supported by scientific evidence. However, there are challenges to overcome among residents, obstetric nurses and obstetricians regarding interprofessional education and relationship that help the consolidation of the collaborative model in Teaching Hospitals.

Final considerations and implications for practice

Obstetric Nursing in everyday life needs to advance in management solutions which promote better publicity, knowledge and multiprofessional participation in this health project, as well as the valorization of the specific care developed by the obstetric nurse, a member of the multidisciplinary team who works in the field of labor and birth in teaching hospitals.

Keywords:
Interprofessional Education; Obstetric Nurses; Teaching Hospitals; Humanization of Assistance; Health Policy

Resumo

Objetivo

Descrever a percepção de egressas e da coordenação do Programa de Residência em Enfermagem Obstétrica sobre a implantação da enfermeira obstétrica em sala de parto de uma Instituição de Ensino, Pesquisa e Assistência integrante do projeto Apice On.

Método

Investigação descritiva, exploratória com abordagem qualitativa, realizada com cinco ex-residentes em Enfermagem Obstétrica e uma coordenadora do Programa que vivenciaram a execução desta proposta política em 2019. Após aprovação do Comitê de Ética em Pesquisa, realizou-se entrevista semiestruturada entre setembro a outubro de 2021, e os dados foram submetidos à análise de conteúdo.

Resultados

O cuidado da enfermeira obstétrica e sua formação profissional encontram-se sustentados nas evidências científicas. No entanto, constatou-se desafios a serem superados entre residentes, enfermeiras obstétricas e médicos obstetras no que tange a educação e as relações interprofissionais que favoreçam a consolidação do modelo colaborativo em Hospitais de Ensino.

Considerações finais e implicações para a prática

A Enfermagem obstétrica no cotidiano necessita avançar em soluções gerenciais que promovam melhor divulgação, conhecimento e envolvimento multiprofissional com este projeto ministerial, bem como na valorização do cuidado específico desenvolvido pela enfermeira obstétrica, membro integrante da equipe multiprofissional que atua no campo do parto e nascimento em hospitais de ensino.

Palavras-chave:
Educação Interprofissional; Enfermeiras Obstétricas; Hospitais de Ensino; Humanização da Assistência; Política de Saúde

Resumen

Objetivo

Describir la percepción de egresas ​​y de la coordinación del Programa de Residencia en Enfermería Obstétrica sobre la implementación de enfermeras obstétricas en la sala de partos de una Institución de Enseñanza, Investigación y Asistencia que forma parte del proyecto Apice On.

Método

Investigación descriptiva, exploratoria con abordaje cualitativo con cinco exresidentes de Enfermería Obstétrica y una coordinadora del Programa que vivieron la ejecución de esta propuesta política en 2019. Se realizó entrevista semiestructurada entre septiembre y octubre de 2021 y los datos fueron sometidos a análisis de contenido.

Resultados

El cuidado de la enfermera obstétrica y su formación profesional están respaldadas por evidencia científica. Sin embargo, hay que superar desafíos entre residentes, enfermeros obstétricos y obstetras en cuanto a la educación y relaciones interprofesionales que favorezcan la consolidación del modelo colaborativo en Hospitales de Enseñanza.

Consideraciones finales e implicaciones para la práctica

La enfermería obstétrica en el cotidiano necesita avanzar en soluciones gerenciales que promuevan una mejor difusión, conocimiento e involucramiento multiprofesionales con esta política de salud, así como la valorización del cuidado específico desarrollado por la enfermera obstétrica, integrante del equipo multiprofesional que actúa en el campo del trabajo de parto y nacimiento en hospitales de enseñanza.

Palabras clave:
Educación Interprofesional; Enfermeras Obstetrices; Hospitales de Enseñanza; Humanización de la Atención; Política de Salud

INTRODUCTION

The International Conference on consensus on the appropriate use of technologies in prenatal care, childbirth and birth, organized in 1985 by the Pan American Health Organization (WHO/PAHO), recommended incentives for vaginal delivery and changes in obstetric routines, which served as a reference for the development of policies and campaigns by the Ministry of Health (MH).¹ This established an initial counterpoint for questioning current obstetric care, characterized by a hegemonic intervention model centered on the fragmentation of care and the verticalization of professional actions.

Since then, the consolidation of public policies in this area has been deepening, such as the 1996 publication by the WHO of the classification of obstetric practices shown to be useful for conducting childbirth based on scientific evidence² and the Stork Network Program, established by Ordinance GM/MS No. 1,459/2011, considered a historic milestone in the country for defining in its guidelines the safety and good practices of childbirth care, with a focus on humanized care. To this end, it enabled an increase in the number of specialized professionals, in-service training and an increase in qualification courses, as it understood that the implementation of care that prioritizes humanized obstetric care and maternal and fetal well-being was based on a change in professional training.³,⁴

In this context, there were government incentives to train and reduce the structural deficit of obstetric nurses in the country through the National Residency Program in Obstetric Nursing (PRONAENF), a partnership established between the Ministry of Health and the Ministry of Education in 2012, due to the understanding that these professionals are aligned with good recommendations for obstetric care. It therefore aims to train specialists in the residency modality to work in women's health care in the areas of reproductive health, prenatal care, childbirth and the puerperium, in line with the health policies in force in the Unified Health System (UHS).⁵,⁶

Also, in the field of training and professional development, in 2017 the Ministry of Health implemented the Project for Improvement and Innovation in Care and Teaching in Obstetrics and Neonatology (Apice On). Its conception is based on the qualification of care, management and training processes in Teaching Hospitals, transforming them into models with practices based on evidence, safety and humanization, with one of the highlights being the assistance to habitual risk deliveries by obstetric nurses in these institutions.⁷

The above-mentioned health policies support professional training through health residency programs as potential for change in the childbirth care model⁸ which, together with international evidence, consolidates the obstetric nurse as an important element in the composition of the team and in guaranteeing high quality obstetric care.⁹ This corroborates national studies, which point out that care models that ensure the inclusion of these professionals as de-medicalizing agents have positive results, such as a reduction in unnecessary interventions and an increase in the use of beneficial practices, leading to a reduction in caesarean section rates and ensuring women's satisfaction.¹⁰,¹¹,¹²

Given the above and the evidence describing the profile of the institutions participating in the Apice On project, as well as the strategies and their implementation process in Teaching Hospitals,¹³,¹⁴,¹⁵,¹⁶ it was considered relevant to understand the expected results indicated in the document describing this ministerial initiative, which are: “normal low-risk deliveries assisted by obstetric nurses or midwives”; “educational strategies developed and publicized that allow collaborative learning between groups of students from different health professions”; and “articulation between care and teaching and integrated work between multi-professional teams”,⁷:39 according to the perspective of the actors involved with professional training in the Obstetric Nursing Residency modality, in a Teaching Institution.

Therefore, the aim of this study is to describe the perception of graduates and the coordinators of the Obstetric Nursing Residency Program about the implementation of the obstetric nurse in the delivery room of a Teaching, Research and Assistance Institution that is part of the Apice On project, a process that represented the unprecedented introduction of this specialist in the field of labor and birth in this scenario.

METHOD

Descriptive, exploratory research with a qualitative approach, which seeks to understand and explain the dynamics of social relations through meanings, motives, aspirations, beliefs and values.¹⁷

The setting for this investigation was the maternity ward of a Federal Teaching, Research and Assistance Institution in the municipality of Rio de Janeiro/RJ, which is a benchmark in women’s, children’s and adolescents’ healthcare and has been operating as a Teaching Hospital since 2006. In March 2018, the institution was selected to join the Apice On Project, with the aim of qualifying the field of maternal and neonatal care, ending its participation in June 2020. Its service profile in 2021 listed 3,346 obstetric visits, 944 births, of which 435 were normal deliveries and 509 were caesarean surgeries. As an institution that offers specialized and more complex care, it recorded 256 and 40 births of fetal malformations and twins, respectively.

Five former obstetric nurses and the obstetric nurse coordinator of the Obstetric Nursing Residency Program at this unit took part in the study. The inclusion criterion for the study was having been a second-year resident and coordinator of the Obstetric Nursing Residency Program in 2019, as well as having experienced the historical process of implementing obstetric nurses in the delivery room based on the Apice On project. It is worth noting that these residents were carrying out their practical activities in the delivery room of this teaching hospital at the time and that they were considered by the maternity hospital’s nursing management to be important figures who, in conjunction with the two staff nurses hired by the ministerial initiative to work exclusively in the delivery room, could strengthen the care protocol for obstetric nurses in habitual risk deliveries. The exclusion criterion was medical leave during the data collection period.

Prior contact with the participants to present the research objectives and invite them to take part was made via WhatsApp, using the number provided by the Residency Program Coordinator, who has a record of all the obstetric nursing residents who have passed through the unit. The data was collected from all the nurses, as this was the only number of participants who met the criteria defined above. There was one refusal to participate.

Data collection took place between September and October 2021 and was carried out by a single interviewer who, at the time, was an obstetric nursing resident, adequately trained by the first author, who was responsible for guiding this research. The pre-scheduled meetings took place in reserved environments that guaranteed privacy and confidentiality, in a room made available at the maternity hospital or remotely, via the Google Meet platform, at the participant’s home.

After the participant’s authorization, the semi-structured interview followed, guided by a script containing open-ended questions: Considering positive and negative aspects, how was the participation of obstetric nursing in the Apice On Project?; Evaluate the Obstetric Nursing Residency Program; Do you see strategies that allow integrated learning between the Medical Residency Programs in Gynecology and Obstetrics and Obstetric Nursing? The interviews lasted an average of 45 minutes and were recorded on a digital device.

Content analysis in the thematic modality¹⁸ was used to structure the content of the transcribed narratives, comprising three recommended stages: 1) pre-analysis of the statements; 2) exploration of the material and treatment of the results; 3) inference and interpretation. Therefore, after the transcription and in-depth reading of the material, the recording units were identified using the “Text highlight color” feature in Microsoft Word®. The process resulted in the participants' speeches being decoded into 133 recording units, which were then grouped by similarity and gave rise to eight thematic nuclei: “value of obstetric nursing”, “training of obstetric nursing residents”; “implementation of the Apice On project in the maternity ward”; “impact of implementing the Apice On project in the maternity ward”; “obstacles with the medical team”; “emotional distress”; “position of the medical team” and “integration with the medical team”. In turn, the following categories were organized: “Humanized obstetric nursing care based on their professional training” and “The obstetric nurse’s implementation path in the delivery room of a teaching hospital based on the Apice On project”. It is worth noting that the research team has theoretical expertise in the subject and in the qualitative approach and contributed to deepening this stage. Subsequently, connections were made between the data generated and the conceptual frameworks of the subject.

In order to comply with National Health Council (CNS) Resolution No. 466/2012, this research registered the participation of those selected by signing the Informed Consent Form (ICF), which emphasizes voluntary participation and guarantees confidentiality and anonymity, in printed form or in printed form or by scanning it with the respective signature for those interviewed online. To this end, each interviewee was given a fictitious code name, identifying them by the letter I, for “Interview”, followed by the number corresponding to the order in which they were interviewed.

The project was submitted to the Ethics Committee of the Fernandes Figueira National Institute of Women’s, Children’s and Adolescents’ Health/IFF-Fiocruz and approved on September 2, 2021 under opinion no. 4.950.643 and CAAE no. 50235921.4.0000.5269.

RESULTS

Of the group of six participants, four were aged between 25-30, one between 35-45 and one between 45-55 years. Two nurses graduated from private institutions (33.3%) and four from public institutions (66.6%). All of them have the title of Specialist in Obstetric Nursing through the residency modality. In terms of average time working in obstetrics, the graduates had 3.5 years of experience in obstetrics and the coordinator had 32 years.

Below are the categories drawn up from the analysis of the narratives, which recall important moments for the institution in terms of the work of obstetric nurses and multidisciplinary relations in the delivery room, adding knowledge, values and meanings to a historic milestone for this Teaching Hospital, which joined this health initiative.

Humanized obstetric nursing care based on their professional training

The graduates and the coordinators of the Residency Program in Obstetric Nursing pointed out that, in their daily training and professional practice, obstetric care was characterized by good care practices, such as the use of non-pharmacological methods for pain relief, offering safety and support to women.

We used to do more midwifery, we used technologies, aromatherapy [...], we had the opportunity to provide indirect care while still in labor (I3).

I’ve used massage as a method, I could use the ball [...] we midwifed as best we could (I5).

And obstetric nursing isn’t just about direct childbirth care, there’s a lot you can do for the woman, a simple touch, just being by the woman’s side is already very significant [...] we deliver more, we respect the woman more, we see this woman as the protagonist of childbirth (I6).

Since the professional practice of obstetric nurses is based on the precepts of humanization and scientific evidence, they provide a counterpoint to the technocratic model. Therefore, the graduate obstetric nurses realized that they constitute potential and are responsible for driving changes in traditional care towards the desired model of humanized care.

We make a difference in the delivery room [...], we assist women in a different way [...] and that has an impact (I1).

We have a very important role to play in humanizing the patient, we are able to take a different approach [...]. I believe in the importance of our inclusion in this market, to encourage women's empowerment and humanization in itself (I4).

[...] we are gaining more ground, the evidence shows that where there are obstetric nurses you have a reduction in obstetric violence, an increase in natural births without episiotomy and fewer indications for caesarean sections (I5).

It can be understood that the guarantee of this assistance in the daily care of obstetric nurses reflects their training process. This aspect elucidated by the participants relates to their training base, the Obstetric Nursing Residency Program, with its syllabus structured from the Pedagogical Project guided by public policies to promote Women’s Health, strengthening the construction of their knowledge by articulating theory and practice.

We have guidance on other ways of caring for women, practical and theoretical classes, we have practices from aromatherapy [...], the possibility of taking professional courses (I1).

In the residency, I realize that our classes are very focused on practices based on scientific evidence, which gives us support to apply theory in practice (I2).

We’re always looking to improve the syllabus. [...] We build with the residents themselves, asking them to evaluate the syllabus and make suggestions to enrich the program (I6).

However, the participants evaluated the integration between the Obstetrics and Gynecology Medical Residency Programs and the Obstetrics Nursing Residency Program at this Teaching Hospital.

We knew how important integration was. The coordinators asked us to take part in rounds, [...] we tried, but the feeling I got was that we were just dividing up the field (I1).

I can’t see this integration, it's all very separate. It was even a complaint we had about obstetric nursing and the other residency courses. [...] everyone took part in everything, except medicine (I4).

The speeches point to attempts to maintain interprofessional articulation identified by educational strategies, but there is a lack of integration of common pedagogical proposals between the programs, due to the distance between the medical team. This makes it impossible for these professionals in training to participate effectively in teaching activities that take interprofessional education into account.

The obstetric nurse’s implementation path in the delivery room of a teaching hospital based on the Apice On Project

This category discusses the experiences of the graduates and the coordination of the Residency Program in Obstetric Nursing during the period when obstetric nurses were hired to work in the delivery room, according to the guidelines of the Apice On Project. Initially, the participants expressed satisfaction and enthusiasm at the arrival of this new ministerial proposal and saw it as an opportunity to get closer to the childbirth scenario by the hiring two obstetric nurses. This was because, in this hospital, the presence of specialists in the delivery room was non-existent due to a shortage of human resources, which directed the work of existing professionals in the wards of this educational institution.

Before implementing Apice On, we had a very difficult time getting into the Obstetric Center [...]. And afterwards, it became a little easier [...] because nurses were hired for the Obstetric Center (I2).

There have been many changes, [...] the biggest was when they managed to hire obstetric nurses to work there [in the Obstetric Center]. It was a step towards improving this insertion (I3).

I remember that at first we were very excited [...] it would be our chance to improve care (I5).

In the reports, it was observed that one of the results after the obstetric nurses became effective in the Delivery Room at this Teaching Hospital as a result of the project was better insertion to work with repercussions on the transformation of care conducts, qualifying care processes and favoring a model with practices based on scientific evidence, the humanization of care and the guarantee of women’s rights.

The Stork Network has been investing in obstetric nurses since 2011, followed by Apice On. This investment ends up providing a great gain for women, they have a positive childbirth experience, I'm not going to say that they are 100% free of violence, but it reduces a lot, even because obstetric nursing is attentive on these points (I5).

With Apice On, we’ve made progress on a number of issues that are part of the project, such as reducing obstetric violence and the number of interventions, I’ve never seen a Kristeller again, the episiotomy rate has decreased [...], we’ve made progress on newborn care, encouraging breastfeeding in the first hour of life [...]. We were able to midwife in the monitoring of labor (I6).

However, it is worth highlighting the adversities faced during the implementation of the Apice On project by the group of graduates who worked in partnership with the obstetric nurse preceptor to act, according to the precepts of good obstetric practice. Situations permeated by difficulties in understanding the proposal, its benefits and adherence by other members of the team, especially the medical category, pointed to resistance in this process.

We knew there would be clashes [...]. The medical team was very firm from start to finish and they didn't accept the introduction of obstetric nursing in childbirth care (I1).

I see the maternity ward with a very strong medical hegemony, they are resistant to change, so they clashed with the obstetric nurses [...] making the process even more difficult (I2).

The nurses [...] were full of ideas and enthusiastic, but the medical clash made it difficult, [...] they didn't want to listen to or understand our proposals, [...] this is very discouraging (I4).

As a result, these clashes were reflected in the collaborative practice between graduates of the program, the obstetric nurse preceptors and the team of obstetricians, as the categories and specialties showed limitations in working together due to difficulties in communication, mutual understanding, lack of knowledge of the expertise of their peers, which in turn made it impossible to articulate knowledge.

Not everyone was open to us working together, [...] we couldn’t share patients’ cases, they decided on the conduct and we weren't informed, [...] we had to accept it (I3).

In my opinion, what gets in the way is the team that doesn’t want to share the space they work in, let alone their knowledge, [...] but they [doctors] forget that we also have something to offer and they lose out too (I5).

Such attitudes on the part of the multi-professional team are not conducive to collaborative practices, they disregard the collective construction of decision-making processes regarding care, weaken inter-professional relationships and make it impossible to provide broader forms of care, taking into account the main common objective, which is scientific and humanized care for women.

DISCUSSION

The results of this study showed that the Obstetric Nursing Residency Program at this teaching hospital understands that caring for pregnant women during labor is reflected in the use of non-pharmacological methods for pain relief, whether through the use of the ball, massage, aromas and incense, which are configured in a developed and structured knowledge to give new meaning to labor.¹⁹,²⁰ But it is also permeated by a sensitive approach to issues that go beyond the biological aspects of the pregnancy-puerperium cycle and involve valuing the relationships established through bonds, support, the offer of safety and a closeness that fosters women's autonomy and empowerment by ensuring their participation in decision-making and control of the parturition process.⁹

In this understanding of the praxis of the obstetric nurse and its impact on the qualification of obstetric care, institutions that count on the presence and work of these professionals have better results for practices that are proven to be useful, such as walking, feeding, upright positions, the use of non-pharmacological methods for pain relief, which result in higher rates of normal delivery and, consequently, favor the reduction of interventionist practices, such as the Kristeller maneuver, episiotomy, oxytocin infusion and analgesia. In addition, they contribute to the quality of neonatal care through greater encouragement of practices such as skin-to-skin contact and breastfeeding in the delivery room,²¹,²²,²³ as demonstrated in this study, supporting an obstetric model that is intended to be amplified.

Therefore, the presence of the obstetric nurse can be considered a protective factor for these women by avoiding unnecessary interventions, ensuring the promotion of a physiological labor and delivery and offering humanized care, processes permeated by the establishment of empathetic relationships, respect and recognition of women’s rights.

It was found that this Lato sensu postgraduate course brings obstetric nurses closer during their training process to concepts and practices that consider the ideology of woman-centered care and encouraging the use of good obstetric practices, as dictated by national and international standards for the qualification of birth methods. As pointed out in the interviews, this is a consequence of the pedagogical structure that reconciles the theoretical with the practical and enables the acquisition of skills and knowledge resulting from lived experiences, thus enabling the training of professionals capable of building their own teaching and learning process. This puts them ahead of the game by preparing them to work in a context where they often have to balance the promotion of physiological childbirth with the modern demands of interprofessional and technological configurations.⁵,²⁴,²⁵

The challenge has fallen on the implementation of interprofessional education by the Medical and Nursing Residency Programs in Obstetrics at this institution, which are marked by a lack of integration between residents, unilateral participation in obstetric case discussion sessions and disputes and segregation during practical work and learning. This dynamic of coexistence can be explained by the characteristics of teaching hospitals, as they train their professionals based on traditional models of content selection and evaluation, with an emphasis on specialties.²⁶ Consequently, this leads to unpreparedness to work from the perspective of interdisciplinarity and indicates a process that goes against the grain of reorienting health training processes, which should consider the precepts of Interprofessional Health Education (IHE). This is conceived when students from different professions learn about each other, with each other and among themselves to enable collaborative work and expanded health outcomes based on collective dialog and the exchange of experiences, providing a better understanding of roles, responsibilities and the performance of their work.²⁷,²⁸

In this sense, the obstacles to interprofessional education presented in this study pointed out the challenges of the path to be followed in order to achieve the expected result proposed by the Apice On project in the participating Teaching Hospitals, established in the formalization of the use of educational strategies that enable collaborative learning.⁷ To this end, it is proposed to stimulate a process of in-service training that goes beyond theoretical content, with emphasis on the relationships that are established between practice and reflection on each action that makes it possible to improve what is done.²⁹ In this way, it strengthens the restructuring of care towards new learning and multidisciplinary collaborative practices that go beyond scientific evidence in labor and birth care.

So, in order to break away from the traditional patterns of teaching and care that are characteristic of a model of care led by the obstetrician, the first institutional measure was established for the implementation of the Apice On project: the hiring of obstetric nurses as an opportunity to maintain the definitive presence of these professionals in the delivery room and to be qualifying agents of obstetric care. This strategic action was of great value to the participants, as it gave them the power to act and the possibility of echoing the benefits related to the unprecedented presence of this category in the hospital's delivery room. This result showed progress when compared to the initial profile drawn up in the participating institutions about the quantitative difference in professionals qualified to assist in normal childbirth, in which only 0.9% of the human resources staff was made up of obstetric nurses, while 5.9% corresponded to obstetrician gynecologists.¹³

Even though these obstetric nurses are not fully operational, through an institutional protocol that guarantees that these specialists provide care for normal-risk deliveries, according to the result to be achieved by this health policy,⁷ it has been shown that their presence in the delivery room, as part of the Apice On project, means that they are responsible for promoting care that takes good practices into account. As a result, it has repercussions on the de-medicalization of care in a Teaching Hospital, by being able to reduce the chances of unnecessary and harmful interventions for women and their babies.

Although the value of the humanized care offered by obstetric nurses is evident, there were challenges expressed in the power relations, devaluation and less credibility given to these professionals when they work alongside medical professionals. As a result, obstetric nurses are limited in providing safe care, defending women’s rights and implementing a humanized obstetric model.³⁰

This finding corroborates the context in which this ministerial project was implemented in another teaching institution in the interior of the state of São Paulo, according to a study that described factors that compromise interdisciplinary action, such as care centered on the doctor, the idea of hierarchy between the team members and the opposing presence of the obstetric nurse, according to the doctors' perception.¹⁶ Unfortunately, these confrontations are related to a hegemonic model of obstetric care, which disregards the practices implemented by these nurses, based on the principles of humanization and which generate change in teaching hospitals.³¹

This reality brings back the cultural context of teaching hospitals. As they have the most complex health resources in the UHS, they have a model of care that exalts medical hegemony in the configuration of interprofessional relationships, making them disjointed and with fragile links established, which have implications for the development of decision-making power on care issues.³²,³³ As an effect, this model of care reflects on the professional autonomy of obstetric nurses and their legal competence to carry out their activities, making it impossible to provide care for normal risk births in these settings.

From this perspective, this research revealed that the collaborative care model in obstetrics, or shared care, in which responsibility for managing care lies with different professionals, with obstetric nurses providing the majority of obstetric care during labor and delivery at normal risk and ensuring immediate referral to the obstetrician in cases where complications are identified,³⁴,³⁵ is not fully consolidated in this Teaching Hospital. This is because the work dynamic is configured by the presence and action of the obstetric nurse during labor for some women, with the medical professional taking complete responsibility for the care. This is a methodology that distances this professional from the field of labor and birth and from the possibility of offering care that is characteristic of her. This represents an obstacle to the success of integrated work between multi-professional teams, as proposed by the Apice On Project.⁷

It is understood that in order to strengthen collaborative relationships, it is necessary to consider adopting new professional attitudes based on non-hierarchical relationships, trust and mutual respect, in other words, reorganizing roles and making professionals jointly responsible for planning and decision-making.³⁶,³⁷

Therefore, there is the possibility of recovering the understanding that the joint work of both professionals is essential, because each one, based on their competencies, enhances care for women, especially when it comes to Teaching Hospitals, which are generally references for high-complexity obstetric care. This is because it aligns the expertise of the obstetric nurse, who values the physiological aspects of childbirth and female protagonism, together with nursing care in specialized care, with the medical professional responsible for monitoring women at maternal and fetal risk. This reflects common care projects, with a convergence of views and actions so that each professional has their own disciplinary contribution to the therapeutic objective in favor of quality health care.³⁸

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE

This study made it possible to ensure that the work process of the obstetric nurse in the maternity ward of a teaching hospital is sustained by the value of the relationship and by offering comfort measures to women in labor. This is a set of actions that guarantee the unique care of this professional and provide positive birth experiences, based on good obstetric practices, good maternal and fetal outcomes and less exposure to unnecessary interventions, which are so common in these institutions that determine their actions centered on the technocratic vision of gestation and childbirth.

Considering the premise of this project, instituted by the Federal Government with the aim of reorienting the obstetric model in teaching hospitals based on qualified and integrated professional training for a collaborative work process, it can be seen that the Obstetric Nursing Residency Program is aligned with providing access to theoretical and practical content that takes into account the care guidelines determined by the regulatory bodies. However, there is still a need to advance in educational strategies that bring the Obstetrics and Nursing Residency Programs closer together for interprofessional education, which is responsible for training future professionals who are multipliers of actions that foster communication, the exchange of knowledge and skills for shared action among peers. This is to favor the future consolidation of obstetric nurses in the care of normal risk deliveries, as professionals who make up the field of labor and birth in educational institutions.

It is worth highlighting the limits of this research in terms of looking from the perspective of one of the actors participating in this process of implementing a ministerial proposal, which makes it impossible to represent the more than 90 institutions that are part of the Apice On project, and points to the need to expand the investigation to other scenarios. However, the evidence presented in this study suggests management guidelines for units that are undergoing a process of changing care paradigms, such as the need for all professionals to be better informed and recognized about the purpose of the new policies and their benefits for care practice, respect for institutionally defined regulations and appreciation of the specificity of obstetric nurses’ care. Consequently, to guarantee the strengthening and results of collaborative care models in obstetrics.

• a
  Extracted from the Residency Conclusion Paper - A inserção de uma maternidade de um Instituto Federal no projeto ApiceOn sob a ótica do Programa de Residência de Enfermagem Obstétrica - presented to the Lato Sensu Postgraduate Program of the Fernandes Figueira/Fiocruz National Institute for Women’s, Children’s and Adolescents’ Health, in 2022. Author: GABRIELA CIRQUEIRA LOPES. Advisor: Thalita Rocha de Oliveira.

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Edited by

Associated editor

Ivone Evangelista Cabral https://orcid.org/0000-0002-1522-9516

Scientific editor

Ivone Evangelista Cabral https://orcid.org/0000-0002-1522-9516

Publication Dates

• Publication in this collection
  12 Feb 2024
• Date of issue
  2023

History

• Received
  18 Sept 2022
• Accepted
  20 Nov 2023