NURSING PROCESS DIRECTED TO NEWBORNS IN A USUAL RISK MATERNITY WARD: NURSES' PERCEPTIONS

ABSTRACT Objective: to know nurses' perception in relation to the Nursing Process directed to newborns in a usual risk maternity ward. Method: an action-research study was conducted between September 2021 and January 2022 with nurses from a usual risk maternity ward in southern Brazil. The data collected through focus groups were submitted to content analysis. Results: the organized and analyzed data resulted in two thematic categories, namely: Nursing process: a self-reflection and self-criticism inducing device; and Nursing process: a (re)signifying care tool for newborns. In synthesis, it is shown that the Nursing Process is a driver of best practices in the Obstetric and Neonatal Nursing context. Conclusions: the Nursing Process directed to the care of newborns in a usual risk maternity ward is not only constituted as a theoretical-methodological tool to guide and qualify the care provided, but as a self-reflection and professional self-criticism inducing technology, with a view to the development of new knowledge and practices both in the scope of management and in Nursing care.


INTRODUCTION
The care provided to newborns immediately after birth is vital for their adaptation to extrauterine life, an indicator that contributes to the reduction of neonatal morbidity and mortality.Immediately after birth, newborns need to assume their own vital needs, which were provided by their mother through the placenta during the gestational period.Thus, the professionals who receive each newborn become assistants in the delivery process and are primarily responsible for the safety and quality of the immediate care to be provided [1][2][3] .
In the meantime, neonatal care has undergone many transformations and the emergence of new technologies has led to more expressive care spaces for newborns.The Neonatal Nursing practice stands out, which encompasses a grouping of conceptions that adapt to the structuring of the mutual collective care process 2 .Therefore, due to the nature of their work, nurses are fundamentally important to the detriment of the relationships/interactions in everyday care and organization.In addition, the act of touching to care enables the professional's approach and interaction with newborns, aiming at the qualification of neonatal and pediatric care, with the Nursing Process as theoretical-methodological support [3][4] .
The Nursing Process is a Nursing work tool that qualifies and optimizes care systematization.This constitutes a theoretical-practical activity that demands specific technical-scientific skills, capable of guiding clinical reasoning and diagnostic decision-making, results and interventions [5][6] .Under this approach, the Nursing Process induces best practices in the immediate care to be provided to newborns and favors the achievement of better results both in terms of management and care [7][8] .
Previous studies show that nurses have difficulties operationalizing the Nursing Process in the everyday practice.These difficulties can be related to the lack of appropriate technologies to perform the different stages, especially those related to diagnosis and to the systematic use of an adequate classification for designing the Nursing Process [9][10] .
In order to broaden the discussions, favoring the creation and consolidation of trigger products and/or that assist in the effective execution of the stages and in the qualification of the Nursing Process in relation to the planning and execution of care actions for the newborn, through technical-technological production, reflections and questions are directed to the understanding of these processes in the eyes of nurses working in the area.Thus, the objective was to know nurses' perception in relation to the Nursing Process directed to newborns in a usual risk maternity hospital.

METHOD
This is an action-research study [11][12] that, in addition to developing an investigative process, aims at contributing to the professional practice through sensitization meetings and the implementation of technology to contribute to the qualification of the Nursing Process.
Action-research is organized and systematized in stages, which are sequential and complementary at the same time, namely: identification of the problem in the context; survey of relevant data; analysis of the data collected; significance of the data collected; identification of the need for change; design of prospective strategies; intervention-action; and, finally, evaluation of the process, in order to evidence the advances 11 .
However, in this study, the results related to the second stage of the action-research "data survey" will be described, namely: Conducting a focus group with nurses who work in a usual risk maternity ward, in order to know their perception in relation to the Nursing Process directed to newborns.

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The maternity ward in question is part of a teaching hospital 100% accredited by the Unified Health System, a reference for usual risk pregnancies, located in the central region of the state of Rio Grande do Sul.Its physical structure consists of 18 beds, two pre-delivery beds, one evaluation room, two nurseries, one risk classification room, one vaccination room, one C-section room, two rooms for normal deliveries and two pre-delivery/delivery/post-delivery rooms.The maternity ward is a reference for all 33 municipalities that are part of the 4 th Regional Health Coordination Office of the Rio Grande do Sul central region.
The participants in this study were Obstetric Nurses from the aforementioned maternity ward and resident nurses in the 2 nd year of a Residency Program in Obstetric Nursing in the Rio Grande do Sul central region.This maternity ward employs six Obstetric Nurses, six first-year Resident Nurses and six second-year Resident Nurses from the Obstetric Nursing Residency Program.
The study included obstetric nurses with a specialization and/or residency in Obstetric Nursing and residents of the first and second year of the Obstetric Nursing Residency Program of a University from Rio Grande do Sul, and who had worked in the sector for at least six months.The obstetric and resident nurses who were on medical evaluation, with a medical certificate or on vacation during the data collection period were excluded.Based on these criteria, 6 nurses agreed to participate in the study.It is noted that, according to the inclusion criteria, all were eligible to participate; however, two nurses were on vacation and 10 did not agree to participate.
Data collection took place between September 2021 and January 2022 through the Focus Group 12 technique.This technique is characterized as a discussion group on a particular and specific topic, underwent and shared by experiences common to the group of participants, who received triggering proposals to begin the debates.Interaction and discussion of strategies among the group participants is one of the main characteristics of this technique.
Dynamization of the meetings/focus groups had the participation of a coordinator, in this case the main researcher, who assumed the role of moderator of the debates, and of an observer, with academic experience in the focus group technique.The observer supported the process of moderating the meetings and was responsible for the recordings, notes and reminders.
In all, five meetings/focus groups were held, and in each of the meetings one of the five Nursing Process stages was addressed, namely: Data collection, Nursing diagnosis, Planning, Implementation and Nursing evaluation, although these stages have been approached in a circular and complementary way.In the condition of the meetings, the coordinator followed a didactic script, which in this research favored the discussions and conduction of the tasks.The discussions of each focus group were audio-recorded for a maximum of two hours.
The didactic script followed some triggering questions to start discussions on the central theme of the research, with the following among them: What can you say about the Nursing Process?Do you consider the Nursing Process important for the reality where you work?What is the importance of the Nursing Process for Newborn care?How important is to create a product with the NP stages of the Process for Newborn care?
The recordings of the meetings/focus groups were fully transcribed by the main researcher.After being organized, the data were analyzed according to Content Analysis 13 , determined by the following phases: Pre-analysis, Exploration of the material; and Treatment of the obtained results and interpretation.
In this path, the pre-analysis consisted in a floating reading of the material with the objective of constituting the corpus based on completeness, representativeness and pertinence.The exploratory phase consisted in coding the material and defining the thematic categories.In the third and last

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phase, which consisted in data treatment, they were interpreted through theoretical and practical inference.In this phase, all the information was condensed and highlighted for analysis in order to enable inferential interpretations, based on intuition and on reflective and critical analysis 14 .
Therefore, the analysis took place by coding the data related to the participants' testimonies.Codes were created for the topics emphasized in the focus meetings in order to consolidate the thematic categories that emerged.
Throughout the action-research process, Resolution No. 466 of the National Health Council and dated December 12 th , 2012, was considered, with regard to the guidelines and regulatory standards for research studies involving human beings 15 .The research project was submitted to and approved by the Research Ethics Committee.The participants were identified throughout the text by means of the letter N (Nurse) plus a number.

RESULTS
Five meetings/focus groups were held, in which the five stages of the Nursing Process were treated in depth.All the six nurses who agreed to participate in the research were female and aged between 23 and 55 years old.Of these, five were second-year residents of the Obstetric Nursing Residency Program and there was an Obstetric Nurse from the aforementioned maternity ward in which the research was carried out.
The organized and analyzed data resulted in two thematic categories, namely: Nursing process: a self-reflection and self-criticism inducing device; and Nursing process: a (re)signifying care tool for newborns.

Nursing process: a self-reflection and self-criticism inducing device
From the perspective of the participants included in this study, the Nursing Process is an important resource to qualify Nursing care.It can cause ruptures, overcome barriers and raise (re) constructions in the course of health care.Under this impulse and accompanied by technologies, the Nursing Process is an important inducing device for self-reflection and self-criticism of the everyday professional practice.
Taking into account everything we comment here and everything that will be brought to discussion, I think a product that explains the Nursing Process is very important.However, while the peers were talking, I realized that we have many flaws, not only in the issue of pregnant and puerperal women, but mainly in terms of the newborns.I think you need to invest in this process in a more qualified and complete way through products and technologies (N1).
It was evidenced that, in addition to organizing, optimizing and singularizing Nursing care, the Nursing Process also has the potential to qualify communication between team members and between them and other health professionals.Under this approach, it is noted that the everyday routine sometimes mechanizes and automates the care process, due to the inefficiency of systematized and agreed paths with all the professionals involved in care.
[...] the Nursing Process systematizes care to qualify it and also to improve communication with the team.It's a way to have the care by the technical team that is necessary with that newborn in the patient's medical chart, because they follow the medical prescription that contemplates other things.This care we have a routine, but many times, this routine isn't monitored because we don't have any systematization of this assistance.The Nursing Process goes far beyond prescription and care because it involves all the care stages.It includes from the patient's arrival at admission, the history that we make, then the diagnoses that we'll list for her, the care plan, the interventions, and the evaluation to determine if this was efficient for the care provided to the patient [...].Sometimes

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we have a very attentive look at the parturient woman, do all this process with her, but with the baby it ends up not being done.With the baby it turns out that we don't perform some of these stages.And systematizing is important to have the records and improve the service as a whole (N2). [

...] it's important because it's a way of organizing information and qualifying communication (N4).
Another recurring element in the discussions is related to the care focus for puerperal women and for newborns, which is most often relegated to the background.In this direction, the collective discussions about the Nursing Process contributed to self-evaluation and to a reflection on the need to include newborn care.Under this approach, the discussions contributed to reviewing attitudes and agreeing upon improvement strategies in relation to care systematization.
So I think it's really important.And in fact, the Nursing Process comes to organize, structure the service and improve the quality and serve each patient in their uniqueness.We end up doing a process there, but if there was a standard, a model, a technology would be very relevant (N3).
Although the participants mentioned the relevance of a technology to support the effective implementation of the Nursing Process in this usual risk maternity ward, the discussion was not limited to the generation of a support product.Above all, they enabled a self-analysis process about the everyday professional practice and led to new thinking and acting, more integrative, aggregating and innovative.Therefore, in addition to the results achieved, the discussions in the focus meetings enabled inducing self-reflection about being and doing in Nursing in the everyday practice.

Nursing process: a (re)signifying tool for newborn care
In the participants' testimonies, the relevance of the Nursing Process as a tool that induces new knowledge and practices associated with newborn care was evidenced.In addition to expanding the view about the managerial and care aspects, the Nursing Process directs the best care course of action to be adopted with each newborn.Under this approach, the Nursing Process is not reduced to a specific work routine but directs to the best action to be taken in each situation, as expressed below: [...] from the patient's admission in the unit, it contemplates all the care measures, from materials that we need to provide for care, the team [...] phases that we're filling for the care of the newborn and how to best direct this care, in each situation (N1).
I think that the process is just that, everything we can see in the patient is already planning that care.Everything that's observed in the appointment will already generate specific care (N3).
[...] to improve and organize care quality so that this team may offer continuity of the care measures (N5).
Several times, the participants reinforced that the Nursing Process is not reduced to a document, a prescription or a daily evolution.The process involves a round trip, based on reflection and critical reasoning, as well as on a Nursing theory.
Although the participants mentioned the importance of the Nursing Process, the need for professional qualification for its effective implementation is noticed at some moments in the professionals' practice.The Nursing Process expands possibilities and leads nurses to an expanded perception of the care provided.Therefore, it is also a tool that enhances initiatives and innovative paths to promote care.
[...] one of the things that's observed in the maternity ward and that has already been said is that the Nursing Process is directed to the parturient, but at the beginning, when the patient arrives, that history that we did is the evolution of the evaluation.There are many more things to be expanded and qualified in our practice.There's a range of options that can be expanded and implemented in the maternity ward, especially in newborn care (N6).

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In the participant's testimonies, it can be seen that the Nursing Process carried out does not coincide with the perspective of care individualization, interfering with the humanization principles.In addition, based on the above, it can/should be considered an important (re)signifying care tool, especially for newborns.Nursing care cannot be treated as a specific and linear action but needs to be contemplated as a prospective movement that involves both the professional-user relationships and interactions and the theoretical-methodological resources that support it as a theoretical-methodological Nursing technology.

DISCUSSION
The Nursing Process directed to newborns from a usual risk maternity ward cannot be dissociated from the care provided to the mothers.The care for the mother-infant dyad should be conceived as a complex unit.Therefore, professional mobilization in favor of the humanization of birth has instigated, on a daily basis, health professionals to research the relationship between scientific and technical factors that are indispensable to the provision of safe and good quality newborn care [14][15] .
Given the complexity of a birth and nurses' role in the everyday work related to newborn care, it becomes necessary to broaden the focus of the discussions and consider that the Nursing Process is an important facilitating resource for the assistance/care provided by nurses, as it fosters a clinical and inquiring sense, in addition to favoring resolute and prospective actions.Furthermore, its applicability demonstrates professional commitment to the promotion and conduction of care as a singular and multidimensional process 16 .
In the meantime, within the humanization context, which occurs through the provision of singular and integral care, nurses are encouraged to be undertakers, in order to go beyond the technocratic model.It is essential to exchange diverse knowledge between professionals and users during the care implementation process, because it is through such specificity of the Nursing Process that the nurses' bond with the users and families is strengthened [6][7][8][9][10][11][12][13][14][15][16][17] .
In this sense, comprehensive care for the mother-infant dyad is effective when provided by a team, based on resources that contemplate the interactive and associative care dimension concomitant with different phases that involve systematization.Although health professionals recognize the importance of comprehensive care, their attitudes still move in a fragmented and dichotomous way, mainly in situations in which the biological aspect stands out from the other dimensions [18][19] .
The participants of this study highlighted the importance of the Nursing Process directed to newborns considering that, in the aforementioned usual risk maternity ward in which they work, the emphasis of care is on pregnant/parturient/puerperal women.Therefore, the following question is asked: How to promote and systematize Nursing care in order to contemplate the mother-infant dyad?Is it possible to conceive care that is not integrative and aggregating?It is noted that, although the Nursing Process has already showed its relevance in nurses' everyday professional practice, it is still frequently carried out in a routine and careless way, unaccompanied by critical-reflective thinking 19 .
In addition to specific technical knowledge, the Nursing Process demands cognitive, psychomotor and affective skills and abilities from nurses, which require critical judgment, flexibility and creativity in the design of shared care plans in view of the specificities of each user [18][19][20] .
It was also noted that, although considered relevant and pertinent by the research participants, the Nursing Process raises doubts regarding how to record it appropriately and systematically, usually due to work overload, which exerts impacts on the generation of diverse evidence on the quality of

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the Nursing actions in the nurses' clinical practice context.To ensure safety, effectiveness, quality and sustainability, the Nursing Process depends both on effective communication between team members and on clear and reliable records 21 .In this approach, it becomes necessary that the Nursing Process is supported by a Nursing Theory, which directs the performance of a professional category.
It is noted that Nursing has several classification systems for the development of one or more stages of the Nursing Process.Thus, in this research we opted for Wanda de Aguiar Horta's Theory of Basic Human Needs, due to the perception that newborns require specific care, promoting the adequate registration of their clinical characteristics.
In this assertion and under this approach, the quality of the documentation and records has been the object of countless studies and research, in addition to inducing policies, such as the CAPES/ COFEN Agreement.A number of studies 6,22 show that lack of understanding and scientificity for its execution, precarious environment, reduced and overloaded staff, low remuneration, professional devaluation and non-support from the service management are some of the factors that hinder effectiveness of the Nursing Process in the practice.Understanding how nurses experience the everyday care routine and the applicability or not of the Nursing Process makes it possible to understand the reasons that hinder or facilitate the process of using the method for professional decision-making in their everyday work.
When addressing issues inherent to the Nursing Process stages, they clarify that, in relation to newborns, many of them are partially performed in the usual risk maternity ward where the data were collected.In this sense, a study 22 pointed out that all advances related to the assistance provided and inherent to the development of good practices optimize neonatal care and enable achieving better results, as they organize care in the work environment itself by resorting to a specific method, instruments and personnel.
The creation and institutionalization of routine care protocols in Nursing care for newborns favors the work process and aligns communication between the team members, with a view to minimizing adverse events.Under this approach, the protocols and standard operating procedures are established, such as procedures ordered in a systematic way, so as to enable the Nursing/Health team to execute them through predetermined steps and conducted based on validated theoretical and practical frameworks 23 .
The limitations of this study are associated with the non-participation of all nurses and residents eligible by the inclusion criteria, previously listed, as well as with the fact that this research was carried out in only one usual risk maternity ward, which precludes generalizations.
It is noted that the main contribution to the Nursing area is associated with sensitization of the nurses participating in this research about the relevance of the Nursing Process directed to newborns in usual risk maternity wards, considering that few studies have been located in this perspective.Thus, the results of this research may come to leverage prospective strategies related to the Nursing Process, both within the management scope and in terms of Nursing care.

CONCLUSION
The Nursing Process directed to newborn care in a usual risk maternity ward does not only represent a theoretical-methodological tool to guide and qualify the care provided, but a technology that induces self-reflection and professional self-criticism, with a view to the development of new knowledge and practices both in the management scope and in Nursing care.

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In this approach, it is concluded that the objective of knowing the nurses' perception in relation to the Nursing Process directed to newborns in a usual risk maternity was achieved and that, in addition, it was possible to verify that the participants consider the Nursing Process as an important (re)signifying tool for Nursing care.Thus, it is shown that the Nursing Process is a driver of best practices in the Obstetric and Neonatal Nursing context.
Thus, the new knowledge produced is the focus that the Nursing Process cannot be treated as a specific and linear action but that it needs to contemplate a prospective movement, which involves both the professional-user relationships and interactions and the theoretical-methodological resources that support the Nursing Process as an inducer of new Nursing knowledge and practices.
In addition, referring again to the Nursing team, they are the professionals that participate promptly so that the public policies are implemented, for humanized assistance to be provided and by the search for constant knowledge, aiming to qualify the care provided to newborns through technology and scientific basis.Such professionals are responsible for the recognition of good practices implemented in the unit and for the provision of comprehensive care.
Finally, advances in research studies related to the theme in question are suggested, particularly involving the practical field inherent to newborns, in order to evaluate the applicability of the Nursing Process and the professionals' adherence to the care technology for qualifying the assistance provided to newborns.It is hoped that this research may contribute to fostering the debate about the implementation of the Nursing Process for newborns in usual risk maternity wards, in addition to leveraging new studies that show the Nursing advances in this area in particular.