Introduction

In the past, childbirth was an event that took place at home with the aid of the midwife, a woman the family trusted. ¹ During the twentieth century, the process migrated from an individual and family context to the hospital where new players devised a new set of standardized and interventionist practices.²The irrational and indiscriminate use of technologies has led to a perinatal paradox because, despite improving new-born survival, there is no evidence maternal mortality has improved.³

The increase of the rate of caesarean sections and the use of technologies changed childbirth care and led to a range of interventions in the physiological process of giving birth.⁴ The humane care model emerges as a response to this state of affairs. Its goal was to return to a process that respects the physiology of childbirth, in which interventions are based on scientifically proven criteria that take into consideration cultural and social aspects and women’s autonomy.⁵

In view of the level of maternal and perinatal morbidity and mortality as well as the high rates of caesarean sections, the Department of Health implemented policies aimed at changing childbirth care and supporting natural birth practices. Amongst such practices was the incorporation of an obstetrical nurse in childbirth and childbirth care.⁶ These professionals are trained to respect the physiology of childbirth, to establish a balance in the use of necessary interventions and to promote low-intervention in low-risk pregnancies. It is important to point out that the obstetrical nurse assists normal deliveries but is expected to call immediately for an obstetrician in case of complications. ⁷

Considering the obstetrical nurse’s legal competencies regarding the monitoring of labour, norms, regulations and decrees contribute to the humanization of childbirth and the delivery of high-quality care, as well as help to restore women’s predominant role in childbearing. These professionals can go beyond an interventionist model and propose practices that promote an individualized and humane care.³

There are few Brazilian studies that deal with the perception of obstetrical nurses on the models of care provided in hospitals and on professional autonomy and that take into consideration workplace, resources and professional relationship within the team. Therefore, this paper aims at identifying the view of obstetrical nurses of the healthcare model and practices in a philanthropic maternity hospital.

Methodology

This is a descriptive and exploratory research with a qualitative approach which allows a broader evaluation of the results obtained, and enhances description, explanation and understanding of the object of study.⁸

In Belo Horizonte, Minas Gerais, some maternity hospitals encourage multiprofessional teamwork and acknowledge the obstetrical nurse as the provider of humane care to pregnant women. The philanthropic maternity hospital in question is fully subsidized by the Unified Health System (SUS) and offers equal access care. Its team of obstetrical nurses provide comprehensive care to pregnant and postpartum women and new-borns. They deliver antenatal care to low-risk women; perform admission assessment and follow-up before and after delivery including hospital discharge and new-born evaluation. This professional also performs management and continuing education activities. Thirteen of a team of sixty-four obstetrical nurses answered the interview questions. The inclusion criterion was obstetrical nurses who worked at the hospital for at least two years. Professionals who were on sick leave, maternity leave, had time off for training or those on notice were excluded. The researchers consider that length of service contributes to familiarization with and recognition of the model of care used.

An interview was scheduled as soon as potential research subjects accepted invitation to participate. Semi structured interviews were held at the institution, during lunch time, tea break, or after working hours, in a reserved location. The average twenty-minute interviews took place from September 2015 to February 2016. After the 13th interview the researchers detected data saturation and concluded this step. The interviews collected the subjects’ personal identification and professional data, length of service at the hospital, health care practices, and their perception about them, as well as the health care model practiced at the institution. The interviews were audio recorded and later transcribed in full. This text was then revised in order to improve style and eliminate vices of language and repetitions.

Treatment of data used Bardin’s content analysis which comprises a set of techniques that aims at analysing narratives through systematic procedures that describe message content. The process analysis followed three steps: 1) pre-analysis, which involves skimming the text in order to become acquainted with the content; 2) exploration of the material that seeks better interpretations and inferences; and 3) treatment of results that selects relevant information after critical and reflective analysis.⁹

The names of the participants were replaced by names of Greek goddesses chosen by the researcher. Theoretical saturation occurred when data became redundant or repetitive. At this point, new participants were no longer necessary and data collection was suspended.¹⁰ The study complied with Resolution 466/12 of the National Health Council that legislates over research with human beings. The project was submitted to the Research Ethics Committee of the Federal University of Minas Gerais and approved under case No. 39444614.6.0000.5149 dated April 1, 2015. The interviewees signed two copies of the informed consent form; one copy was given to the participant and the other to the researcher.

Results and discussion

The profile of the 13 participants is presented quantitatively. Table 1 displays the characterization of the obstetrical nurses.

Table 1 – Characterization of obstetrical nurses of a philanthropic maternity hospital in Belo Horizonte. 2016. N = 13

Variables	n	%
Age
30-34 years	5	38
35-39 years	3	24
≥ 40 years	3	38
Sex
Female	13	100
Length of specialty training
7-10 years	9	69
11-14 years	4	31
Length of time employed at the hospital
5-10 years	8	61
11-16 years	4	31
≥17 years	1	8
Workload
24-30 hours	3	23
31-37 hours	3	23
≥38 hours	7	54
Duties performed
Childbirth care	6	46
Childbirth care and management/coordination	2	15
Childbirth care, management/coordination and women’s health clinic	1	8
Care during labour and other areas	4	31
Working in another hospital
Yes	5	38
No	8	62

Source: data collected by the authors, 2016.

The analysis of the interviews revealed five categories: actions based on humanization of care and good practices; nurse autonomy; experienced professionals as reference for decision making; teamwork; performance model.

Performance based on humanization of care and good practices

In this category, the interviewees mentioned a health care model based on the principles of humanization and good practices. Humanization for them is linked to the respect to the parturient’s wishes regarding choice of birth companion, childbirth position and the physiology of birth. This is reflected in the following statements:

My performance generally focusses on and respects the woman’s needs. I try to find out whether she has a birth plan, how labour is developing, never overlooking hers or her partner’s opinion. (Leto)

The woman’s right to walk around, shower, drink, use the exercise ball, her right to have a companion, to good practices. (Gaia)

The narratives also exposed the need for improvements and the difficulties related to service demand and attitude of some professionals who did not incorporate good practices principles adopted by the institution. These situations revealed weaknesses that could compromise quality health care.

We know some colleagues do not share these principles [...] Skin-to-skin contact, presence of a companion, choice of birth position. Professionals from other institutions have not yet assumed such practices. When medical professionals do not follow humane care practices, conflicts with staff happen. So sometimes we clash, especially with doctors who are not fully aware of the protocols. In some cases, we have to intervene, in the Kristeller manoeuvre, for instance. Such actions are not attuned to humane practices favoured by the staff, but we believe that over time, they will embrace this cause. (Selene)

[...] The hospital approach is based on humane principles and it provides high quality care [...]; improvements are needed especially with regard to the workload, but it yields good results and I believe the tendency is to improve. (Artemis)

Obstetrical nurses reported acting autonomously, seeking humanization and good practices. They recognized the importance of their work and of team building and sough to provide care whose outcomes are positive for both mother and child.

In order to humanize obstetrical care, interpersonal relationships with women, new-borns and labour companion have to be secured. Nurses should as well consider the peculiarities of each situation.¹¹ In the parturition process, good quality and humane care should be safeguarded with the adoption of good practices during labour and birth. A study carried out at public maternity hospitals in Rio de Janeiro totalled 3,197 deliveries in maternity A and 2,190 in maternity B. The study revealed that obstetrical nurses used higher percentages of noninterventionist techniques such as non-pharmacological methods to relieve pain, massage (1,014 = 34.80%), warm water spray (684 = 23.48%), freedom of movement (1,616 = 55.48%) and pelvic exercises (573 = 19.67%), as well as provided emotional support. ¹ Such findings corroborate the reports of the present study.

Job demands and the difficulties of teamwork revealed weaknesses that influence assistance negatively. Inadequate communication between nurse and team hinders their relationship. Opening up a channel of communication would offer the possibility to strengthen the relationship between nurse and other health professionals.¹²

Work overload interferes with and impairs quality of care, and can lead to intolerance, stress, personal demands, physical exhaustion, and frustration amongst team members. These situations can be triggered by professionals who feel unable to provide the type of care they want which can lead to demotivation and dissatisfaction.^13-14

To the interviewees humanization of childbirth means respect for the parturient’s choices and her companion’s, as well as fewer interventionist practices and attention to the normal physiology of birth. On the other hand, the lack of report on humanized surgical births is noteworthy. The researchers inferred then that the nurses’ perception of a humanized childbirth was limited to low-risk vaginal deliveries. Also, in this category, the nurses mentioned the conflicting relationship between fellow nurses and other health professionals, mainly the obstetrician. This jeopardizes the provision of a comprehensive, qualified and humanized care, besides hindering a harmonious teamwork.

Autonomy

In this category reports of nurses that believed they were acting autonomously and providing continuous and integral assistance to women were included. Bonding with users begins during antenatal care and goes through to admission, labour, delivery and postpartum, treatment of complications and hospital discharge. Nurses claimed to have knowledge and competence to provide care in all stages of the puerperal pregnancy cycle.

[...] We have autonomy from antenatal to hospital admission; we can do this monitoring labour and delivery until patient discharge. I consider this to be comprehensive care in low-risk pregnancies. (Medusa)

The nursing professionals used their knowledge and continuous learning experiences in decision making and believed that institutional support is a facilitating factor that enables autonomy, since it provides protocols and opportunities for continuing education, as can be seen below:

[...] in a low-risky labour I have autonomy to assist the woman. We can make decisions based on the institution’s protocol (Medusa).

[...] we can achieve this objective because of the conditions created here. The issue of autonomy of obstetrical nurses, the dissemination of protocols, and continuing education, greatly helps our performance (Hecate)

Autonomy and comprehensive care contribute to the success of the assistance provided. Nurses are free to make decisions and choices, but they need their approach to be differentiated, according to ethics and knowledge, as well as their problem solving ability.¹⁴ Thus, it can be inferred that nursing autonomy is linked to positive outcomes, credibility and respect towards team members and users.

Autonomy is achieved through quality training based on up-to-date studies and international guidelines. The objective is to improve practices, skills and attitudes.¹⁵ Professional update through continuing education programmes improves work process, quality of care, and the collaboration between multidisciplinary team and institution. Such programmes are usually designed to secure previously acquired experiences and knowledge.¹⁶

Given the reports about autonomy, the researchers concluded that knowledge confers confidence, especially when the professional has institutional support, uses and can access easily updated protocols. The Council of Nurses also supports nursing autonomy and decision making, which was mentioned throughout the interviewees’ reports.

Experienced professionals as reference for decision making

In this category, the participants analysed their performance in complications and high-risk cases. They, initially, follow the institution's established protocol and, when necessary, call on more experienced nurses or the medical team.

[...] During labour or clinical case, whatever the situation, if any complication happens, we follow the protocol. We discuss the case with the professional on duty, whether it is an obstetrical nurse, an obstetrician or another professional, depending on the situation. (Sofia)

[...] Cases are discussed with the obstetrician on duty; even within the obstetrical nurses’ team talking is stress-free. (Selene)

The presence of a skilled and experienced nurse confers confidence and security to women helping them to face labour with serenity, patience and ease.¹⁴ The obstetrical nurse’s performance displays autonomy associated with decision making ability directed to good management practices. This professional is able also to share with the team decisions that involve pre-delivery, delivery and postpartum care.¹²

Decision making and autonomy were abilities detected amongst obstetrical nurses in a study carried out in Ireland. It aimed at identifying the model of these professionals’ advanced and specialized practice, as well as the benefits in assisting women and babies by means of the partnership between the obstetrical nurse and the medical team. The study also described the holistic and attentive care provided, which generated positive clinical outcomes.¹⁷

The interviewees discussed their experience on autonomy and team integration during complications. They emphasized the importance of protocols that favour safe decision-making, as well as the exchange of knowledge with work colleagues which contributed to creative problem solving and quality care for high-risk women.

Teamwork

Research participants had similar opinions about teamwork. They were unanimous in reporting that decisions were collectively taken and recognized the importance of implicating different health professionals in the process. They reported that doctors assist high-risk cases, but that obstetrical nurses’ participation is important.

[...] the team only works when each member participates, and our ultimate aim is to provide high quality care to women during delivery and birth. So, we must have a harmonious, balanced team in which all involved are speaking the same language. So, the role of the obstetrical nurse is to make sure all team members are on the same page. (Athena)

[...] Decisions, most of the time, are made by the team, they very rarely are individual decisions. We work closely with the doctors, so decisions are made with them. (Pandora)

[...] the ON has a very important role within the team. (Ariadne)

The obstetrical nurse should seek a collaborative model, which counts on the participation of all professionals involved. When the team works together, challenges are overcome more easily since cooperation reinforces the exchange of experiences and consequently furthers health professional’s understanding of the delivery process.¹³ Multiprofessional teamwork means the union of team members, and each member communicates and connects care techniques for decision making. Healthcare work processes recognize the work of others and require the establishment of a partnership between those involved, mediated by communication and sustained by respect and ethics. This method enables health professionals to understand the importance of implementing a set of systematic and consistent practices.¹⁸

The participants’ narratives suggested that nursing professionals should strive to achieve high-quality care through teamwork. Such collaborative efforts would guarantee the professionals’ coexistence and the exchange of knowledge towards a joint decision making. To this end, each of them has a unique and prominent role in monitoring labour, delivery and postpartum.

Care model

When asked how they define the hospital’s care model, the interviewees were not able to specify one, but were able to conclude that they provide assistance based on humane care and on a teamwork model.

[...] Care based on good practices. (Gaia)

[...] I define this as multiprofessional. (Sofia)

[...] Humanization model. (Afrodite)

[...]Respect for women when giving birth (Selene).

Although the participants did not specify a health care model during the interviews, it is possible to infer that their interventions are close to a humane model which considers the individual’s biological, social, psychological, and spiritual needs.¹⁹

The humane model of care views childbirth as a physiological process that needs to be monitored. Biopsychosocial, affective and cultural aspects are observed, and technology is rationally applied. When used such practices give greater satisfaction to the user who participates and is the protagonist of the event.²⁰ The professional interacts with the parturient and communicates with her so decision making is shared. There is a balanced use of science and technology which is subjected to scientific evidence and to the humane treatment of woman and her family. Delivery and birth are assisted by a multiprofessional team.²¹

The participants’ narratives also mentioned a new perspective of health care as a collaborative effort, in which professionals extend care to patients and their families. This model allows health providers to work in teams, building partnerships and establishing an environment of mutual help.¹³ According to them this way of working is beneficial and has a positive impact on quality of care, and on the user’s and professional’s satisfaction.

Final considerations

There have been several advances in obstetrical care in Brazil like the reintroduction of obstetrical nurses in the puerperal cycle. These professionals are recognized as providers of care based on good practices. They are more respectful of the physiology of childbirth by being less interventionist.

The study revealed that the obstetrical nurses were part of a team, considered dialogue as a vital mechanism for professional collaboration, and recognized the importance of different players in the work process, as well as the relevance of their own expertise. Hospital administrators made significant contributions to their interventions, when they encouraged and appreciated their input. Institutional support helps the performance of the obstetrical nurse and the multidisciplinary team, contributing to their autonomy and to the adoption of good practices.

Work overload and disagreements about practices may be a source of conflict among team members. These types of situations can be solved or minimized by increasing and better qualifying the workforce, especially obstetrical nurses enhancing, therefore, their performance.

Professional autonomy is endorsed by the presence of obstetrical nurses in different areas and dealing with various levels of complexity. A continuing education programme should be promoted by the institution and based on scientific evidence. Protocols are important tools that standardize and assist in decision making.

The present study was developed in a single institution, which limited its results. Investigations in more maternity hospitals are necessary in order to identify other models of obstetrical care and contribute to the inclusion of obstetrical nurses in a multidisciplinary team.

The researchers expect that this study will help to overcome challenges for the insertion of the obstetrical nursing professional, both within healthcare team and management. Furthermore, it subsidizes studies related to the nursing practice. It is also necessary to create strategies to overcome conflicts and improve a collaborative and humane health care model.

The research hindering factor was the impossibility to compare its results with those of other institutions which might have contributed to broaden the propositions arising from it.

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Corresponding author

Torcata Amorim

E-mail: torcata@enf.ufmg.br.

Endereço: Escola de Enfermagem - UFMG. Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, Brasil.

CEP: 30130-100

Author Contributions

1 – Torcata Amorim

Design and planning of the research project; Collection or analysis of data; Interpretation of data; Essay; Critical revision.

2 – Aline Carolina Marques Araújo

Design and planning of the research project; Collection or analysis of data; Interpretation of data; Essay.

3 – Eliane Marina Palhares Guimarães

Interpretation of data; Critical revision.

4 – Solange Clessêncio Ferreira Diniz

Interpretation of data; Critical revision.

5 – Helen Martins Gandra

Interpretation of data; Essay; Critical revision.

6 – Maria Cecília Rodrigues Macedo Cândido

Interpretation of data; Essay; Critical revision.

How to cite this article

Amorim T, Araújo ACM, Guimarães EMP, Diniz SCF, Gandra HM, Cândido MCRM. Perception of obstetric nurses on the care model and practice in a philanthropic maternity hospital Rev. Enferm. UFSM. 2019 [Acess at: Year, Month, Day];vol e29: Px-Px. DOI:https://doi.org/10.5902/2179769234868