Rev. Enferm. UFSM, v.14, e4, p.1-13, 2024
Submission: 9/15/2023 • Acceptance: 1/16/2024 • Publication: 1/31/2024
Original Article
Identification of the family and social context in records of nursing consultations with the mother-baby binomial
Identificação do contexto familiar e social em registros de consultas de enfermagem ao binômio mãe-bebê
Identificación del contexto familiar y social en registros de consultas de enfermería para el binomio madre-bebé
Márcia Beatriz Berzoti Gonçalves I
Ana
Paula de Miranda Araújo SoaresII
Ana
Izaura Basso de OliveiraII
Diene
Monique CarlosII
Aline
Cristiane Cavicchioli Okido II
I Secretaria Municipal de Saúde de Ribeirão Preto. Ribeirão Preto, SP, Brasil
II Universidade Federal de São Carlos. São Carlos, SP, Brasil
* Extracted from a Course Completion Paper "The look at the family and social context in nursing consultations for the mother and newborn binomial" of the Specialization in Pediatric Nursing of the Federal University of São Carlos, 2023.
Abstract
Objective: to identify information related to the family and social context in records of the first nursing consultation with the mother-baby binomial. Method: Mixed-methods study with Concomitant Data Incorporated Strategy. A script was used consisting of eight questions with dichotomous answers and space to transcribe the sentences related to the family and social context. Data was analyzed using descriptive statistics and deductive content analysis. Results: of the 326 records, 30% described the presence of other family members at the appointment and the emotional state of the puerperal woman. Information on family structure and support networks was present in 27.3 and 21.8% of them, respectively. The experience of pregnancy was the least mentioned aspect (4.3%). The diagnosis most commonly included was "Mother-child bond preserved". The sentences converged and indicated a limited exploration of the context and a focus on the biomedical model. Conclusion: the majority of records lacked information on the family and social context.
Descriptors: Nursing; Family; Mothers; Infant, Newborn; Primary Health Care
Resumo
Objetivo: identificar informações relacionadas ao contexto familiar e social em registros da primeira consulta de enfermagem ao binômio mãe-bebê. Método: estudo de Métodos Mistos com Estratégia Incorporada Concomitante de Dados. Utilizou-se roteiro composto por oito questões com respostas do tipo dicotômicas e espaço para transcrever as sentenças relacionadas ao contexto familiar e social. Dados analisados por estatística descritiva e análise de conteúdo dedutiva. Resultados: dos 326 registros, 30% descreveram a presença de outros familiares na consulta e o estado emocional da puérpera. Informações sobre estrutura familiar e rede de apoio estavam presentes em 27,3 e 21,8% deles, respectivamente. A experiência da gestação foi o aspecto menos mencionado (4,3%). O diagnóstico comumente incluído foi “Vínculo mãe e filho preservado”. As sentenças convergiram com os dados quantitativos ao indicar limitada exploração do contexto e centralidade no modelo biomédico. Conclusão: na maioria dos registros não constava informações sobre o contexto familiar e social.
Descritores: Enfermagem; Família; Mães; Recém-Nascido; Atenção Primária à Saúde
Resumen
Objetivo: identificar información relacionada al contexto familiar y social en registros de la primera consulta de enfermería para el binomio madre-bebé. Método: estudio de métodos mixtos con estrategia integrada de datos concomitantes. Se utilizó un guion compuesto por ocho preguntas con respuestas dicotómicas y espacio para transcribir las frases relacionadas con el contexto familiar y social. Datos analizados mediante estadística descriptiva y análisis de contenido deductivo. Resultados: de los 326 registros, el 30% describió la presencia de otros familiares en la consulta y el estado emocional de la puérpera. La información sobre la estructura familiar y la red de apoyo estuvo presente en el 27,3 y el 21,8% de ellos, respectivamente. La experiencia del embarazo fue el aspecto menos mencionado (4,3%). El diagnóstico comúnmente incluido fue “Vínculo preservado entre madre e hijo”. Las frases convergieron con los datos cuantitativos al indicar una exploración limitada del contexto y la centralidad en el modelo biomédico. Conclusión: la mayoría de los registros no contenían información sobre el contexto familiar y social.
Descriptores: Enfermería; Familia; Madres; Recién Nacido; Atención Primaria de Salud
A safe and welcoming environment, conducive to relational and affective care, provides the basis for a child's healthy development from the beginning of their life. The quality of family relationships, access to the minimum resources for life development, and the cultural, social, economic, and political context experienced within the family must all be taken into account when assessing the child's growth and development.1-2
From this perspective, it is important to recognize the family as central to newborn care. Child and Family Centered Care (CFCC), as both a philosophy of care and a model of care, is based on the premise that each child is unique and must be considered in their family context. The health professional who adopts CFCC supports and values caregivers and family members, and includes them in decision-making, intending to provide the child with healthy conditions for their full development.3
However, the lack of focus on family and community actions was one of the challenges pointed out in a systematic review that aimed to analyze the quality of child health care in PHC in Brazil.4 According to the authors, care is primarily centered on individuals, with limited focus on the environment in which they are inserted.4 In the same direction, another systematic review that describes the recommendations for postpartum care for women in PHC also emphasizes the importance of investigating family and social support, as well as pointing out that the nursing consultation is an opportune moment to identify these issues.5
The birth of a baby is a phase of intense physical, mental, emotional, and social transformations and adaptations.6 Some of the main challenges are the excessive concern for the baby's safety and well-being, problems with breastfeeding, and the baby's excessive crying.7 Consequently, family and social support can minimize possible psychological suffering and facilitate women's transition to safe motherhood.7 According to a narrative review that looked at the factors that affect women's adaptation to postpartum changes, marital satisfaction, and family interactions play a crucial role in supporting women in the postpartum period.8
In Brazil, the National Policy for Comprehensive Child Health Care (NPCCH) emphasizes that the work of the Primary Health Care (PHC) health team should follow the approach centered on the mother-baby binomial from the first visit, which is recommended in the first week of the child's life.1
Routinely, the nurse performs this initial health consultation, which focuses on assessing the newborn's (NB) growth and development, encouraging exclusively breastfeeding, providing guidance on the immunization schedule, collecting the heel prick test, analyzing the results of other neonatal screening tests, addressing NB care and identifying difficulties, risk factors and vulnerabilities that may be present, and planning the necessary health actions.1 This initial consultation is strategic for reducing infant mortality and childhood illnesses, as provided for in national maternal and child care policies.1
In view of the above, the aim of this study was to identify information related to the family and social context in records of the first nursing visit to the mother-baby binomial.
This is a mixed-methods study with a concurrent data incorporation strategy9. Thus, quantitative and qualitative data were collected simultaneously and the main approach guiding the investigation was quantitative, with the following notation to represent it: QUAN (which). The integration of the data occurred in the presentation of the results, as the incorporation of qualitative data had the role of supporting the quantitative information.
The research was conducted in a municipality located in the inner state of São Paulo, organized into five health districts, with 47 PHC health units, 17 of which were Family Health Units (FHU) and 30 Basic Health Units (BHU).10 There was no direct approach to human beings, and the data was collected from retrospective documentary analysis between July and August 2023.
The population was made up of records of nursing consultations with the mother-baby binomial, accessed through computerized medical records. It is worth mentioning that although the care of the binomial occurs simultaneously, in an integrated manner, the records are kept in the individual medical records of both. The first consultation with the mother-baby binomial is routinely carried out by the PHC nurse. This care is scheduled while still in the maternity ward, through the Floresce uma Vida (A Life Blossoms) Program, a program set up in 1995 with the aim of reducing infant mortality through responsible discharge and the timely linking of the binomial to PHC units.10
In order to select which records would be analyzed, the selection criteria were those referring to births that took place in public maternity hospitals in the month of October 2022. There were no exclusion criteria. It should be emphasized that the selection of this time frame was random, with no criteria established a priori. However, public maternity hospitals were chosen because the Floresce uma Vida Program is specifically linked to institutions accredited by the Unified Health System.
This information was taken from the Sistema de Informação em Saúde da Criança (SIS-Criança - Child Health Information System), software used to record health information on all children born. SIS-Criança has a database that allows reports to be issued and health indicators to be monitored. It is possible to identify all births on a monthly and annual basis, as well as other information such as place of birth, date of first appointment, and referral unit, among others. It is worth mentioning that the average number of births per year is 8,000, 660 per month, of which 60% occur in public maternity hospitals and 40% in private maternity hospitals.
This report was used to identify the births that had taken place in the month in question, then a numerical code was assigned to each of the binomials and a draw was made using a free digital program available on the < www.sorteador.com.br > portal. In this way, 50% of the attendances were drawn. The percentage of records to be analyzed was determined by analyzing the feasibility of collecting them on time, and no sample size was calculated.
The records were analyzed using a semi-structured script made up of eight questions with dichotomous "YES" and "NO" answers, and space to transcribe sentences recorded by the nurses that referred to the social and family context (qualitative data). This guiding instrument was developed by the authors themselves, taking into account the current literature on the subject. It was then pre-tested by analyzing ten random, ineligible medical records, requiring minor adjustments before the final application. Based on this script, one of the authors, with authorization and login access to the SMS computer system, analyzed all the records of the selected nursing consultations.
With regard to data analysis, the quantitative results were analyzed first, since this was the primary database for the concomitant incorporated strategy. At this stage, the information was entered into a Microsoft Excel® spreadsheet and then subjected to descriptive analysis using absolute and relative frequencies. In a second step, the qualitative data was incorporated and organized in such a way as to cover each of the objective questions in the script, characterizing a deductive analysis.11
Considering the participation of human beings in the research, this study was submitted to the Research Ethics Committee in compliance with Resolution 466/2012 of the National Research Ethics Committee of the National Health Council and was approved in July 2023, under protocol number 6.207.923. The anonymity of the nurses responsible for the records was guaranteed. Since the data was collected from a secondary source of information, the use of a Free and Informed Consent Term was waived. It is worth mentioning that the project was approved and duly authorized by the Municipal Health Department.
In October 2022, there were 575 births, 368 of them in public maternity hospitals. Of these 368, 352 binomials showed up for a nursing consultation. However, only 326 (92.6%) consultations were duly recorded in the computerized medical records, while the rest had an attendance status, with no record of the nursing consultation.
As described in the method, 50% of the consultations were analyzed, totaling 163 binomial consultations and 326 records. With regard to the model of care in force, 271 (83.12%) records came from UBS and 55 (16.87%) from FHU. Table 1 shows the frequency distribution of records that mentioned aspects of the family and social context.
Table 1- Frequency distribution of records (n=326) with information related to the family and social context. Ribeirão Preto - SP, Brazil, 2022.
|
It appears in the record... |
Yes n (%) |
No n (%) |
|
Who were the other family members present? |
99 (30.4) |
227 (69.6) |
|
Reference to support network? |
71 (21.8) |
255 (78.2) |
|
Information about the family structure? |
89 (27.3) |
237 (72.7) |
|
The emotional state of the puerperal woman? |
100 (30.7) |
226 (69.3) |
|
About the pregnancy experience? |
12 (3.7) |
314 (96.3) |
|
Nursing diagnoses related to the family and social context? |
94 (28.9) |
232 (71.1) |
Although approximately 30% of the records mentioned the presence of other family members at the nursing appointment, they were brief and lacked detail.
Maternal grandmother attends this appointment and also receives guidance. (R34)
The puerperal woman and her partner are collaborative and attentive to the instructions, without any doubts. (R151)
NB attends accompanied by mother and father. (R21)
The presence of a support network and family structure were mentioned in 71 (21.8%) and 89 (27.3%) records, respectively. In general, the sentences recorded show little exploration of the social and family context.
Family support present (R11. R72, R100)
Family support absent. (R4. R15)
Common-law marriage (R106)
However, records were identified that detailed important aspects of the family structure and/or support network.
Father, 29, works as a bricklayer's assistant. Mother, 30, high school graduate, works as a sales agent. (R33)
32-year-old puerperal woman, high school graduate, travel agency sales assistant, born and resident in Ribeirão Preto, lives in her own home with her 30-year-old partner, high school graduate, sales assistant. (R 122)
Refers to having suffered domestic violence from her partner. She has been seen by a social worker and says she lives elsewhere with her NB and her 7-year-old son. The other children don't live with her. (R71)
Similar to the other aspects analyzed, the records related to the emotional state of the puerperal woman were not very detailed.
Psycho-emotional aspects: happy with the baby's arrival (R41, R147)
Psycho-emotional aspects: no changes (R143)
Calm mother understands the instructions well. (R2)
Happy and bonded with the NB. (R96)
Even in situations where some alteration was identified, no possible questioning was described with the intention of understanding the puerperal woman's experience, nor were there any records of intervention strategies.
She seems calm but with traces of postpartum depression. (R165)
Mother and NB bond is compromised by mother's lack of patience. (R09)
Mother anxious about feeding. (R82)
The experience of pregnancy was rarely explored, with only 12 (3.68%) records identifying this information. Furthermore, the main aspects of the pregnancy experience that were reported referred to pregnancy planning or clinical complications.
Unplanned but wanted pregnancy.(R04,R19)
Unplanned pregnancy (R75)
Pregnancy complications: gestational diabetes, without adverse outcome, with blood glucose control. (R82)
Mother did not have prenatal care (R71)
Mother reported anemia, treated with Noripurum, and urine infection [...] treated with antibiotics. (R162)
Pregnancy data: G2A1P1 (CP) [two pregnancies, one miscarriage, and one cesarean section], had ten prenatal consultations, low risk. Mother denies any complications during pregnancy. (R13)
As for the Nursing Diagnoses (ND), 94 (28.9%) of the records listed NDs relating to the family and social context. The ND "Mother-child bond preserved" was the most commonly used, listed 87 times. The ND "Family bond present" was the second most frequently mentioned, appearing in 15 cases. The NDs "Home maintenance impaired", "Family bond absent", "Family support impaired", "Risk of maternity and paternity impaired" and "Anxiety due to current state of health" were only mentioned once.
Finally, another characteristic identified was the similarity with notes common in hospital settings.
Puerperal woman admitted to the unit for consultation. (R05, R18, R 111)
At 10:00 a.m., NB admitted to this unit for a childcare consultation. (R134)
Conscious, oriented, communicating verbally with coherence (R10, R87)
The integration of quantitative and qualitative data allowed for a better analysis of the issues related to the family and social context present in the records of the first nursing consultation with the binomial. Although approximately one-third of the records highlight these issues, which are also present in the EDs, they do so in a very detailed and timid way. Relevant aspects such as the emotional assessment of the puerperal woman and the gestational experience are explored inconsistently or centered on the biomedical model.
According to the results presented, 26 (7.4%) nursing consultations took place but were not recorded in the computerized medical record. A study that investigated the Nursing Processes in Primary Care found that 22.7% of nurses did not use the Electronic Citizen Record (e-SUS) to record their activities, an even higher percentage than that found in this study. According to the authors, overload, the accumulation of duties and a shortage of human resources are the most commonly found justifications.12 However, the medical record is an important tool for shared communication between health professionals, ensuring continuity and comprehensiveness of care.13
Most of the care recorded took place in UBS. This scenario reflects the model of health care that predominates in the municipality studied, where only 25% of the population is covered by the Family Health Strategy (FHS).10 However, according to a systematic review, the ideal would be FHS coverage of >70%, in order to expand access to health services, increase coverage of prenatal care, vaccinations, improve nutritional and environmental conditions and encourage breastfeeding.14
The attendance of other family members at the consultation was poorly described and the father's participation was rarely mentioned. This finding may be indicative of the absence of the father figure in the consultation or of the fact that nurses devalue him as a potential caregiver for the NB. It is important to problematize this aspect, since the literature points to the father's involvement in caring for the newborn as beneficial for building and strengthening family ties, as well as mitigating the various damages associated with his absence in terms of child development.15 Furthermore, the lack of professional encouragement legitimizes men's failures and lack of interest in the pregnancy-puerperium process, especially in the puerperium.
In general, the records analyzed superficially considered the family and social context, corroborating the results of an investigation based on the participatory observation of 21 nursing consultations with children between zero and two years old. According to this study, nurses occasionally considered some elements of the child's life context and family environment during consultations, but did not address the family's cultural and economic issues.16
Although the support network and family structure have been little explored, some records have detailed important aspects such as the occupation and education of the parents. According to a study that assessed socioeconomic factors associated with child development in the first year of life, based on information from 3,061 children, mothers with low levels of schooling, symptoms of depression, two or more children under the age of seven living at home and who did not report self-perceived support/help during pregnancy had lower development scores in all the domains assessed.17
It was also possible to infer, from the records analyzed, that issues related to the mental health and emotional state of puerperal women were not highly valued, despite the fact that postpartum depression can affect puerperal women, especially those in situations of vulnerability and in the absence of social support.18 This data is worth noting, considering that women experiencing the puerperal period can feel alone, insecure, and express concerns about the practice of motherhood, increasing the risk of mental health problems.18-19
The findings indicate that some nursing consultation records for the puerperal/newborn binomial tend to reproduce a hospital-centric logic, using jargon and language specific to the hospital context, such as "was admitted to the health unit". This tendency was also identified in a study carried out with 52 professionals working in home care services in the state of Minas Gerais, showing discourses centered on high-tech equipment.20
The NDs recorded also valued the biological aspects of the binomial's health. It was observed that breastfeeding, as a physiological process, was emphasized in the nursing consultation records, detached from the family context, which is essential for maintaining breastfeeding. These results corroborate the literature, which points to a focus on biological processes that reflect a privileged view of already established problems, to the detriment of health promotion.21
Despite PHC being the central and coordinating axis of care proposed as the Brazilian model of care, nursing education still seems to have a hospital-centered and disease-centered logic. Even with the delimitation of health promotion competencies recommended in health courses, which involve the promotion of healthy development present in PHC, this perspective is still a challenge. Considering the construction of a practice based on the logic of CFCC and salutogenesis involves a constant critical analysis of nursing practice, as well as looking at the training of nurses - which requires methodologies that involve the active participation of the subject in the teaching-learning process, the construction of a contextualized view of reality and the development of autonomy for analysis and decision-making.22
It is important to note that the records analyzed refer to the binomial's first consultation, so it is possible that information related to the family and social context was investigated later, as the bond between nurse and family is established. In this direction, a qualitative study which analyzed the experiences and meanings of nursing consultations in childcare identified nurses' statements in the sense of making efforts to get closer to the family, getting to know their demands and their history.23 The authors also reinforce the importance of a greater number of consultations in order to form a bond and build trust.23
As for the limitations, we highlight the failure to record nursing consultations in some medical records; incomplete progressions or with generic information, without singularizing the care; and lack of clarity in the record, an aspect that may have compromised the analysis. It is recommended that further research be carried out on a longitudinal analysis of care and that participant observation be used as a complementary data collection strategy.
Finally, this research also outlines contributions to advancing knowledge in nursing. There is a need for ongoing education and training to support the construction of knowledge that is pertinent to the autonomous practice of nurses in PHC for children, their families and communities. Approaches using case studies, which bring practical realities into play, could be possible ways forward. In addition, a look at maternal overload and support from other family members is necessary.
Most of the records of the first nursing visit to the mother-baby binomial did not contain information about the family and social context. Approximately one third wrote, albeit superficially, about the family structure and emotional aspects of the puerperal woman, as well as listing nursing diagnoses related to the family and social context. The experience of pregnancy was the least mentioned aspect.
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Authorship Contributions
1 – Márcia Beatriz Berzoti Gonçalves
Nurse. Master of Science. Ebeatrizberzoti@gmail.com
Conception, development of the research and writing of the manuscript, review and approval of the final version.
2 – Ana Paula de Miranda Araújo Soares
Psychologist. Master in Psychology - apmasoares@gmail.com
Review and approval of the final version.
3 – Ana Izaura Basso de Oliveira
Nurse. Doctor of Science - anaizaura@gmail.com
Review and approval of the final version.
4 – Diene Monique Carlos
Nurse. Doctor of Science - dienecarlos@ufscar.br
Review and approval of the final version.
5 – Aline Cristiane Cavicchioli Okido
Corresponding Author
Nurse. Doctor of Science - alineokido@ufscar.br
Conception, development of the research and writing of the manuscript, review and approval of the final version.
How to quote this article
Gonçalves MBB, Soares APMA, Oliveira AIB, Carlos DM, Okido ACC. Identification of the family and social context in records of nursing consultations with the mother-baby binomial. Rev. Enferm. UFSM. 2024 [Access at: Year Month Day]; vol.14, e4: 1-13. DOI: https://doi.org/10.5902/21797685076