Model maternity with exclusive care by nurses: social representations
Danelia Gómez Torres1, Dolores Martínez Garduño1, Gabriela Téllez Rojas1, Elizabeht Bernardino2
1 Universidad Autónoma del Estado de México
2 Federal University of Paraná
ABSTRACT
Aim: Determine, based on the perception of the users, the type of model of attention of a maternity hospital whose care is exclusively performed by nurses. Method: Research of qualitative and descriptive approach, based on Moscovici's theory of social representations, whose scenario was a maternity hospital. The social actors were 34 users assisted during the perinatal phase. Results: The data were coded from the information collected from the interviewees, extracting the categories: education, culture, humanism, trinomial, gender and administration, as integrative elements. Discussion: From a global perspective, new perspectives of attention can be offered for both theory and practice, thus creating public health policies. Conclusion: the users perceive the model that pays attention to natural childbirth as care based on education and interculturality, which enables the humanized assistance of gender and personalized by nurses for the trinomial.
Descriptors: Nursing Services; Neonatal Nursing; Social Perception; Humanization of Assistance; Transcultural Nursing.
INTRODUCTION
MODEL BACKGROUND
In 2000, Mexico signed the United Nations Millennium Declaration, which explicitly aimed to reduce maternal mortality between 1999 and 2015. In 2005, the code of obstetric nurse was reinstated and a series of studies were conducted, showing support for professional obstetric nurses in the care and attention of labor and delivery. Thus, in the strategy to reduce maternal mortality, the Mexican Health Secretariat focuses its efforts on the practice of humanized childbirth, promulgated by the WHO(2). In addition, it establishes this model of non-medical care, in which the obstetrician nurse attends the birth with technical quality and performs the double function of closely monitoring the woman throughout the process(3). Therefore, the maternity services are completely provided by obstetric and perinatal nurses, thus favoring the personalized assistance of pregnant women.
The services are divided into two major areas. The outpatient area includes prenatal surveillance, puerperium and breastfeeding clinic services, family planning, early stimulation, and perinatal psychoprophylaxis and immunizations. For low-risk childbirth care, the maternity ward has obstetric screening services, a labor room, a birth room, and a recovery room. This maternity also includes the areas of training for obstetric nurses, and is the headquarters of the post-graduation in perinatal nursing.
When planning, the mission of this maternity hospital is established, which is to provide quality and humanistic care of highly professional nursing to women during the entire reproductive process, through the realization of timely and assertive actions of prenatal vigilance that lead to healthy pregnancies, safe childbirth, uncomplicated puerperium, birth and successful parenting with the participation of the couple and the family.
Thus, the vision of maternity is to consolidate the model of obstetric nursing as part of the maternal network at the Instituto de Salud del Estado de Mexico, through the management and innovation of comprehensive care for pregnant women. This can be seen in the evidence shown, in which the nurse has a theoretical-scientific basis and legal support in low-risk prenatal care. The nurse is expected to accompany and care for the pregnant population, becoming the basis of care and thus achieving the goal of contributing to the care of low risk pregnant women, in prenatal control, pregnancy, delivery, postpartum and newborn.
This maternity hospital also has nursing professionals with extensive obstetric knowledge and the ability to perform actions with a high degree of competence in the centralized care of the pregnant woman, including exclusive care in emergencies. All care is based on scientific evidence, the ethical structure of the profession, regulations, and institutional programs.
Model Advantages - Full perinatal care and/or attention in a public health system is shown, thus validating the obstetric and perinatal nurse as a professionally qualified and effective element in birth care. At the same time, the importance of social care and its favorable repercussions on the mother's and family's satisfaction are defended. With an intercultural approach, the model highlights the incorporation of the concepts of the predominant native culture (Mazahua Culture). This has been added to the fact that professional practice models stimulate autonomy, job satisfaction, responsibility, practice control, positive and collaborative relationships among professionals for the professional development of nurses, added(4) to the result that the humanization of care has in the process of recovery of people. This model promotes the efficient use of resources in the care of low-risk births, in addition to the appropriate referral to municipal and general hospitals of cases that present some condition of maternal and/or perinatal risk, where the care is open, with the program of zero rejection, and at no cost to users, offering referral of patients with obstetric urgency.
In relation to the services offered by the institution, this model changed the paradigm of hospital delivery in public health institutions.
SOCIAL REPRESENTATIONS (SR)
Social representation is a specific form of knowledge, whose function is to develop behavior and communication between individuals(5). The objective of research of this nature is to clarify the meaning or representation involved in the thought process related to some social phenomenon in a given society at a given time. These investigative techniques, commonly applied in investigations based on Moscovici's theory, study representation mainly in their more general socio-cultural and ideological approach, not exhausting representation in its totality in its subjective approach because it does not address the study of unconscious and pre-conscious roots that submit to thought processes, of which representations are an expression(6). Consequently, the study of social representations, instrumented with these techniques, matches the study of ideas, approached not from a macro perspective of the consensual and socially conceived, but from a micro perspective, which would be the subjective construction, that is, of the psychological construction. The applied theory foresees the objectification of ideas as an integral part of a process that, through this passage, allows the transformation of ideas, which are reasons that converge to defining it as theory of social knowledge(6), providing the proposal that consists in formulating a study of representations.
METHOD
In order to comply with the ethical aspects of research marked in the general Mexican health law, in matters of health investigations, according to chapter I, article 14, item V, where the participants are concerned, consent was requested and the informed consent form was signed, as established. This same law also mentions, in article 14, item VIII, that research may be carried out when the project has the authorization of the institution that must supervise the ethical aspects; therefore, the institution has authorized the investigation by means of document number 217B200012 / 3269, after which it was instructed that it did not present any risk according to the classification established in article 17, item I of the same law.
The research uses a qualitative and descriptive methodological approach, in which reality was addressed from a holistic perspective, with reference to the Social Representations (SR) of Moscovici, since these SRs are forms of knowledge built and used by people to explain socially relevant phenomena, such as common sense theories, using their own language, in addition to using concrete thinking to understand and interpret the event(7). The study took place in a daily environment for the participants, to get to know the social study group, which allowed a description of the facts observed, with knowledge that aimed to protect the belief of what was learned from each individual. The research scenario was a maternity hospital and the subjects were 34 social actors, chosen under the selective criteria of having been attended since prenatal and being of legal age. The socio-demographic aspects of the women interviewed, such as age, education, religion, marital status and place of origin, were considered. These data gave social knowledge on the observed group.
Data collection was carried out by means of an interview, consisting of a personal, flexible and direct meeting between researchers and participants, for a better understanding of experience(8), with the support of an interview script composed of twelve open questions. An Olempusmod DS30 recorder was used to record the interviews, which were conducted from June to August 2016. From the information obtained, the data were captured textually and several readings were performed, from which the data were coded and the categories extracted were: services, education, trinomial, natural childbirth, humanisms, gender, and administration. This information provided the elements for the design of the model. This interpretative analysis of the data began with the comprehensive reading of the selected material, followed by the exploration of this material, ending with the elaboration of the interpretative synthesis, promoting the comparison of statements from different contexts on the same phenomenon. From this movement, when the thematic categories emerged, the perceptions, feelings and expectations on the question of normal childbirth were revealed.
After the selection of texts that show the users' perception of the model of maternity care, the results were discussed. First, the category was conceptualized and later the empirical data were presented in order to be able to compare with the theoretical framework, which would allow the logical reasoning. This discussion was developed from the users' understanding of the moment of care received and the whole context of delivery, thus representing the diversity of stimuli received during their stay in the maternity hospital.
RESULTS
ATTENTION MODEL
The model of maternity care presents distinctive characteristics, reflected in the way of providing integral perinatal care in a public health system, validating the obstetric and perinatal nurse as the most technically qualified resource in childbirth care. Obstetric nurses are valuable elements in providing such care, with different prenatal surveillance actions leading to a healthy pregnancy and, consequently, to a safe delivery. The exclusive intervention of this type of professional, in which the female sex is one of the outstanding characteristics, is based on education for the health of women in their reproductive phase. This resulting perspective of care is represented in the following Diagram 1.
Scheme 1. Model of obstetric care by nurses. Maternidade Atlacomulco, Mexico, January, 2019
Source: Prepared by the authors.
MODEL SERVICES
The services offered by the institution cover the diagnosis of pregnancy, prenatal, childbirth, postpartum, and up to two years of life of the child:
They told me that they had various services, that they controlled him here and that, when the baby is born, they continue with the care until he grows and develops (N-6).
They told us that afterwards they gave the babies consultations and provided us with all the services, such as nutrition and psychoprophylaxis course. It's very good because they teach us everything (N-28).
I came and a nurse assisted me and explained how it worked. She told me it was just normal births, because I had never heard of this hospital. I just knew there was early stimulation, and when I arrived and saw that there were only female nurses, I felt very good (N-29).
Integral care is demonstrated from elements that make up a set of services and interventions aimed at satisfying the needs of users.
EDUCATION-BASED ATTENTION
The care model allows nurses to act with excellence in the construction of different educational settings, to make users aware of a care structure focused on prevention and early detection of complications during pregnancy. The knowledge transmitted is focused on the health needs or well-being of users, and this is reflected in the testimonials:
I really liked the workshops because they helped me a lot. It wasn't hard for me to take the courses, because I enjoyed being here. If I had any doubts, they would be cleared up. They taught me a lot about breastfeeding and they also made me very confident (N-24).
I didn't take part in the psychoprophylaxis classes, but when I was in labor, one of the nurses who were with me started to explain everything to me and to make me calm when the strongest pains came. That felt very cool to me (N-21).
Well, we also love that they give us courses for babies, how to treat them, and how to care for them (N-3).
The importance of social support and the positive repercussions on the satisfaction of mothers in the intervention are observed.
NATURAL CHILDBIRTH
Childbirth should take place in the best conditions of intimacy, respect, delicacy and freedom, in an environment that provides comfort for the mother. This aspect is described by the users in this way:
They [the nurses] also told me that here they only deliver natural births (N-10).
I was fascinated by the idea that he could be born in a natural way, that my son would descend in a natural way and I liked it very much (N-1).
Because here they teach you to have children in a natural way, so I thought that if they said that it was because they provided good service [...]. They teach you what the process of childbirth is like and if it's going to be painful and then they teach you things [...] and here they don't give you medicine, unless it's necessary, and that's what's best for our body, because it's all natural (N-30).
FEMALE STAFF ATTENTION
As one of the care policies instituted by the institution, the human capital offered is female, with a sound policy. As one of the marked differences in this model, it is an essential feature that childbirth care occurs from one woman to another, according to the participants' narratives:
[…] it's very comfortable for me that they're just women, just female nurses. As I'm a little shy, I'd rather be cared for by a woman (N-28).
Another girl told me that they treated her very well here, that there were only female nurses, that there were no doctors, that they treated you and didn't leave you alone (N-19).
Users react differently when they are cared for by people of the same gender and report discomfort, a change in their well-being, when cared for by a man. This shows that obstetric care in the institutionalized model causes embarrassment.
CULTURE-ORIENTED ATTENTION
The intercultural approach allows freedom to develop in the current reality. In a present time in which paradigms are broken, hospitals are created according to the demand and the need for care in health institutions, with the model standing out. Due to the incorporation of the concepts of regional culture, it also shows a difference with other institutions, according to the version of the users:
In the course, they asked me how I wanted to have my baby, whether sitting, lying down or standing up, as they taught us in the psycho-prophylaxis courses (N-33).
I said I would like you to sit down and they even put on some music (N-5).
[…] They encouraged me to feel free and talk about how I felt. Sometimes you don't even know how to express how you feel and this time it was different here. The nurses reassured me and told me to talk and do as I pleased (N-31).
Nursing, in this way, is coherent with the values, beliefs, practices and ways of life of each person, reflecting assistance with social knowledge that is shared before a vision, in the construction of common realities of different cultures.
TRINOMIAL CARE
In the valuation of users, the importance of follow-up and its repercussions on the satisfaction of the service received are highlighted. In the maternity ward, this follow-up is promoted by the attention model, where the couple plays an active role during care, and this is not characteristic in other health system institutions. This highlights the importance of active participation by the father in the reproductive process, as expressed by pregnant women and their partners:
It was very nice because the three of us were supporting each other, our baby, my husband and I. I was never alone (E-21).
Well, the nurses tell you what to do and when to do it, and also how to help you with the different positions so we can push and facilitate birth. It was very nice, because the three of us were working for our child's birth (E-21).
They invited me to a conversation with my husband about reproductive health for the well-being of the family (E-18).
This model of non-medical care shows that obstetric nurses not only offer technical quality to the work, but also perform the dual function of closely monitoring women throughout the process, considering the importance of creating a model of care of the mother, father and son trinomial and this is perceived and recognized by users.
HUMANIZED ATTENTION
The patients' perception marks the singularity of the institution, in which the nurses make their intervention represented in a humanized care, valuing the women received and the treatment offered.
I would recommend this maternity because it was a more humane birth; it was a very different experience (E-32).
They asked me if I had ever eaten, because they gave me something to eat. For me, it was very nice to come here and see this very different treatment (E-31).
As we came from far away, they didn't want me to go back to where I live. They gave me shelter and I slept. By around three in the morning I started to have the strongest pain and at five in the morning my baby was born (E-8).
Users express with words and feelings the meaning of the care received by nurses through signs of integral support, based on social behavior and interaction with the nurse.
ADMINISTRATION
Management as professional training in nursing is the set of actions aimed at forming the socio-occupational exercise, which requires the execution of a series of functions at different levels of attention. This area of knowledge is an evolutionary thinking process necessary for the development of nursing actions, in which services are planned, organized, directed and evaluated, applying improvements in problem solving. This function was reflected and interpreted by the users as coordination and communication during the interventions performed during the nurses' care:
I saw them leaning on each other and saying to each other, bring me that, bring me the other and, all their actions very coordinated (E-16).
Yes, because the nurses are good; they make a team, so they're totally committed. I saw that both of them were coordinated (E-10).
They were coordinated; there was a lot of coordination among the nurses who assisted me; there was a lot of communication among them (E-28).
Nursing administration arises as an indispensable need that allows the stimulation of critical thinking to face the current problems of assistance, management and education in this practice, directing this action to the effectiveness, efficiency of processes, and well-being of patients.
DISCUSSION
Maternity rescues a model in which the need to offer qualified and integral care during pregnancy is established under the public health system. During this research, one of the aspects identified and that makes the difference between the care of the studied maternity and the other institutions in the health sector is the exclusive care by nurses.
Birth assistance by a nursing professional is designed by pregnant women between the natural and the cultural, demonstrating that women's lives, marriage and the role of mothers can be enlightened and considered as an art of living better(7). This has been having a positive impact on users, since the care provided by same-sex employees promotes a climate in which users are free to express both positive and negative feelings related to the stage they are experiencing. The needs of the patients are also prioritized and both parents are recognized as protagonists of the process, in addition to the team that performs minimal interventions. Likewise, the couple and the family are involved in the birth of the baby(9).
The users reported their experiences from the services they received, according to their perception. In addition, they express their experiences in the services offered by maternity, establishing the social representation of obstetric care from the perspective of those who promote it and the vision of those who receive it. Pregnant women receive optimal health care, based on a set of services and therapeutic diagnoses. Russo(10) points out that the attribution of this new meaning implies an intense reassessment of maternity, based on the reconfiguration of the ideals of autonomy and on how this reconfiguration is articulated to a certain conception of body nature, because in the field of reproductive health, from a global perspective, new and interesting insights can be offered, both in theory and practice, for the generation of public policies.
The results reflect a consistent humanistic professional intervention by nurses, as indicated by Motta(11), mentioning that it is important to raise awareness and provide a welcoming position in the relationship between nurses and pregnant women, considering the fragility that pregnant women present in this moment of life, since the health of the mother and the newborn is maintained over time as an event of high social impact. In this scenario, the inclusion of humanization in care as a relevant element requires the relationship of nurses, mother, father and newborn. In this sense, nursing is one of the professions that come closest to the patient and her family during care. In the same way, this consistency is reflected in the users' perception of the nurse's intervention, which distinguishes the importance of inclusion of the trinomial care: mother-newborn-father.
Unfortunately, in the history of some countries, when obstetrics is medicalized, women are detached from participation as a couple in the birth process because of hospital restrictions. Thus, the experience lived by the couple, due to active collaboration, support and awareness of the role of the father during participation in prenatal control and the reproductive process, leaves a mental representation in the actors. A representation always means something to someone, to you or to other people, because the essence of a representation is to make an idea understood and shared with the same liveliness as a perception or an emotion and vice versa(12). In this case, the meaning of integration into the integral care of the users in maternity is not limited to emotional support, but the consciousness and role that, as a man, must take on in the couple's relationship.
These antecedents mark a consistent representation in which the subjective of the lived experience and its function try to understand the ways of thinking, feeling and acting of the subjects, located in specific places and roles in institutional spaces(13). In the same way, the human actions applied by the maternity hospital in the intervention of the nurse make a difference in the service. Thus, its meanings are valued as differentiated care, in a positive or satisfactory sense, generating the construction of a model of this reality, where the patients reveal the care received during the care in the institution. This denotes a form of care that distinguishes what is perceived by the experience of pregnant women, reaches important criteria to have a good attitude, as well as the education offered to improve their state of health and thus clarify the meaning or representation involved in the thinking process related to the phenomenon present at any given time(6). In this sense, when reproducing a perception, it remains in the memory and this allows us to express the reality, thus explaining and justifying the experience, projecting a different model in the service offered and received.
Another relevant aspect is cultural care, in which acts of care, respect for different beliefs, practices and cultural values aim to provide consistent and sensitive care. Unfortunately, childbirth as a culturally contextualized event has lost its essence in the face of control over the reproductive process and the power of the female body, favoring a change in women's position from protagonist to collaborator(8). Nevertheless, the importance of the relationship of factors is maintained essentially as the ethnicity (culture) of pregnant women and other psychosocial variables. It is undeniable that when this new model is implemented, this fact requires changes in professional practice, requiring guidelines that detail a form of humanized childbirth assistance(9).
With this model, the contribution to the quality of professional nursing care that projects its positive role in maternal and child care is evident. This perception is also characterized by identifying integral care and a high commitment to the care offered by nursing professionals, in such a way that this model indicates an opportunity for the discipline, since it can be replicated in different national and international spaces. In relation to study limitation, time restriction is delimited to expand the study and know in depth the perspective of the spouses, due to their interest in participating in the study.
CONCLUSIONS
With this research, the aims were not only achieved, but also elements were obtained to outline a new method of care. Therefore, this model of care breaks the paradigm of the nursing profession by offering exclusive care with a team from this discipline. Professional skills are widely reflected, as nurses are changing the concept of childbirth care under a concept of inclusive reproductive education, as care is directed at the trinomial, with a close interpersonal professional relationship, due to the characteristics of the female sex. In addition, the staff working in the institution seems to have the intention that every woman who arrives at this unit has a satisfactory experience.
The obstetric care model favors the reduction of complications during pregnancy, childbirth and puerperium, and also, because it is based on education, it shows that through training in the psychoprophylaxis techniques established and instrumented by the nurses, it allows the safety and tranquility of the users during childbirth and helps to develop early attachment to the child.
REFERENCES
1. Jean-Claude A. Prácticas sociales y representaciones. México: Ediciones Coyoacán; 2001.
2. Perdomo-Rubio A, Martínez-Silva PA, Lafaurie-Villamil MM, Cañón-Crespo AF, Rubio-León DC. Discourses on obstetric violence in newspaper reports of Latin American countries: changes and continuities in the field of attention. Rev Facultad Nac Salud Pública [Internet]. 2019 [cited 10 dic 2019]; 37(2):125-135. Available from: http://www.scielo.org.co/scielo.php?script=sci_abstract&pid=S0120-386X2019000200125 doi: 10.17533/udea.rfnsp.v37n2a14
3. Stallings-Welden LM, Shirey MR. Predictability of a professional practice model to affect nurse and patient outcomes. Nurs Adm Q [Internet]. 2015 [cited 2018 jul 22]; 39(3): 199-210. Available from:https://pubmed.ncbi.nlm.nih.gov/26049597/ doi: http://dx.doi.org/10.1097/NAQ.0000000000000106 .
4. Rodríguez AM, Concha PJ, Pereira DI, Machuca LL. Adaptación transcultural y validación de un cuestionario de cuidado humanizado en enfermería para una muestra de población Chilena. Rev Cuid [Internet]. 2018 [cited 13 dic 2018]; 9(2):2245-2256. Available from: http://www.scielo.org.co/scielo.php?pid=S2216-09732018000202245&script=sci_abstract&tlng=pt doi:http://dx.doi.org/10.15649/cuidarte.v9i2.531
5. Moscovici S. Social Representations: Studies in Social Psychology. Cambridge: Polity; 2000.
6. Stein-Sparvieri E. Representaciones psicosociales. Un aporte a la teoría y la investigación en psicología social. Subjetividad y procesos cognitivos. 2019[cited 15 abr 2019]; 22(1): 124-146. Available from: https://www.redalyc.org/articulo.oa?id=339657511006
7. Emiliani F, Palmonari A. La psychanalyse, son image et son public: Le volume à la base de la théorie des représentations. Editions des archives contemporaines, sociales [Internet]. 2019 [cited 2018 november 16]. Available from: https://doi.org/10.17184/eac.9782813003317 .
8. Páez CML, Arteaga HLF. Duel for perinatal death. Need for a differential and integral attention. Archivos Med [Internet]. 2019 [cited 2019 nov 21];19(1):32-45. Available from: https://www.redalyc.org/articulo.oa?id=2738/273859249003
9. Macías-Intriago MG, Haro-Alvarado JI, Piloso-Gómez FE, Galarza- Soledispa GL, Quishpe-Molina MC. Triviño-Vera BN. Importance and benefits of humanized delivery. Dom Cien [Internet]. 2018 [cited 2019 mar 6];4(3): 392-415. Available from: http://DOI: 10.23857/dc.v4i3.815
10. Russo JA, Nucci MF. Giving birth in paradise: humanized birth, oxytocin, and the bodily production of a new maternity. Rev Interface (Botucatu) [Internet]. 2020 [cited 2020 abril 20]; 24 (e180390):1-14. Available from:
https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-32832020000100213&tlng=pt
11. Pereira RM, Fonseca GO, Pereira ACCC, Gonçalves GA, Mafra RA. Novas práticas de atenção ao parto e os desafios para a humanização da assistência nas regiões sul e sudeste do Brasil. Ciênc Saúde Colet [Internet]. 2018 [cited 2018 out 16];23(11): Available from: https://doi.org/10.1590/1413-812320182311.07832016
12. Moscovici S. Trois présupposés sur les représentations sociales. In: N. Kalampalikis. Textes rares et inédits Editions des Archives contemporaines. Paris [Internet]. 2019 [cited 2019 jan 22]. 16p. Available from: http://DOI: 10.17184/eac.1471
13. Ortega-Bastidas J, Pérez-Villalobos CE, Arellano-Vega J, Inzunza-Melo B, Arias-Lagos L, Bustamante-Durán C. An approach to social representations of science in university teachers. Rev Interciencia [Internet]. 2019 [cited 2020 jan 21];44(5):280-286. Available from: https://www.redalyc.org/articulo.oa?id=339/33959375010
All authors participated in the phases of this publication in one or more of the following steps, in according to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the version submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf
Received: 09/23/2019
Revised: 04/08/2020
Approved: 04/24/2020