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Management challenges for best practices of the Kangaroo Method in the Neonatal ICU

Desafíos gerenciales para buenas prácticas del Método Madre-Canguro en la UTI Neonatal

ABSTRACT

Objective:

To understand the conditions that influence the adherence and application of best practices by nurses in the context of the Nursing care management in the Kangaroo Mother Care in the Neonatal ICU.

Method:

Study of qualitative approach, whose theoretical and methodological frameworks were Symbolic Interactionism and Grounded Theory, respectively. We used the in-depth interview with 8 nurses from the Neonatal ICU of a public maternity hospital in the city of Rio de Janeiro.

Results:

The conditions involved in adhering to the best practices of humanization in the Neonatal ICU are related mainly to human resources, interaction among professionals, work processes and leadership strategies; and care management.

Conclusion:

Professional and institutional challenges have been identified that need to be addressed to improve adherence and implementation of the Kangaroo Mother Care best practices.

Descriptors:
Nursing; Intensive Care Units; Kangaroo Mother Care; Infant, Premature; Health Services Administration

RESUMEN

Objetivo:

Comprender las condiciones que influencian la adhesión y aplicación de buenas prácticas por enfermeros en el contexto de la gestión del cuidado de Enfermería del Método Madre-Canguro en la UTI Neonatal.

Método:

estudio de abordaje cualitativo, cuyos referenciales teórico y metodológico fueron el Interaccionismo Simbólico y la Teoría Fundamentada en Datos, respectivamente. Se utilizó la entrevista en profundidad con 8 enfermeros de la UTI Neonatal de una maternidad pública en la ciudad de Rio de Janeiro.

Resultados:

las condiciones intervinientes en la adhesión de las buenas prácticas de humanización en la UTI Neonatal están relacionadas principalmente con los recursos humanos, la interacción entre los profesionales, los procesos de trabajo y las estrategias de liderazgo y gestión del cuidado.

Conclusión:

Se plantearon desafíos de orden profesional e institucional que necesitan ser atendidos para mejorar la adhesión y aplicación de las buenas prácticas del Método Madre-Canguro.

Descriptores:
Enfermería; Unidades de Cuidado Intensivo Neonatal; Método Madre-Canguro; Recién Nacido Prematuro; Administración de los Servicios de Salud

RESUMO

Objetivo:

Compreender as condições que influenciam a adesão e aplicação de boas práticas por enfermeiros no contexto do gerenciamento do cuidado de Enfermagem no Método Canguru na UTI Neonatal.

Método:

estudo de abordagem qualitativa, cujos referenciais teórico e metodológico foram Interacionismo Simbólico e a Teoria Fundamentada nos Dados, respectivamente. Utilizou-se a entrevista em profundidade com 8 enfermeiros da UTI Neonatal de uma maternidade pública na cidade do Rio de Janeiro.

Resultados:

As condições intervenientes na adesão às boas práticas de humanização na UTI Neonatal estão relacionadas principalmente aos recursos humanos, interação entre os profissionais, processos de trabalho e estratégias de liderança; e gerenciamento do cuidado.

Conclusão:

Foram elencados desafios de ordem profissional e institucional que precisam ser atendidos para melhorar adesão e aplicação das boas práticas do Método Canguru.

Descritores:
Enfermagem; Unidades de Terapia Intensiva Neonatal; Método Canguru; Recém-Nascido Prematuro; Administração de Serviços de Saúde

INTRODUCTION

The Neonatal Intensive Care Unit (NICU) is a sector that involves nursing care in high complexity, considering risk, vulnerabilities and technical and technological demands in the care of premature and low birth weight infants. Working with this population is an important challenge because it is in the stage of maturation of the organs in environment antagonistic to uterine conditions, therefore, the NICU environment must promote the necessary safety for the care and survival of the newborns(11 Stelmak AP, Freire MHS. Share applicability recommended by kangoroo method. Rev Pesqui: Cuid Fundam[Internet]. 2017[cited 2018 Apr 30];9(3):795-802. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/4429/pdf
http://www.seer.unirio.br/index.php/cuid...
).

Thus, nursing care in this sector needs to reconcile the relevant technological advances, which have ensured the increase of survival, with approaches of humanized care practices that are configured as best practices. Skin-to-skin contact, noise and brightness control, family presence and participation, adequate nutrition, individualized handling, and respect for the newborn's behavioral cues are some of the best impact practices for neuroprotection(22 Acevedo DH, Becerra JIR, Martínez AL. The philosophy of the developmental centered care of the premature infant (NIDCAP): a literature review. Enferm Glob[Internet]. 2017[cited 2018 Apr 30];16(48):590-602. Available from: http://scielo.isciii.es/pdf/eg/v16n48/en_1695-6141-eg-16-48-00577.pdf
http://scielo.isciii.es/pdf/eg/v16n48/en...
).

These strategies comprise the care model of the Brazilian Kangaroo Mother Care, which is composed of three stages, the first two hospitals and the last ambulatory in interface with Primary Care. The NICU is the main setting of the first stage and, as it is a densely technological space, presents additional challenges to guarantee actions involving love, heat and breast milk triad, which is the basis of actions in the Kangaroo Mother Care. This strategy has the following benefits: shorter hospital stay, better thermal stability, decreased crying, increased breastfeeding and weight gain, affective bonding, pain relief, among others(33 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde, Área Técnica da Saúde da Criança. Atenção humanizada ao recém-nascido de baixo peso: Método Canguru[Internet]. 2011[cited 2018 Apr 30]. Available from: http://www.redeblh.fiocruz.br/media/manualcanguru.pdf
http://www.redeblh.fiocruz.br/media/manu...
).

However, while these benefits are already proven evidence, the development of the Kangaroo Mother Care at the NICU is still challenging, especially with regard to adhering to the best practices recommended in this program(44 Silva JL, Leite JL, Scochi GS, Silva LR, Silva TP. Nurses' adherence to the Kangoroo Care Method: support for nursing care management. Rev Latino-Am Enfermagem[Internet]. 2015[cited 2018 Apr 30];23(3):483-90. Available from: http://www.scielo.br/pdf/rlae/2015nahead/pt_0104-1169-rlae-0339-2579.pdf
http://www.scielo.br/pdf/rlae/2015nahead...

5 Souza LPS, Souza EV, Gomes GCS, Souto DF, Pereira LB, Pinheiro MAM, et al. Kangaroo-mother method: perception of the nursing staff in the neonate's health promotion. Rev Bras Promoç Saúde[Internet]. 2014[cited 2018 Apr 30];27(3):374-80. Available from: http://periodicos.unifor.br/RBPS/article/view/2731/pdf_1
http://periodicos.unifor.br/RBPS/article...
-66 Gomes JATS, Martins MJL, Hertel VL. Método Mãe Canguru: percepção da equipe de enfermagem. Rev Eletron Enferm Vale Paraíba[Internet]. 2015[cited 2018 Apr 30];1(8):63-79. Available from: http://fatea.br/seer3/index.php/REENVAP/article/view/39
http://fatea.br/seer3/index.php/REENVAP/...
). In addition, clinical conditions of the newborn and standards of some units, such as restricted visiting hours, lead to the separation of the baby from his/her mother, father or family, negatively influencing the adherence to the Kangaroo Mother Care.

Thus, it is relevant the managers' view regarding the implementation and quality of neonatal health care production and conditions of work in the unit, emphasizing the need to change the behavior of the team and the institution's philosophy, in order to offer best practices of care in the care of the newborn and his/her family(66 Gomes JATS, Martins MJL, Hertel VL. Método Mãe Canguru: percepção da equipe de enfermagem. Rev Eletron Enferm Vale Paraíba[Internet]. 2015[cited 2018 Apr 30];1(8):63-79. Available from: http://fatea.br/seer3/index.php/REENVAP/article/view/39
http://fatea.br/seer3/index.php/REENVAP/...
).

OBJECTIVE

To understand the conditions that influence the adherence and application of best practices by nurses in the context of the nursing care management in the Kangaroo Mother Care in the Neonatal ICU.

METHOD

Ethical aspects

The project was submitted to assessment by the Research Ethics Committee of the institution used as setting, Maternidade Escola (School Maternity) of the Universidade Federal do Rio de Janeiro (UFRJ). All the participants accepted voluntarily to integrate the research and signed the Free and Informed Consent Term, being assured their anonymity, therefore, the speech excerpts are identified with an alphanumeric code that represents their category (N of nurse) and the order of the interviews.

Theoretical-methodological framework

This is a qualitative research, guided by the methodological framework of the Grounded Theory. The theoretical framework that allowed interpreting the data in depth was the Symbolic Interactionism, which conceives the symbolic nature of social life, proposing that social significations are produced by interactive activities of agents. Thus, discussing meanings involves analyzing processes by which people determine their behaviors, considering their interpretations about the world(77 Charon JM. Symbolic interactionism: an introduction, an interpretation, an integration. 10tª ed. Boston: Prentice Hall; 2010.).

The Grounded Theory was adopted as a method with an interpretative basis, which has a high degree of systematization and rigor in the interpretation of data in order to explain structures and regularities of social phenomena. Its roots are also in Symbolic Interactionism and, therefore, the understanding of the phenomenon occurs from the meanings involved in social relations and the researcher interprets them from the analytical emergence of the concepts, which are rooted in the data(88 Strauss AL, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. 2ª ed. Porto Alegre: Artmed; 2008.).

Type of study

This is an exploratory research with a qualitative approach.

Methodological procedures

In the Grounded Theory, data collection and analysis are done simultaneously by the constant method of comparing data. This process ran from October 2011 to May 2013.

Study setting

A Neonatal ICU of a public maternity hospital in the capital of Rio de Janeiro, which has the Kangaroo Mother Care applied in its three stages since 2000. This is a tertiary-level maternity hospital, being reference in the care of gestation, childbirth and high-risk birth, especially with regard to fetal risk. The neonatal care of this setting counts on sixteen beds in the intensive care unit and six intermediate beds. The structure also has an Alojamento Mãe-Canguru (Mother-Kangaroo Accommodation), for the development of the second stage of the method, with three beds for binomials and a follow-up clinic for children at risk.

Data source

The in-depth interview was conducted with eight NICU nurses. The inclusion criteria were: to have more than one year of experience in the Neonatal Intensive area; to have at least six months in the NICU of the institution; and to know the first stage of the Kangaroo Mother Care. As an exclusion criterion, the professional removal was used during the collection period. The interviews were individual, previously scheduled with the professionals and held in a private place, near the NICU. The nurses were approached through personal contact with the researcher in the work setting and the conduction of the interviews was carried out by a trained researcher known to the professionals. The interview script had the following startling questions: Which aspects of the Kangaroo Mother Care do you highlight as the most important in your work at the NICU? What can you develop? What motivates you? What are the difficulties? What management strategies do you use?

Two sample groups were formed, the first one consisting of four day-shift nurses and the second composed by four nurses on the job. The search for the first sample group of this study (day-shift nurses) was guided by the fact that these professionals had a frequency and range of leadership performance in the NICU, being important personalities in joining the Kangaroo Mother Care in the NICU. The search for the second sample group (on-duty nurses) was guided by data that pointed out the need to understand the possibilities and perspectives of those who manage care continuously 24 hours a day.

Collection and organization

In this study, the interviews of the two sample groups had an average duration of 49 minutes, totaling 4.8 hours of voice recording. They were transcribed as they were obtained to be submitted to analytical processing. The collection was closed from the theoretical saturation that in the analysis process indicates conclusion for a specific category or even for the end of the study. At the first level, the researcher realizes that an additional data will not change the consistency and density of concepts obtained, and at a higher level, that the relationships between the categories are well established and validated(88 Strauss AL, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. 2ª ed. Porto Alegre: Artmed; 2008.).

Data analysis

The analysis in the Grounded Theory is comparative, and followed the steps of open, axial and selective coding. In the first step a microanalysis was performed, line by line of each interview, in search of analysis units that gave origin to preliminary codes. These were grouped by similarities, generating conceptual codes, which in turn, when compared, generated the categories and their subcategories.

In the second stage, the axial coding, we sought a theoretical integration between categories and subcategories, based on inductive clusters. In this study, this integration followed the conditional-consequential model that is formed by the following elements: causal conditions, central phenomenon, context, intervening conditions, strategies of action/interaction and consequence. This codification enables the researcher to think of structure and process to evidence the phenomenon through the data(88 Strauss AL, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. 2ª ed. Porto Alegre: Artmed; 2008.).

The third stage comprises the emergence of the central category through the integration and refinement of categories in terms of properties and dimensions. Noteworthy is the importance of notes in the form of memoranda and making diagrams as important analytical tools in all these stages.

Finally, the validation of this analytical process was performed with 17 professionals from the multiprofessional health team (10 nurses, 2 neonatologists, 2 speech therapists, 1 social worker, 1 physiotherapist, and 1 nutritionist), with the objective of verifying compliance with criteria such as adjustment, comprehension and theoretical generalization. The criteria for inclusion were: to be a professional of the health team working in the neonatal area, to have at least one year of experience in this area, to meet the Kangaroo Mother Care, to work in a hospital/maternity where the first stage of the Kangaroo Mother Care is developed. Validation consisted of the group presentation of the research and its main findings for the evaluators, followed by the submission of an individual form to record the characterization of the professional and his/her opinion regarding the naming of the categories, the concepts presented and the representativeness of the diagrams.

RESULTS

All participants were female, ranging from 30 to 45 years, with a mean of 39 years. The training time ranged from 04 to 19 years, with an average of 11 years. In relation to the time of action in the maternal-infant area, the same ranged between 3 and 10 years, with an average of 6 years. With regard to specialization, only one nurse declared that she did not have a Graduate degree and the other ones (87.5%) reported having specialization in related areas. In terms of scale and function, four participants were day-shift workers, developing supervision and management activities, and four were on-duty workers, developing supervisory activities and team leadership. All reported having theoretical and/or practical training in the Kangaroo Mother Care.

From the data analysis, the central phenomenon emerged: Being a multiplier of values and practices for the (dis)continuity of the Kangaroo Mother Care in the NICU, which addresses nurses' adherence to the Kangaroo Mother Care in its first stage. This article deals with the fourth category Facing challenges for the adherence and implementation of the Kangaroo Mother Care, which presents itself as intervening conditions, in the theoretical model that emerged from the data.

The relevance of highlighting this category in this article is in its theoretical density represented in eleven subcategories, as represented schematically in Figure 1. The diagram illustrating the impact of the drop of water on a liquid surface seeks to highlight that adherence to the Kangaroo Mother Care's best practices involves the impact of theory with the complex and multidimensional reality of nursing work at NICU, which implies a situational diagnosis of reality and the design of management strategies to improve practices.

Figure 1
Diagram

In the Diagnosing the current reality of the first stage in the NICU subcategory, nurses reported material, structural and operational difficulties for a comprehensive development of the first stage of the Kangaroo Mother Care, especially by adherence to the practice of skin-to-skin contact.

This skin-to-skin contact is of the utmost importance and this is something that also saddens me because it has not been done in the first step. [...] I see less and less the position. (N1)

Nowadays I am seeing a technical method, also it isn't taken care of the temperature, the heating, the heat, but it lacks that humanized thing. It is becoming careless. (N6)

In the Needing people and time subcategory, the lack of time was highlighted as a limiting factor for the practice of the Kangaroo Mother Care. The dynamics imposed by the intensive environment, the routine, the work overload, allied to the scarcity of human resources, limit the availability of the professional to be present and dedicate themselves to time-consuming care, such as care for the premature infant's breastfeeding.

Sometimes we try to make a type of sucking stimulus, a caress, we try to put on the mother's lap, depending on the situation, but it has been so rushed these days that there is no time. [...] I think the dynamics has increased, there are more bureaucratic things about paperwork (N6).

So the work overload has been absurd, [...]. We have to prioritize the care, [...] then, I will make everyone start a diet, but I will not be able to do with the quality that we used to do before. (N10)

In the Needing theoretical and practical knowledge subcategory, nurses reported that although they know the scientific basis of the Kangaroo Mother Care, they still consider themselves to be poorly trained and inexperienced in the application. Technical insecurity and lack of knowledge undermine professional adherence to best neonatal practices.

[...] a single training doesn't transform the person. I think what transforms is the practice itself, is to see it working out, you really put it into practice. [...] it is no use giving a course of breastfeeding if the person doesn't practice it, the person doesn'tt live day-to-day situations that are differentiated. (N1)

Because I think even the theory people have, [...] but now I think the actual practice of the Kangaroo Mother Care isn't well recognized by people, because they cannot develop it right. (N5)

In view of this, they reinforce the need for a Permanent Education program that promotes awareness raising and ongoing training for team qualification in the Kangaroo Mother Care.

People who took the course before, many are gone, other teams arrive, so I think this training has to be continuous as well. When you have a mixed team that changes a lot, your training cannot stop because, otherwise, it will not solve. (N2)

In this context, the practical knowledge of the Kangaroo Mother Care was pointed out as a positive factor and in the Needing to change visions and conceptions subcategory, nurses emphasized that the resistance is related to little experience and, therefore, practical experiences in the Kangaroo Mother Care is that they allow redefine care at the NICU and give more value to relational technologies and change attitudes in caring.

I think when the person is a bit tough, the person did not have that real experience at all. [...] the person starts to have more experience, then she begins to see that it isn't silly to shower and weigh wrapped, to diminish the sound, she sees that the behavior of the child changes. (N8)

The nurses affirmed that a limited and reductionist view makes impossible the integrated work with the baby and his/her family, culminating in a mechanized, outdated and professional-centered practice.

Some people, even working a lot of time in the ICU, I think they have practice, but it is an unfortunately mechanized and outdated practice. [...] People unfortunately don't want to stick to new practices, new things that come to improve the life of this baby. (N5)

In the Needing better attitudes in care subcategory, the nurses highlighted the need for greater sensitivity and attitudes of availability to be with the mother and to carry out the Kangaroo Mother Care.

[... ] the mother had already to stay there hours and hours with the baby and she could do [the kangaroo method]. I think that lacks availability, perception, sensitivity of providing this to the mother. (N7)

The work mate who is more experienced comes to us and speaks 'guys, it is not like that' and we, like many years of the ICU think that he knows everything ... but he has a professional who does it [kangaroo method] and really feels gratified even professionally, as person. (N5)

In the Needing to modify the care environment subcategory, the nurses pointed out that the NICU's sonority and agitating mood alter the professionals' perceptions, attitudes and behaviors. Thus, they recognized that there is a mutual influence between the behavior of the professional and the atmosphere of the care environment.

The ICU environment is very hectic and by itself it determines conduct. People get very agitated, it sure determines, everyone gets restless, there are just those bombs and oximeters beeping... (N2)

When you try to work in a hectic environment with this excess of encouragement, but you have another experience in another environment, then you begin to realize how good it is to be in a milder environment, a calmer, less encouraging environment. How much is good for you professional and much more for the baby and the family member. (N8)

It was also highlighted the need for teamwork to account for the application of the Kangaroo Mother Care in its first stage. Thus codes, such as respect among members, communication, accountability, articulation and a good relational climate made up the Needing to work as a team subcategory, and can be observed in the following speech:

[...] when we work as a team we can see this whole and that is what people sometimes don't understand. They think that one wants to go over the other all the time and work as a team is not like that. (N2)

In the Needing autonomy and multiprofessional support subcategory, the nurses reported that their decision and performance are limited by medical restriction, facing criticism and resistance in the practice of the Kangaroo Mother Care in the NICU.

I feel weird when they [referring to the doctors] don't allow, when we ask 'Can I put the baby on my lap?'. Because for me, the Kangaroo Mother Care is our positioning, but when you ask to put it on your lap, you think you're capable of it, there's not going to be any risk, and medicine puts you in the way, you cannot because you have a catheter'. (N3)

On the other hand, the Ensuring continuity of practice subcategory addresses the nurses' concern to ensure a continuous application of the care provided by the Kangaroo Mother Care and which are considered as best neonatal practices. In the testimonies, there were reports of discontinuity of these practices among professionals and shifts, with special attention to the night shift.

Regarding the kangaroo position and explaining to the mother that she can touch the baby that she can stay close to the baby, this issue of breastfeeding and all is very erratic yet. There are teams that do and others that don't, there are teams that like and others that don't like. (N2)

[...] they usually say 'at night is to do the basics and because we get some rest we cannot waste time'. And that also depends on the group and the nurse because it is not because of the rest that we will stop doing, even if the mother is present. (N6)

Sometimes I can put that mother in the Kangaroo Mother Care and such, but sometimes I just cannot go on. And that is the hardest part, to follow that mother up in the whole process. (N4)

In view of this reality, the Needing for leadership subcategory was based on the need emphasized by nurses for greater involvement, interaction, supervision and encouragement from the managers and leaders for the team's adherence to the Kangaroo Mother Care.

[...] and that it also start from the coordination, because if coordination doesn't have that thought, it doesn't get involved with it, of course the team will not get involved, because it will not be charged for it. (N1)

I think it needs more motivation by professionals who are more enlightened as to these techniques, practices, understood? [...] We have the closest leaders; we have daily supervisors who could help us more because our life there in the ICU is sometimes a damn rush. (N5)

Still in this context, nurses reported difficulties in managing the Kangaroo Mother Care at the NICU and assumed the need for strategies for safer leadership, greater staff motivation, conflict coping and supervision. They consider mandatory Kangaroo Mother Care practices and standardization through routine and care plan at the NICU. These codes comprised the Needing management strategies subcategory that is represented in the following sections:

I think if you have training for this, if everyone already knows the importance and isn't being done, it's a matter of turning into order. [...] I think that's the only way. (N2)

What I have learned is: With the routine you create habit and the habit becomes a lifestyle. That's what you need to have in the ICU, that routine, every day you have to do it. Bath, if you can't wrap it up, just don't do it. It would be an imposition, 'go bath the baby, wrapped bath, weighing the rolled baby or just don't do it, because then it forces you so much to do it that later you can't do without it. (N10)

Based on the above, the subcategories presented present the challenges related to structure, dynamics and work processes in the individual and collective dimensions for adherence to best practices in the context of the Kangaroo Mother Care in the NICU.

DISCUSSION

One of the important tools of management is the situational diagnosis that involves the operational analysis of the operation of a process, system or model, to enable the planning of strategic activities. In this study, it was evidenced the need for a situational diagnosis to know the context, resources, processes, structure and results of the Kangaroo Mother Care. Through a situational diagnosis, it is possible to establish priorities for interventions that are necessary for the quality of care, as found in experiences reported in the literature in other care and teaching contexts(99 Freire EMR, Martinez MR. Situational diagnosis: an aid tool in quality management. Rev Enferm UFPE[Internet]. 2014[cited 2018 Apr 30];8(5):1405-12. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/9827/10017
https://periodicos.ufpe.br/revistas/revi...
-1010 Lima CA, Rodrigues BG, Araújo JGC, Cardoso NR, Rocha PT, Ribeiro CDAL, et al. Diagnóstico situacional na unidade de saúde: uma experiência na perspectiva de graduandos de enfermagem. Rev Eletron Gestão Saúde[Internet]. 2014[cited 2018 Apr 30];5(3):1109-19. Available from: http://periodicos.unb.br/index.php/rgs/article/view/22702/0
http://periodicos.unb.br/index.php/rgs/a...
).

This diagnosis related to the development of best practices in the NICU should consider as a priority the quantitative relationship between nursing professionals and neonatal patients, in the context of complexity. Often, there is a mismatch between the needs of the baby and his/her family, and the effective capacity to produce the care of the team, thus, supply is below demand. The equation of this relationship is determinant for the time factor for care, which was highlighted in this study and found resonance in other studies(1111 Branco LLWV, Beleza LO, Luna AA. Nursing workload in neonatal ICU: application of the nursing activities score tool. Rev Pesqui: Cuid Fundam[Internet]. 2017[cited 2018 Apr 30];9(1):144-51. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/5280/pdf_1
http://www.seer.unirio.br/index.php/cuid...
-1212 Vieira FPC, Garcia PC, Fugulin FMT. Nursing care time and quality indicators at a pediatric and neonatal intensive care unit. Acta Paul Enferm[Internet]. 2016[cited 2018 Apr 30];29(5):558-64. Available from: http://www.scielo.br/pdf/ape/v29n5/en_1982-0194-ape-29-05-0558.pdf
http://www.scielo.br/pdf/ape/v29n5/en_19...
).

The NICU environment in this study has proved to be a challenge because its own technological structure imposes difficulties to promote a neuroprotective environment for the premature. The alarms and tension characteristic of this environment end up interfering in the behavior of the baby, the relatives and the professionals. Studies also identify environmental conditions as one of the main unfavorable factors for the promotion of the Kangaroo Mother Care(1313 Heinemann AB, Hellström-Westas L, Nyqvist KH. Factors affecting parent's presence with their extremely preterm infants in a neonatal intensive care room. Acta Paediatr[Internet]. 2013[cited 2018 Apr 30];102(7):695-702. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23590800
https://www.ncbi.nlm.nih.gov/pubmed/2359...
-1414 Kymre IG. NICU nurses' ambivalent attitudes in skin-to-skin care practice. Int J Qual Stud Health Well-being[Internet]. 2014[cited 2018 Apr 30];9:23297. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24559549
https://www.ncbi.nlm.nih.gov/pubmed/2455...
).

The acquisition of knowledge was pointed out in this research as a fundamental process for the development of a contextualized vision, thus favoring the implementation of best practices of the Kangaroo Mother Care. Theoretical knowledge will allow the professional to develop a cognitive arsenal of judgment of care situations for decision making. However, it is the confluence of a continuous process of theoretical-practical knowledge construction that has greater potential for improvements in care outcomes. Studies corroborate the idea that theoretical knowledge must be articulated with the behavioral change of the team, working carefully in the implementation of management strategies that facilitate adherence in clinical practice(66 Gomes JATS, Martins MJL, Hertel VL. Método Mãe Canguru: percepção da equipe de enfermagem. Rev Eletron Enferm Vale Paraíba[Internet]. 2015[cited 2018 Apr 30];1(8):63-79. Available from: http://fatea.br/seer3/index.php/REENVAP/article/view/39
http://fatea.br/seer3/index.php/REENVAP/...
,1515 Costa R, Klock P, Borck M, Custódio Z, Barcelos M. Interdisciplinaridade na atenção humanizada ao recém-nascido de baixo peso em um centro de referência nacional do Método Canguru. Holos[Internet]. 2015[cited 2018 Apr 30];31(3):404-14. Available from: http://www2.ifrn.edu.br/ojs/index.php/HOLOS/article/view/2730/1111
http://www2.ifrn.edu.br/ojs/index.php/HO...
).

Studies emphasize that professional qualification is an important management strategy to improve adherence to best practices, but should not be isolated from a management of clinical practice(1616 Lemmen D, Fristedt P, Lundgvist A. Kangaroo care in a neonatal context: parents' experiences of information and communication of nurse-parents. Open Nurs J[Internet]. 2013[cited 2018 Apr 30];7:41-48. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23802029
https://www.ncbi.nlm.nih.gov/pubmed/2380...

17 Almutairi WM, Ludington-Hoe SM. Kangaroo care education effects on nurses' knowledge and skills confidence. J Contin Educ Nurs[Internet]. 2016[cited 2018 Apr 30];47(11):518-24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27783834
https://www.ncbi.nlm.nih.gov/pubmed/2778...
-1818 Magela MM, Lima FET, Matias EO, Siqueira AEOB, Magalhães FJ. Humanized assistance to the newborn at risk: implementation of the first stage of the kangaroo method. Rev Enferm UFPE[Internet]. 2015[cited 2018 Apr 30];9(10):1602-7. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/10876/12117
https://periodicos.ufpe.br/revistas/revi...
). Relevant is the incorporation of knowledge and skills applied in care practice to strengthen the development of the Kangaroo Mother Care, as well as a permanent process of raising demands for education for professional improvement.

The results obtained here reflect that the experience of the Kangaroo Mother Care is fertile soil for the acquisition of skills and technical safety, but also for the sensitization of the individual, since the situations of interaction with the baby and his/her family generate, through reflection, the transformation vision and professional action. Sensitization is therefore a process that benefits both the baby and his family as well as the professional in the autonomy and development of best practices. Thus, in the management of care, the valuation of previous experiences of the individual contributes to the transformation and cancels the uncritical reproduction(1919 Lopes TRG, Oliveira SS, Pereira IRBO, Romeiro IMM, Carvalho JBL. Humanization of care to newborns in the Kangoroo Method: experience report. Rev Enferm UFPE[Internet]. 2017[cited 2018 Apr 30];11(11):4492-7. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/25089
https://periodicos.ufpe.br/revistas/revi...
-2020 Paim CC, Ilha S, Backes DS. Permanent education in health in an intensive care unit: the perception of the nurses. Rev Pesqui: Cuid Fundam[Internet]. 2015[cited 2018 Apr 30];7(1):2001-10. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/3586/pdf_1442
http://www.seer.unirio.br/index.php/cuid...
).

When experiencing numerous situations of care for the baby and his family in the NICU, the professional is organizing the information acquired in order to meet a set of values, beliefs, expectations and individual and collective needs that allow him to take an attitude. In this sense, the human attitude is quite complex, because it involves cognitive, behavioral, affective-emotional and volitional aspects. It is the social relations established for care that provide nursing professionals with the acquisition of new information and the experience of different feelings. It is in this context that the professional, through the meanings, gives meaning to the care of the newborn in the Neonatal ICU(2121 Sá Neto JA, Rodrigues BMRD. The intentional action of nursing team to caring for the newborn in the NICU. Ciênc Cuid Saude[Internet]. 2015[cited 2018 Apr 30];14(3):1237-44. Available from: http://www.periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/22320/15384
http://www.periodicos.uem.br/ojs/index.p...
).

In this study, the results pointed to the need to change conceptions and attitudes. These are influenced by the continuous process of signification of the individual in the symbolic interaction with himself and with others, in a given historical-social context. In the Kangaroo Mother Care, nurses' practice is influenced by organizational culture, the care model, and the complex interplay of beliefs, norms and evidences. Thus, there is an ambivalence in the nurses' attitudes towards skin-to-skin contact between the parents and the premature baby in NICU, in order to promote as much as possible or not always to facilitate the best care conditions for multidisciplinary issues, to be a supporter of parental involvement or practice the Kangaroo Mother Care as a routine without much knowledge and relational sensitivity(1414 Kymre IG. NICU nurses' ambivalent attitudes in skin-to-skin care practice. Int J Qual Stud Health Well-being[Internet]. 2014[cited 2018 Apr 30];9:23297. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24559549
https://www.ncbi.nlm.nih.gov/pubmed/2455...
,1616 Lemmen D, Fristedt P, Lundgvist A. Kangaroo care in a neonatal context: parents' experiences of information and communication of nurse-parents. Open Nurs J[Internet]. 2013[cited 2018 Apr 30];7:41-48. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23802029
https://www.ncbi.nlm.nih.gov/pubmed/2380...
).

In the context of multiprofessional relationships, another challenge highlighted by nurses in this study was autonomy for making decisions related especially to skin-to-skin contact and breastfeeding in premature infants. However, there is often a false interpretation of the term "autonomy" as total independence and self-sufficiency to decide and act alone. On the contrary, true autonomy is achieved when the professional acts in a context of interdependence between the various professionals with whom he works, respecting the limits of his duties, complying with agreements, solving situations and acting in a safe and effective manner(2222 Santos PF, Silva JB, Oliveira AS. Percepção da enfermagem sobre o método mãe-canguru: revisão integrativa. Rev Eletrôn Atualiza Saúde[Internet]. 2017[cited 2018 Apr 30];6(6):69-79. Available from: http://atualizarevista.com.br/article/percepcao-da-enfermagem-sobre-o-metodo-mae-canguru-revisao-integrativa-v-6-n-6/
http://atualizarevista.com.br/article/pe...
-2323 Santos EI, Gomes AMT, Marques SC, Ramos RS, Silva ACSS, Oliveira, FT. Comparative study of representations of professional autonomy produced by first and last-period undergraduate nursing students. Rev Latino-Am Enfermagem[Internet]. 2017[cited 2018 Apr 30];25:e2927. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614237/
https://www.ncbi.nlm.nih.gov/pmc/article...
). Therefore, autonomy is also a professional stance that reflects maturity and permanent self-criticism and a relationship pattern built for work.

In this respect, the studies show that the commitment of visibility and the lack of recognition of the profession by the other health team workers reflect on the difficulties of establishing trust ties, with negative results in the implementation of best practices(2424 Avila LI, Silveira RS, Lunardic VL, Fernandes GFM, Mancia JR, Silveira JT. Implications of the visibility of professional nursing practices. Rev Gaúcha Enferm[Internet]. 2013[cited 2018 Apr 30];34(3)102-9. Available from: http://seer.ufrgs.br/index.php/RevistaGauchadeEnfermagem/article/view/37874/27296
http://seer.ufrgs.br/index.php/RevistaGa...
-2525 Felix TA, Ferreira FV, Oliveira EN, Eloia SC, Gomes BV, Eloia SMC. Prática da humanização na visita em unidade de terapia intensiva. Rev Enferm Contemp[Internet]. 2014[cited 2018 Apr 30];3(2):143-53. Available from: https://www5.bahiana.edu.br/index.php/enfermagem/article/view/381
https://www5.bahiana.edu.br/index.php/en...
). For quality, health team members need to recognize the importance of sharing and striving for the achievement of established collective goals. But in practice, teamwork is not an easy task, especially since it involves personal interactions and attitudes of cooperation, respect and communication between professionals.

Teamwork is perhaps one of the most important characteristics of health work that is directly linked to individuals' personal and professional development and the advancement of best practices. The care model of the Kangaroo Mother Care requires networking where the central concern is the comprehensiveness of actions. However, what is observed in practice is disintegration between the various categories that compose the health team working in the NICU, resulting in dislocated and punctual actions. Hence the need highlighted in this research that nursing managers and managers look to the structuring of teams and make investments for a synergistic interaction between people, which provide the feeling of belonging and recognition of the other(2626 Silva EM, Moreira MCN. Health team: negotiations and limits of autonomy, belonging and the acknowledgement of others. Ciênc Saúde Colet[Internet]. 2015[cited 2018 Apr 30];20(10):3033-42. Available form: http://www.scielo.br/pdf/csc/v20n10/en_1413-8123-csc-20-10-3033.pdf
http://www.scielo.br/pdf/csc/v20n10/en_1...
).

The question of the discontinuity of the practices was evidenced in this study as a reflection of the difficulties in the care management and in the systematization of the assistance, as well as in the articulation between the teams, duties and shifts. Another challenge highlighted in this research was the need for leadership for team motivation and continuity of practice in Kangaroo Mother Care. It is critical that nursing professionals and managers be involved in a quality improvement movement, where practices and processes at the NICU are continually reviewed for patient safety and humanization. This, in turn, demands mapping of the difficulties and limitations in the work for planning and interventions that promote the continuity(2727 Carvalho AGF, Cunha ICKO, Cunha ACKO, Balsanelli AP, Bernardes A. Authentic leadership and the personal and professional profile of nurses. Acta Paul Enferm[Internet]. 2016[cited 2018 Apr 30];29(6):618-25. Available form: http://www.scielo.br/pdf/ape/v29n6/1982-0194-ape-29-06-0618.pdf
http://www.scielo.br/pdf/ape/v29n6/1982-...
-2828 Frota LA, Camponogara S, Arboit EL, Tolfo F, Beck CLC, Freitas EO. The nurse's visibility in intensive care units: perceptions of workers. Rev Eletron Enferm[Internet]. 2015[cited 2018 Apr 30];17(3):1-8. Available from: https://www.fen.ufg.br/revista/v17/n3/pdf/v17n3a11.pdf
https://www.fen.ufg.br/revista/v17/n3/pd...
).

The growing complexity of health work has required nurses to have greater management skills, since they occupy a prominent position in the organization of the care process in the different care contexts. Strategies assist the manager in making decisions, motivating the team, setting goals, concentrating efforts on results, and defining the resources needed. Thus, the strategy refers to a guideline, a tool that guides or standardizes the process of care management, giving consistency and better results in the decision-making and assessment process(2929 Sade PMC, Peres AM. Development of nursing management competencies: guidelines for continuous education services. Rev Esc Enferm USP[Internet]. 2015[cited 2018 Apr 30];49(6):991-8. Available from: http://www.scielo.br/pdf/reeusp/v49n6/0080-6234-reeusp-49-06-0991.pdf
http://www.scielo.br/pdf/reeusp/v49n6/00...

30 Silva VLS, Camelo SHH, Soares MI, Resck ZMR, Chaves LDP, Santos FC, et al. Leadership practices in hospital nursing: a self of manager nurses. Rev Esc Enferm USP[Internet]. 2017[cited 2018 Apr 30];51:e03206. Available from: http://www.scielo.br/pdf/reeusp/v51/1980-220X-reeusp-51-e03206.pdf
http://www.scielo.br/pdf/reeusp/v51/1980...
-3131 Santos LG, Lima MADS, Pestana AL, Colomé ICS, Erdman L. Strategies used by nurses to promote teamwork in an emergency room. Rev Gaúcha Enferm[Internet]. 2016[cited 2018 Apr 30];37(1):e50178. Available from: http://www.scielo.br/pdf/rgenf/v37n1/en_0102-6933-rgenf-1983-144720160150178.pdf
http://www.scielo.br/pdf/rgenf/v37n1/en_...
).

Study limitations

Considering that the Kangaroo Mother Care presents different levels of programmatic implementation in maternity hospitals and hospitals, the limitation of this study is that it was developed in a single setting, and it is not possible to generalize the results.

Contributions to the sector of Nursing

This study provides insights into nursing care management in the Kangaroo Mother Care by highlighting the interaction among staff for teamwork as an important area of management investment in order to gain better adherence to best practices in the NICU. It also offers contributions to give greater visibility to the Kangaroo Mother Care as a set of best practices that despite strengthening the humanistic values in neonatal care, still faces resistance and limitations regarding the adherence of professionals.

CONCLUSION

In the hospital context, challenges are present in any stage of an assistance model, from the elaboration, through the implantation and development until the assessment, in a cycle of continuity and feedback. In the context of the Kangaroo Mother Care, the present research highlighted important challenges that involve adherence and, therefore, the development of the best practices proposed in this perinatal model.

In this research, the nurses reported difficulties in fully applying the Kangaroo Mother Care proposal in the NICU, denoting a departure from the goals of the national program. The main reason was the decline or abandonment of practices by professionals, reflecting the low adherence to the model. Challenges such as professional and institutional needs have been addressed to improve adherence and implementation of the Kangaroo Mother Care.

The professional challenges arise when nurses confront their resources (knowledge, experiences, conceptions and attitudes) with the assistance demands of relational technologies for quality care in the NICU. On the other hand, the institutional challenges to the Kangaroo Mother Care's adherence and implementation refer to the structure and work process in the NICU, which are specially designed by the different deliberative bodies that make up the management of services and units.

In this sense, the nurses listed as main necessities the adequacy of human resources, multiprofessional work, programs of Permanent Education and humanization of the environment of the NICU. It then follows that, institutionally, investment in improvements to the implementation of the Kangaroo Mother Care depends on the meaning and dimension that experience with the model has for managers and leaders.

  • FUNDING
    This article obtained support of Carlos Chagas Filho Rio de Janeiro Research Foundation (FAPERJ).

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Publication Dates

  • Publication in this collection
    2018

History

  • Received
    08 June 2018
  • Accepted
    29 July 2018
Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
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