COMPREHENSIVENESS OF THE CARE FOR THE NEONATE: THE ARTICULATION OF MANAGEMENT, TRAINING AND CARE

This study's objective was to understand the practices of comprehensiveness revealedin the ambits of the management, care and training, based on the care given to the new-born hospitalized in the Neonatal Intensive Care Unit. Methods: A qualitative study with a dialectical approach. The data was collected through participant observation and interviews with managers, lecturers and students, and was analyzed using Thematic Content Analysis. Results: Evidence was found of managers' and professionals' practices which contribute to the comprehensiveness of the care for the neonate, such as the de-centralization of management actions, joint decision-making with the health professionals, encouragement to work as a team, and the valuing of the family. The integration of the service's professionals into the teaching-learning process was indicated as a strategy for a training guided by comprehensiveness. Conclusion: It is ascertained that articulation between management, care and training is necessary for the construction of care based on comprehensiveness. 1 Universidade Federal de Minas Gerais. Belo Horizonte MG, Brazil. 2 Universidade Federal de Minas Gerais. Belo Horizonte MG, Brazil. 3 Universidade Federal de Minas Gerais. Belo Horizonte MG, Brazil. 4 Universidade Federal de Minas Gerais. Belo Horizonte MG, Brazil. 5 Universidade Federal de Minas Gerais. Belo Horizonte MG, Brazil. 6 Universidade Federal de Minas Gerais. Belo Horizonte MG, Brazil. RESEARCH PESQUISA INVESTIGACIÓN A integralidade do cuidado ao recém-nascido: articulações da gestão, ensino e assistência Esc Anna Nery (print)2013 Sep-Dec; 17 (4):713 720 Elysângela Dittz Duarte1, Roseni Rosângela de Sena2, Erika da Silva Dittz3, Tatiana Silva Tavares4, Paloma Morais Silva5, Cynthia Marcia Romano Faria Walty6 Atención integral al recién nacido: articulación entre gestión, capacitación y asistencia Neonatal Intensive Care Units; Infant Newborn; Comprehensive health care.


INTRODUCTION
Regardless of the meanings and significances attributed to comprehensiveness in the field of health, one can consider that it is constructed routinely when our view of the other does not place him in the limits of somebody who brings with him a condition which creates suffering.The possibility of this new view is increasingly broadened to the degree in which the relationship established between the service users and the health professionals does not dispense with the subjective and objective aspects which must make up this meeting, opening possibilities for comprehensiveness to be constructed.
Therefore, if we take the context of care for the new-born, this study's object, the care must not be limited only to the aim of prolonging life -it must, rather, also take into account the need to build and strengthen the link between the new-born, the family and the health professionals.This has been an effort which can be identified in the current policies and programs directed at the health of mother and child.
This indicates another aspect to be discussed for constructing comprehensiveness, which refers to its relationship with management actions, where it must constitute the guiding principle at the macro-level of the health policies formulated by the State, in the management of health, at different levels of care, reaching the caring dimension, in which the health professionals' practices in the attention to individuals' health are articulated and developed 1 .
Lastly, but not less important, comprehensive care requires re-constructing and re-organizing the health care, utilizing qualified workers for this 2 .One has to consider, therefore, that models of care which value -among others -comprehensiveness, require it to be included during the health professionals' training 3 .
We have indicated until now how important it is that the discussion on comprehensiveness in health should be made considering different dimensions which can influence its materialization in the health services, these being: the professionals; practice in the care process, the health services' management actions, and the professionals' training.Knowing that these dimensions guide how the health work is produced, guided by comprehensiveness, how are they organized and operated in the context of the health services?
Based on this question, this study's objective was to understand the practices of comprehensiveness revealed in the ambits of management, care and training, based on the care given to the new-born hospitalized in the Neonatal Intensive Care Unit (NICU) of a philanthropic institution located in Belo Horizonte, Minas Gerais.

METHOD
A study with a qualitative approach was undertaken, guided by the dialectical theoretical-methodological framework, considering the historical process in its movement, temporariness and transformation.This study's setting was a philanthropic hospital, located in the municipality of Belo Horizonte, Minas Gerais, specialized in caring for the health of the mother and new-born.It has as its mission to offer service users care guided by comprehensiveness.It has 91 beds for attending high-risk new-borns; of which 41 are for neonatal intensive care, being distributed across four units.Because of its attendance capacity and the quality of the care offered to the new-born and family, this institution is a benchmark for neonatal care in the State of Minas Gerais.
The subjects were managers and health professionals of the NICU and the family members of new-borns receiving inpatient treatment there, as well as lecturers and students from institutions of higher education who were carrying out activities in the study setting.
Data collection was undertaken through participant observation in the NICU and interviews guided by a semi-structured script, both techniques being used simultaneously.The insertion into the field took place in the period January 2009 -March 2010, being undertaken by researchers trained in the area of health, accompanied by students funded by scientific initiation grants, doing the undergraduate nursing degree.All members of the research team participated in workshops for theoretical, practical and ethical discussion of the methods.These workshops aimed, above all, to ensure that the researchers would share the same understanding regarding how to conduct the observation, what was to be observed, and how to record the situations observed.
The observation, this study's central data collection procedure, consisted of the insertion of the researchers into the NICU's routine, monitoring the subjects' actions and interactions in situations of care.This procedure allowed us to grasp the NICU's reality, based on the occurrence of the care.The observations were carried out in the NICU by the researchers, individually or in pairs, on different days and at different times, seeking to cover the diversity of the situations of care.
In total, the observations lasted 25 hours and were guided by a semi-structured script which covered situations of care, such as the passing of news between health professionals, the admission or discharge of the neonate, situations of complications or death, the parents' first contact in the neonatal unit, the parents' participation in the NICU, visits to the new-born, and procedures.The degree of participation varied according to each researcher's involvement with the individuals and activities observed.It The comprehensiveness of the care for the new-born was defined that the researcher would only intervene in the course of the situation being observed if there were a risk to the new-born or her family members.The records of the observations were made by the researchers in a field diary during and immediately after the collection of the data, encompassing: date and time, description of the environment and the subjects, a report of what happened, the subjects' actions, the relationships established and the researcher's perceptions.Weekly evaluations of the records were made until repetitions in the observations were identified, indicating the interruption of the observations, given that the data collected would not change the context understood.
The subjects to be interviewed were defined based on the insertion into the field to undertake the observations.For the 12 interviews, specific semi-structured scripts were used for each group of subjects: 1) 01 undergraduate student and 01 postgraduate, 2) 02 lecturers and 02 health professionals inserted in the NICUs, 3) 03 placement coordinators from the teaching institution with which the student was linked, 4) 03 coordinators from the health service and the NICU.The data was analyzed based on the technique of content analysis, thematic mode, which seeks the manifested and latent meanings in the empirical material 4 .The interviews were transcribed and codified, which was also done with the records from the participant observation.A general reading was made of the data collected through the interviews and observations, followed by an in-depth reading, returning to the study's objectives.The identification of the most recurrent and relevant themes and the separating of the excerpts was carried out.Based on this, the themes were grouped, giving rise to three empirical categories: The health services' comprehensiveness in the care for the new-born; Meanings of comprehensiveness in the care for the new-born; The comprehensiveness of the care for the new-born, and its interface with professional training.
In the presentation of the results, the themes are exemplified with excerpts from the participants' accounts and excerpts from the field diary.When these are from the discourse of the NICU nurse coordinator, they are coded with the letters NC; P, when from the professionals of the health service; RE, when from the person responsible for the teaching institution; RP, when from the person responsible for the placement in the service; CS, when from the NICU coordinator in the health service; and Ob, when the excerpts are from the field diary, followed by a code number from the database.
The research was approved by the Research Ethics Committee of the Federal University of Minas Gerais (Decision 503/07) and that of the research setting, and respected the provisions of Resolution 196/96 of the Ministry of Health 5 .

RESULTS
The analysis of the data obtained in the interviews and observations allowed the capturing of actions which limit or which favor the comprehensiveness of the care for the new-born in the ambits of management, care and teaching.In the results, these aspects are presented separately to facilitate their identification and comprehension; nevertheless, one must take into account their inter-relatedness and mutual influence.

Comprehensiveness in the management of the health services in the care of the new-born
The analysis of the data allowed the researchers to understand practices of the managers which contribute to the comprehensiveness of the care for the neonate in the NICU, such as the decentralization of the management actions, the joint taking of decisions with the health professionals, the encouragement of team work, the valuing of the family and the articulation with the network of health services for the continuity of the care.
In the view of the neonatal unit's coordinators, the decentralization of the management actions and the joint decision-making with the health professionals from the team favor the interpersonal relationships, as the health professionals feel valued and recognized, as evidenced in the account below: I think that this favors the relationships, (...) the person feels more valued by being sought out for deciding something from the NICU, they feel more useful, they feel more part of the team, because the decisions are taken together.(NC) The coordinator's report evidences that the communication with the other professionals of the unit allows the team to be involved in the decision-making process.It also emphasizes the importance of the professionals working as a team to ensure comprehensiveness of the care for the new-born.

Every baby that arrives, straight after admission, has the work team -nursing, physiotherapy, and the doctor -and there's the psychologist, she's going to know what the case is, she'll look for the mother if there's a problem, (...) and we have other professionals, (...) the professionals are highly interlinked and highly present in the NICU. (NC)
Based on the data collected, it can be verified that the recognition of the importance of the mother being with the child is one of the determinant factors for the creation of conditions for the mother to stay in the Institution.For this reason, a house was acquired near the Hospital, offering conditions for relaxation, preparing food, and being monitored by the multiprofessional team.This unit viabilizes the mother's presence full time in the Institution during the child's hospitalization in the NICU.This is indicated by the coordinator as favoring comprehensive care for the neonate.The family's importance is also evidenced in its report in asserting that comprehensive care for the new-born hospitalized in the NICU assumes the embracement of the family and the passing of information on the new-born's clinical conditions.Also identified were management strategies used to ensure the comprehensiveness of the care for the neonate following discharge from NICU, in care spaces of the Institution or of other health services.Among such strategies, the neonatology coordinator emphasizes the preparation of the new-born's family to take on the care at home, and the monitoring of the new-born after discharge from hospital.
In relation to this last, the coordinator reports the existence of a service directed at the monitoring of the growth and development of the new-born who leaves the NICU of the Institution where this study was set.The monitoring of the new-born in other health services is also indicated as fundamental for the comprehensiveness of the care for the new-born.
Although attempts at establishing counter-referral have been identified in the neonatology coordinator's reports, difficulties were revealed referent to the articulation between the various points of care which make up the care network, emphasizing the fragility of the continuity of care between the hospital services and those of primary care.
We get in contact with the health clinics and ask them to do the monitoring with the Family Health team.So we send the child to the network, but we know the child is going to be monitored, and at the same time we ask them to keep in touch with us (...) because we're very scared of losing these children.

(CS)
We want to know: the child who left here, from our NICU, what happened to her?These children's sequelae, prognosis (..

Comprehensiveness in the care for the new-born
The data permitted the identification of care actions directed at the new-born which are under taken by the multiprofessional team, with varying degrees of interaction between the team members, and which seek to respond to the care needs of the new-born and her family.Even though there were situations which evidenced the existence of articulation between the professionals for the undertaking of care, situations were also observed in which the organization of the work process by the NICU team was compromised.
It was evidenced that verbal communication is a trigger for activities in NICU, that is, it is based on this that the majority of the care actions are triggered and organized.The situations observed, and the participants' reports, revealed that the health professionals used strategies which favor the new-born's growth and development.Among these, emphasis is placed on actions directed at reducing noise and handling, guided by the new-born's signs and responses.On the other hand, the observations allowed the identification of moments in which the health professionals were centered in undertaking techniques and procedures but were failing to consider the new-born's reactions and needs.
Situations were identified which favor the parents' participation in the care of their child in the NICU during the group care and through individual guidance undertaken based on a requirement of the new-born and the family members: The nursing technician guides the father so that he can remove the plastic wrap and touch his baby.(...) The father touches his baby with his fingertips.Minutes later, the physiotherapist arrives and advises the father on how to touch the baby.(Ob-42)   It was ascertained that the companion's support, like the recognition and institutional support regarding the importance of the mother's presence for the new-born's recovery, can also be considered to be factors which facilitate the mothers' staying in the NICU and their participation there in the care for the new-born.Situations were identified, however, which indicate limits on the mother and family's participation in the care for the new-born, such as the lack Duarte ED, Sena RR, Dittz ES, Tavares TS, Silva PM, Walty CMRF The comprehensiveness of the care for the new-born of chairs in the NICU for the parents; how seriously-ill the new-born is, and complications in her clinical picture; and the parents' ignorance regarding the equipment in the NICU.
The babies went to the NICU straight after they were born, and the mother reports that she was frightened.In the beginning, she was scared when the devices made noises, but the professionals calmed her down and explained what was happening.(Ob-64)   The father comes up to me and asks if he can hold his baby in his lap, and I ask the nursing technician to advise him.She tells the father that the baby cannot be held, because it is not long since he was extubated.(Ob-42)   In relation to the possibilities for the continuity of the care for the new-born at home, the reports evidence that the family is prepared by the multiprofessional team during the new-born's hospitalization in the different care spaces in the Institution, with the child's route through these spaces, through to discharge, being determined by her clinical conditions and care needs.

The comprehensiveness of the care for the new-born and its interface with the professional training
The data collected evidenced the existence of an agreement between the teaching institution and the health service which formalizes the insertion of students in the neonatal units and their participation in the care for the new-born hospitalized in the NICU.The existence of financial contributions or provision of materials by the teaching institutions was identified, these proposals being evaluated by the health service's Teaching and Research Line and Board of Directors.

The legal instrument established is an agreement, between the teaching institution and the service institution, in which you have all the rules of play, the type of placement, students, in which sectors, whether the placement is mandatory or not, if there will be some sort of grant... or a grant to contribute to the cost of the studies, and what is established by law. (RP-1)
In the study setting, the practices are monitored by lecturers who are also professionals of the Institution, or who already have some sort of professional link which allows a knowledge of the institutional routine.This specific characteristic was presented as able to contribute to the teaching-learning process, as this familiarity with the service's routine makes it possible for them -in addition to meeting the teaching requirements -to preserve and spread the institutional values in the carrying-out of the practice.
The accounts reveal an institutional commitment to the training of professionals for the health system; even though it is not accredited as a teaching institution, it seeks to achieve the mission of training human resources.
It is understood that it is sought to promote teaching practices which favor the comprehensiveness of the care for the new-born, and which, in addition to using existing theory, in the context in which the care is given, lead the student to reflect on the meaning and repercussions of what is being done.
Thus, the comprehensiveness is present as much in the theoretical content as in the practice, and I'm sure of this, that the student is led in the practice such that he may have this view, so there he is, he's not doing a clinical test, a physical examination of the new-born, he is there with the new-born who has a mother or a companion with him, who has a family, and who is in context X.So, this is a view, and he isn't providing this care alone either, it is care given as part of a team, which is another important view for you to work in the perspective of comprehensiveness.(RE-4)   In the process of the students' insertion in the placement fields, a contradiction is evidenced relating to the acceptance of the professionals in the service where the student is placed.It may be verified that, even resisting this insertion, they do not fail to recognize the improvements that the presence of the student affords the health service.

They [the professionals from the service] do not want to collaborate, they think the student gets in the way (...). (RE-7) I think that their insertion [the students] in the learning with us is positive, they often help us in procedures. Because of the practical part, they manage to develop, to observe something which we who work here cannot see, because it ends up so routine that a lot happens and we don't notice. So, somebody who's new and coming from outside can perceive better, sometimes they create something for us, give some idea. (P-2)
The interviewees indicate that one of the challenges to constructing training defined by comprehensiveness is related to the student's unpreparedness, due to a lack of previous knowledge, related to the little content on neonatology offered in the undergraduate courses.

Usually they arrive very insecure about the things they're going to have to take on. Actually, what we see is that there is a
Duarte ED, Sena RR, Dittz ES, Tavares TS, Silva PM, Walty CMRF The comprehensiveness of the care for the new-born certain theoretical gap, no matter how much they arrive in the Institution and think they are prepared.In the practice, what we see is that they have really had no opportunities to see very much, so the opportunity which they see here to be learning also comes with insecurity which they pass on to us.(...) And most of the time, the insecurity really is caused by this, by not having seen much of this in their undergraduate course.(P-1) Differences can be ascertained in how the undergraduate and specialization placements are held.In the former, there is no integration between the health service and the teaching institution for the elaboration of the pedagogical proposal, while in the latter, the proposal was elaborated by the hospital's health professionals, favoring the co-responsibilization.
There isn't, there hasn't yet been, a concern with the pedagogical proposal [of the undergraduate course].We work much more with the operationalization (...) of the placement.(RP-4)

DISCUSSION
The construction of care guided by the principle of comprehensiveness entails access to different types of technology, such as equipment, structured knowledges and the technologies contained in the relationships, such as dialog, link, and embracement.It also presupposes multiprofessional and interdisciplinary work, making possible the articulation of 'doing' and knowledges from different professions through the establishment of a care project which is shared by all those involved 6 .
It was ascertained that, in the care in the NICU, the health professionals use strategies for viabilizing conditions which favor the new-born's growth and development, such as minimal handling and the reduction of noise and light.NICUs are characterized by high incorporation of technology, the uninterrupted work of various categories of professionals and the use of much life support and hospital instruments, which makes the environment noisy and inhospitable 7 , predisposing the child to auditory damage and physiological and behavioral changes 8 .These aspects, to a certain extent, are inherent to the NICU space; nevertheless, if we adopt comprehensiveness as a guiding factor for the care actions, we must consider not only the practices for prolonging and extending life, but also those measures which facilitate the neonate's process of adaptation and development.
In the discourses of the NICU managers, the understanding was evidenced that, for the comprehensiveness of the care for the new-born, a multiprofessional health team is essential, as is that team's members' participation in decision-making.In this view, to overcome the fragmentation of the work of the health teams and to promote the putting into effect of comprehensive care it is imperative to recognize that the different knowledges and responsibilities of each professional category are essential for meeting the health needs presented by the new-born and family 8 .
The managers recognize the importance of the family's presence during the new-born's hospitalization.In order to ensure the mother's right to remain alongside her child, it is expected that the health institutions should recognize the care needs of the mother and family, and adapt their physical infrastructure, norms and routines, and political-administrative structure, 8,9 these practices being identified in the present study.
In the study setting, management practices were identified which were aimed at meeting the care needs of the newborn and family, to the extent that the Hospital was organized and created alternatives for meeting the specific needs of its users, such as the offering of conditions for the mothers to remain there full time.
Studies have shown that the presence of a companion during the hospitalization of a new-born contributes to the family's security in the continuity of care at home 10 and it is recommended that the care should be guided by the needs of the new-born and her family, of the multiprofessional teamwork, of the continuity of the care and of the family's participation 8 .
It is necessary to consider that the family's participation is not limited to having free access to the NICU.It can be seen that, in spite of the mothers and family members being present in the NICU, their participation in the care for the new-born is not always assured 9,11,12 .In addition to this, it may be verified that there are limits on this participation, due to the professionals' lack of recognition of the knowledge that mothers and family members have in relation to the child.It is also emphasized that the inclusion of the mother and family members depends on the professionals' interest in incorporating them 9,13 .This points to the need for change in the planning and implementation of the care for the new-born by health professionals and managers, re-orienting their practice so as to viabilize -in the management and assistential practices -the care carried out by the family.
In relation to the continuity of care following discharge from hospital, it is evident that the period of hospitalization makes it possible to prepare the parents for the care at home.A similar result was verified in other Duarte ED, Sena RR, Dittz ES, Tavares TS, Silva PM, Walty CMRF The comprehensiveness of the care for the new-born studies in which it was also identified that this period provided them with learning to care and, consequently, with security to do so in the home 10,12 .
In the context of care for the new-born in the NICU, dialogical relationships are necessary between professionals and family which favor learning and participation in the care for the child, with clarification in relation to her condition 11,12,[14][15][16] .It is understood that one strategy which contributes to this is information, through understandable language, concerning the child's state and the purpose of the NICU equipment and routines, in addition to the growing interest in shared decision-making 9,10 .
Studies highlight that, to ensure the continuity and comprehensiveness of the care for the new-born, it is necessary to recognize the discharge from the NICU to other services or to the home as a critical stage of the care 11 .This data indicates that, in planning and implementing the discharge, an organized and appropriate plan must be prepared, covering the needs of the child leaving NICU, the preparation of the parents for caring for her, and articulation with the network of services.
The need to establish flows for the continuity of the care in services of the SUS health care network, with actions of referral and counter-referral, remains clear.For the security of the child leaving the NICU and her family, one must seek articulation between the services of the health care network, so as to ensure the continuous attendance for the children while they are at home 17 .Thus, the importance of structuring the care in assistential networks is stressed, making exchange possible between people and institutions 11 .
In relation to the training of the professionals, the lecturers and students indicate, as strategies for training guided by comprehensiveness, the adoption of activities guided by the needs of the student and also of the services, as well as the integration of professionals from the service into the teaching-learning process.
The analysis of the empirical material allows the inference that the articulation between the health service and the training of the undergraduate students in the perspective of integrality remains incipient; the institutions' priority is to meet a need of the student's formal practice curriculum in the placement area.Nevertheless, there is articulation of the roles of the health service and the teaching institution, and -specifically in the specialization course -there is cooperation in the selection of content, in the production of knowledge, and in the development of professional competence, making the learning effective based on the critical reflection of those involved in the training process.
In relation to the professionals' training, the interviews indicate the proposal of teamwork as a strategy for training guided by comprehensiveness, given that collective construction in the teaching viabilizes for the future professional a "training" for the observation of the individual in a comprehensive way, bringing together varying knowledges for one same work action 3 .Teamwork is proposed as a strategy for facing the increasingly accentuated process of specialization in health 18 .
It is necessary to re-evaluate that principles have guided the training of health professionals, as the transformation of the concepts and health practices which guide the training process so as to produce professionals capable of understanding and action relating to comprehensiveness in health practices cannot be restricted to universality 3 .

CONCLUSION
It was possible to grasp discourses and actions guided by meanings of comprehensiveness, such as the perception of the importance for the new-born of the presence of the family and their participation in the care, the valorization of the various professional categories and of teamwork, and the concern with the continuity of care following discharge.However, it is evidenced that it is necessary to improve communication and to create spaces which promote dialogical relationships.The need was ascertained for there to be articulation between management, care and training, and for managers, health care professionals, lecturers and students to have actions guided by the same principles.
When the actions undertaken specifically in the ambit of the management of the neonatal unit are analyzed, it may be verified that a multiprofessional team which works together is needed; however, actions originating from the managers which promote this joint action are not evident.It may also be ascertained that, although the management of a neonatal unit is referred to here, focussing on the care for the newborn assisted in the hospital, it is possible to understand a commitment to the post-discharge care, expressed through the attempt to establish a counter-referral with the other services in the health care network.
Even with resistance from some professionals in relation to the student's insertion in the Service, institutional investment in the implementation of teaching strategies can be verified.In the light of the above, there is the challenge of undertaking teaching activities which dialog with the meanings of the comprehensiveness of health care articulated with the routine of the services and of professional practice.
Although the practice of the professionals in the management and teaching, and in the care carried out for the new-born, allow one to identify the expression of comprehensiveness, and it may be verified that these dimensions have interfaces and to a certain degree strengthen each other, it was not possible to understand Duarte ED, Sena RR, Dittz ES, Tavares TS, Silva PM, Walty CMRF Duarte ED, Sena RR, Dittz ES, Tavares TS, Silva PM, Walty CMRF The comprehensiveness of the care for the new-born