Expectations, motivations and perceptions of nurses on the nurse-midwifery specialization course in the residence modality

Objective: To identify the motivations and expectations of nurses who opted for the nurse-midwifery specialization course in the residence modality and describe the perceptions of these nurses on this modality of lato sensu Post-graduate education. Methods: Qualitative descriptive study, in which the nurse residents of two nurse-midwifery residency programs in the city of Rio de Janeiro were interviewed. We used the thematic content analysis technique. Results: The choice of the residency program is motivated by an emphasis on practical experience; preference for women's health area; obtaining financial aid during the course and professional credentials for the job market. Practical learning is satisfactory, but with limitations in the hospital sectors and integration of theory and practice. Conclusion: The university and service need towork in a more integrated way to improve the educational process in the residency program.


INTRODUCTION
Nursing education has gone through curricular changes in the course of the 20 th century and nurse-midwifery contents have always been present.In the 1970's, the Minimal Nursing Curriculum was reformed and the nursing qualifications in public health, medical-surgical nursing and nurse-midwifery were established through Federal Education Council (CFE) Opinion Nº 163/72 1 .
In the same decade, the first on-the-job training experiences in the residency modality emerge in the country, similar to the medical residencies conducted in hospitals, without any affiliation with the academic institution and without educational regulatory laws, which gave rise to criticism and mistrust as to the quality of these professional training proposals 2 .
As a result of these particularities, nurse-midwifery teaching remained linked to academic institutions.When the Ministry of Education (MEC) established the Minimal Nursing Curriculum through Decree Nº 1.721, on December 15 th 1994, the nursing qualifications were extinguished and nurse-midwifery education was offered through lato sensu post-graduation courses, with a minimum hour load of 360 hours 1 .This link between nurse-midwifery qualification and Higher Education Institutions (HEI) is necessary as the certification is essential for professional practice and for the use of the prerogatives established in the Law of Professional Practice Nº 7.498/86, as well as to comply with the laws that regulate lato sensu post-graduation education in Brazil.
In compliance with this professional legislation, partnership experiences between health services and HEI emerge to offer specialization courses in nurse-midwifery in the residency modality.In the city of Rio de Janeiro, the first course in this modality was proposed by the Municipal Health Department (SMS) in partnership with the Universidade do Estado do Rio de Janeiro, and has regularly been offered since 2004.
It is only as from 2013 that the National Residency Program in Nurse-Midwifery (PRONAENF) is created as a strategic action of the Rede Cegonha (Stork Network).The Ministry of Health, in partnership with the MEC, offered 156 residency places affiliated with the HEI located in all regions of the country.Thirty-six places were destined for the state of Rio de Janeiro.The nurse residents enrolled receive study grants until the conclusion of their residency program 3,4 .
This ministerial program is aimed at training nurses for women's health care, in their reproductive health processes; in prenatal, delivery, birth and post-partum care, including the family in all care phases.This care should be guided by best practices, scientific evidences, guidelines of the Unified Health System (SUS) and the recommendations of the Stork Network, the National Comprehensive Women's Health Care Policy and the Pact for the Reduction of Maternal and Neonatal Mortality 3 .
As a result of these stimuli of public health management, nurse-midwifery education in the residency modality is implemented in Brazil.Thus, the nurses can choose between one of the two formats of professional nurse-midwifery qualification available in the country: a short-term specialization course, taking about two semesters, which generally requires financial investment from the student; and another long-term course, taking 24 months, with emphasis on practical activities and which offers study grants funded with public resources.
As the nurses need to choose the residency modality for this type of specialized education, the following research questions were proposed: What are the motivations and expectations of nurses when they choose the specialization course in nursemidwifery in the residency modality?How do the nurse residents consider their education in this lato sensu modality?
To answer these questions, the study aimed to identify the motivations and expectations of the nurses who chose the specialization course in nurse-midwifery in the residency modality and to describe these nurses' perceptions of the lato sensu post-graduation modality.

LITERATURE REVIEW
Since the 1990's, ministerial actions have been adopted to improve the quality and indicators of obstetric and perinatal care in Brazil, which stimulated the nurse-midwives' insertion in public maternity hospitals 5 .Despite this stimulus, these nurses faced professional difficulties and restrictions, mainly in normal birth care 1 .
In view of these ministerial actions, the Normal Birth Centers (CPN) were created through Decree Nº 985, on August 5 th 1999, which represented another stimulus for the nurse-midwives' care activities for women with physiological pregnancy and birth, as well as in the immediate care delivery to infants.Despite this measure, the CPN proposal met difficulties due to the mistrust towards the care delivered and the nurse-midwife's technical competency to take charge of maternal and neonatal care 6 .
These public measures were also confronted with the limited number of nurse-midwives with professional experience to take charge of the required care responsibilities, whose institutional, corporate and health management barriers in the cities influenced both teaching and care, as well as the fixing of these professionals at the obstetric centers 6 .
This problem demanded an additional ministerial measure, which was the funding of 76 specialization courses in nursemidwifery between 1999 and 2004, resulting in the qualification of 1,366 nurse-midwives in the country.These courses already addressed curricular contents aligned with the humanization policy of delivery and birth and destined two-thirds of the hour load of 460 to 600h for practical activities 5 .
Despite the difficulties faced to work at the maternity hospital, the nurse-midwives who graduated from the funded courses participate in professional qualification programs, like in the state of Pernambuco, where 51.7% of these nurses engage in pedagogical activities for nurse-midwifery residents 5 .
It should be highlighted that these funded courses were insufficient to influence the small number of nurse-midwives, modify the medical care model and revert the upward trend in the number of c-sections in Brazil 6 .

Specialization course at the residence modality
Lima GPV, Pereira ALF, Guida NFB, Progianti JM, Araújo CLF, Moura MAV On the other hand, no policy whatsoever was implemented to fix these professionals in the SUS.Although the Brazilian Classification of Occupations -CBO, established through ministerial decree Nº 397, on October 9 th 2002, includes the occupation of "nurse-midwife", these professionals still enter the public career for the function of "nurses" in most Brazilian cities.
As there is no specific function to enter the career, the nurse-midwives who pass a public exam can be allocated to other nursing functions at the institution, making them dependent on the obstetric service managers to prioritize, or not, these professionals' allocation to normal birth care 7 .
In addition, if the local management does not consider this allocation as a complementary strategy to the ministerial care qualification and encouragement strategies of normal birth, the impact of public investments on nurse-midwifery education is compromised 7 .
Despite this ambivalence in the conduction of political strategies to increase the number of these professionals in the country, a new stimulus emerges for the education and work of the nurse-midwives based on the implementation of the Stork Network in 2011, which aims to reorganize the maternal-infant care network and put in practice the humanized care model for pregnancy, delivery and birth 3 .
This incentive took form through the creation of the PRONAENF, with the publication of Call MS/MEC Nº 21, on September 5 th 2012, which approved the residency proposal in nurse-midwifery of 18 HEI located in Acre, Amazonas, Rondônia, Pará, Piauí, Bahia, Ceará, Sergipe, Mato Grosso do Sul, Minas Gerais, Rio de Janeiro, São Paulo and Rio Grande do Sul 3 .
In 2013, another selection of residency proposals affiliated with educational institutions took place through Call Nº 28, on June 27 th 2013, published by the Secretary of Work Management and Health Education of the Ministry of Health and the Higher Education Secretary of the MEC, with approval of HEI from other states of the federation, such as Goiás and Tocantins 8 .
Regarding the professional insertion of nurse-midwives graduated from the residency courses, a study identified that 73.7% of these professionals work in nurse-midwifery, predominantly in normal birth care (36.8%), prenatal care (26.3%) and obstetric emergency care (26.3%) 1 .Nevertheless, these nurses face barriers in the practice of their specialty, such as the restricted job market, medical resistance and low levels of professional recognition 9 .

METHODS
Descriptive research with a qualitative approach.The participants were the nurse residents from two residency programs in nurse-midwifery in the city of Rio de Janeiro.In the first residency program, the educational contexts are a birth house and five public maternity hospitals affiliated with the SMS-RJ.The other program has mixed practice scenarios, i.e. the University Hospital and three Maternity Hospitals from SMS-RJ.Both are lato sensu post-graduation courses in the residency modality offered by a public university.
Eligible participants should comply with the following criteria for inclusion in the study: nurses regularly enrolled in the specialization courses in nurse-midwifery and who were taking the second year of the residency.Nurses whose registration was inactive, who had dropped out, on health leave or engaged in this research were excluded.
The data collection period went from October till November 2013.In that period, one nurse resident was on medical leave and the other had dropped out of the residency course.Therefore, 13 of the 17 eligible nurse residents participated in the research.
The individual interview technique was used, with the support of a two-part structured script.The first part contained questions to characterize the participants' academic and occupational profile, and the second asked about the motivations, expectations and perceptions about the residency course.
The testimonies were analyzed through thematic content analysis, which comprises the following phases: 1) pre-analysis of the testimonies; 2) exploration of the material and treatment of the results and 3) inference and interpretation.
To preserve the anonymity, the testimonies received a code in the order of the interviews and the place where they worked, predominantly: Resident E1S, Resident E2H, Resident E3S and so forth.
The study received approval from the CEP of the Municipal Health Department (SMS-RJ), opinion Nº 70A/2013.

RESULTS
Among the 13 nurse-midwifery residents identified, ten residents were between 23 and 25 years of age and had recently graduated, within two years before they entered the residency course.Most of them (nine) had taken their undergraduate course at a public university.Only two residents had worked as a nurse before taking the course.

Reasons for choosing the course in the residency modality: emphasis on practical experiences, identification with the specialization area and professional gains
The nurses choose the specialization course in the residency modality as they get more practical experiences, which favors the acquisition of the competences and technical skills needed for professional practice.These motivations were mentioned in the following interview: We have the experience.We spend much more time at the hospital, where one gains different things and you truly learn to be a nurse.(Resident E1S)

Because it offers more work time as a resident. As I had no experience, [the residency] is an opportunity to feel safer, to learn more, to join theory and practice. (Resident E3H)
The nurses also choose the residence in nurse-midwifery because of their identification with this specialized nursing area, Specialization course at the residence modality Lima GPV, Pereira ALF, Guida NFB, Progianti JM, Araújo CLF, Moura MAV which involves the segment of woman's health, maternal-infant health and the particularity of delivery care, as verified in the following statements:

.). I have fought for this, to move on to the residency and one day be a nurse-midwife. (Resident E9 S)
Although less representative among the registration units of this thematic category, the residents mentioned other motivations to choose the residency course, which was the obtaining of professional gains.These gains are both financial, related to the reception of a grant throughout the course, and professional qualification itself, which refers to gaining professional credentials for an easier placement in the job market after concluding the course.
The residents mentioned these professional gains in the following testimonies:

[...] I looked for something that would grant me some recognition in the curriculum. It's complicated! Because they [employers] demand experience. I thought one way was to get the specialization and get experience, and in addition get money [grant] for that. So I joined the useful and the pleasant. (Resident E2H)
The residency also permits more practical experience than a normal post-graduation course, and there's also this financial return through the grant.In this modality, I am able to receive and learn instead of having to pay for that.(Resident E6 H)

Expectations upon entering the residency course: gaining knowledge and skills to work safely in the profession
When they enter the nurse-midwifery residency course, the nurses expect to gain knowledge and technical and political skills to practice the profession safely, which involves care delivery, decision making and work in daily nursing work situations, according to the following statements:

Being able to work in deliveries autonomous and safely, really knowing what I am doing, guaranteeing the safety of mother and baby. (Resident E10S) So I think I felt safer to be a nurse-midwife, to learn more about the mother-child area and really know this job world. (Resident E3 H) My main expectation in the maturing in the profession. You getting the knowledge but, at the same time, you knowing how to cope with routine situations... So, I think that the maturity and safety, linked to the program content [of the course], were the main expectations to enter the residency. (Resident E12 S)
Some nurses mentioned expectations focused on education in woman's health when they entered the residency course.They had no preliminary knowledge on the specific attributions of nurse-midwives.This lack of knowledge suggests that their initial perspective was not to work in the specialty itself, as can be observed in the following testimonies:

Perceptions of the residency course: satisfactory practical learning, but with limitations in the hospitalization sectors and in the integration between theory and practice
The residents consider that the residency course is responding to their initial expectations, mainly in the development of competences and skills needed to gain confidence in professional practice.This fact suggests that the first course year permits the insertion process in the world of nursing work and favors the constitution of the professional being.
In the first course year, the activities are more diversified and include care delivery to women during pregnancy, birth and postpartum.In the second year, the educational activities are more concentrated on normal birth care, when the education of nurse-midwifery specialist is consolidated.This transition process between being a nurse and being a nurse-midwife emerged from the following testimonies:

I started feeling like a nurse as this learning process occurred during the residency course. I don't feel a nurse-midwife yet [...]. But I think the program is valid. The practical issue is very good, it really gives you plenty of opportunity. The nurses are very dedicated to teach us and willing to transmit the knowledge. (Resident E9 S) I find myself much more mature than before [...]. I feel much more confident today. Now I am able to recognize myself as a nurse-midwife, even some months before concluding our education. (Resident E12)
Specialization course at the residence modality Lima GPV, Pereira ALF, Guida NFB, Progianti JM, Araújo CLF, Moura MAV Despite the positive perception of learning in the residency course, the residents appointed limitations in the education process in the hospitalization sectors as they do not always get appropriate supervision and orientation for education in the specialization area.Another critical space in the education was the university hospital, which presents impeditive organizational characteristics for the residents to develop learning for normal birth care, as the following interviews express: We understand that you need to learn the whole, not only the delivery.In R1 [first year of residency], you need that view of the pregnancy, of everything.But it's not fair either for you to stay alone at the rooming-in.( These limitations were not mentioned in the context of the practical scenarios where nurse-midwifery teams working in prenatal and normal birth care, like at the birth house and at the obstetric centers of the municipal maternity hospitals.
Another shortage the residents perceived in the education process is the integration between the theoretical and practical contents, showing a mismatch between what is learned and what is put in practice, as mentioned in the following statement:

DISCUSSION
Education in the residency modality is considered a distinguished professional qualification, which permits developing professional knowledge and competences, confidence in the development of work and satisfaction with the profession 10 .In addition, a positive effect is verified on retention and satisfaction at work, as well as improvements in professional performance 11 .
The course in the residency modality also favors better socialization at work and, therefore, increases the professionals' feeling of valuation and identity reconstruction.Therefore, work is fundamental in the construction process of the professional being 11 .This moment of socialization happens in a collective space, where the collective syntheses of the contents developed, the experiences and the learning issues are shared 12 .
The newly graduated nurses do not consider they are appropriately prepared to play their professional role.This result was also found in a study developed with newly licensed North American nurses.These professionals demonstrate a lack of confidence in their own competency and are afraid of committing errors and causing damage to the patients.The authors recommend that the faculty and preceptors help them to gain experience and confidence to practice professional care 13 .
In the context of the obstetric center, the nurses consider that professional autonomy is related to professional knowledge and competences, as well as to the support granted by the nurse managers of the institution.This support is fundamental in the construction process of the nurses' autonomy and empowerment 14 .Therefore, the nurses at the institution, including the preceptors, influence the professional development and act as a model and reference in the residents' education 15 .
By analyzing the residents' perception on optimizing and limiting factors of preceptorship in oncology nursing, the study highlights that the quality of the institutional infrastructure was perceived as an optimizer for the teaching, research and care activities of the residency program investigated, as well as the offering of grants, housing and meals in the course 16 .Consequently, the appropriateness of the service conditions is fundamental for the pedagogical success of the residency and satisfaction of the nurse residents with the course.
Besides the reception of financial help throughout the course, the nurse-midwifery residents also value the fact that the residency grants professional credentials to work in the area, such as the actual certification of the specialist degree and the experience gained during the two years of the course, which grants them further advantage in the dispute for work places.
This perspective involves the notion of employability, which motivates the worker to gain credentials to improve their insertion in the job market.This notion of employability was also found in the college students' discourse on the importance of the higher education course in their professional life projects 17 .
The focus on employability derives from the educational conception centered on the competences to comply with the job demands, which requires continuous, flexible and qualified learning from the workers, in an individual and creative manner, which leads to the acquisition of professional capacities and skills to perform the required tasks, which are unexpected and adjusted to the logic of the competitiveness of the production model in force 18 .Therefore, the interviewed nurses perceive the nurse-midwifery residency course as a more valued professional certification among the employers in health, in the public as well as in the private segment.
As described earlier, obstetric care in the country goes through transformations and a series of governmental measures has been taken to modify the dominant care model.Among the inducing policies undertaken, the actions established in the Stork Network stand out, which encourage normal birth, normal birth Specialization course at the residence modality Lima GPV, Pereira ALF, Guida NFB, Progianti JM, Araújo CLF, Moura MAV centers, the qualification and hiring of nurse-midwives by the health services.
These actions provoke the expansion of the work places for these professionals in some regions of the country.Most of these places operate within the logic of partnership between the public and the private in force in the SUS today, which furthers the competitive branch to occupy these work places 1 .
These nurse residents perceive limitations in their education, such as the lack of supervision by a nurse-midwife in the care delivered at the hospitalization services, mainly at the rooming-in unit; institutional constraints faced to attend to normal birth at the university hospital and accountability for the care delivered when the staff nurse is absent.These limitations can result from the infrastructure and organization of the nursing staff in the obstetric service network.
As mentioned earlier, there is a limited number of nursemidwives in the country and no specificity for these professionals to enter the public career, so that the nurse midwives are prioritized in the care and management of the obstetric center and the distribution of the generalist nurses across the other hospitalization sectors of the Brazilian maternity hospitals 7 .
In addition, the nursing residency is still conceived as a complementary strategy to respond to the shortage of human resources at the hospital institutions.These conceptions derive from the late regulation of this professional qualification modality in nursing and, in other health professions, except for the medical residency, as well as the historical context of this in-service teaching modality in Brazil.
In the past, this teaching followed the logic of in-service training, whose pedagogical proposal and supervision were limited, focused on the institutional demands and without any affiliation with academic institutions for the certification of the nurses taking the training 1 .
According to the studies 6,7-9 on the theme nurse-midwifery teaching, high-level qualification should provide the students with the updated knowledge needed to practice the specialty safely and ethical-political attitudes to put in practice humanized care and overcome the institutional obstacles for their professional activity.
In view of these educational attributes needed, the interviewed residents consider that there are weaknesses to be overcome in the course, such as difficulties to supervise the preceptorship at the hospitalization units, restriction in the teaching of normal birth care at the university hospital and in the integration between theory and practice.
These weaknesses were also found in a study on nursing preceptorship, which identified the preceptor's limited understanding of the educational role; difficulty to implement integrative activities between theory and practice and shortages in the supervision and assessment of the residents' activities, according to the objectives determined in the course program 17 .
This difficulty to integrate theory and practice partially derives from the distancing between faculty members and preceptors, as the preceptors supervise the practical activities and the teachers conduct the theoretical contents of the subjects.This dissociation between the theoretical and practical moments provokes a paradox in the education process.Therefore, this indicates that the pedagogical work in the residency modality presents difficulties to put in practice in-service teaching as a theoretical-practical activity and suggests the need to establish integrative strategies between the academy and the service.
These strategies should overcome the differences between the knowledge and roles of these institutional actors in the education process; the collective and shared construction of the pedagogical work in the residency modality and the participation of all stakeholders, the residents, the service nurses, the faculty, the managers and the women, who are the fundamental reason for all efforts undertaken in nurse-midwifery teaching and care.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
The study revealed that the nurses choose the nursemidwifery specialization course in the residency modality because it offers more practical experiences, which responds to the needs they perceive in terms of gaining professional competences.The residency also involves receiving financial aid throughout the course and grants a certificate for work in the specialization area, which offers an advantage in the dispute for a place in the job market.
The residents expect to gain knowledge and skills to work confidently in the profession, which was partially achieved in the first year of the residency course for nursing care in the pregnancy-postpartum period.Nevertheless, the self-perception as a nurse-midwife is still under construction and the education period in normal birth care seems to be fundamental to consolidate the professional being in the specialty.
It is highlighted that the residents' expectations were circumscribed to gaining technical competences to achieve a job contract, leaving aside other emerging issues in nurse-midwifery, such as the possibilities of autonomous work, the search for professional autonomy, the ethical and legal responsibilities, the implications of the tensions between the existing care models, the medical and the humanized, for the work.This restricted view of the residents reveals that the residency education program needs to encourage the discussion of these professional issues during the course.
The limitations of the residency course were also related to the places where the nurse-midwives are absent from direct care or the residents' supervision, like at the university hospital, where these professionals cannot participate in normal birth care, and at the hospitalization or nursing wards of the maternity hospitals.
The pedagogical work comes with weaknesses due to the perceived dissociation between theory and practice, compromising the education from the perspective of nursemidwifery practice, which involves not only the articulation between the knowledge and practice, but the understanding Specialization course at the residence modality Lima GPV, Pereira ALF, Guida NFB, Progianti JM, Araújo CLF, Moura MAV that practice is a theory in action.This problem demands that the academy and the service work in a more integrated manner.
It should be highlighted that this research comes with limitations and that its results cannot be generalized, but are restricted to the investigated group.Nevertheless, it offers preliminary contributions to the understanding of the particularities and complexities of nurse-midwifery teaching in the residency modality.In addition, the limited number of studies on the education process of nurse-midwives is highlighted, mainly in the residency modality, which represents a challenge the faculty and researchers in this nursing specialization area need to overcome.
To like woman's and infant health!I have always liked the classes on this subject in my undergraduate course.And because I want to take the residency course too.(Resident E7 S) I have taken the undergraduate training (...) and I really fell in live with the nurse-midwives' work and said: That is what I want for me! (..