PERCEPTIONS OF NURSE-MIDWIVES OF THEIR RESIDENCY TRAINING AND PROFESSIONAL PRACTICE PERCEPÇÕES DAS ENFERMEIRAS OBSTETRAS SOBRE SUA FORMAÇÃO NA MODALIDADE DE RESIDÊNCIA E PRÁTICA PROFISSIONAL PERCEPCIONES DE ENFERMERAS OBSTÉTRICAS SOBRE SU

This study aimed at describing the perceptions of nurse-midwives of their training in the residency modality and its interfaces with the professional practice. This is a qualitative research conducted with twenty-five nurse-midwives qualified in the residency specialization course. To analyze the semi-structured interviews, the thematic analysis technique was applied. The results showed that nurse-midwives have a positive perception of their training in a residency program, but they mention contradictions between the theoretical teaching focus on the humanized care and the persistence of the medicalized model in the teaching-in-service situations. Regarding the professional performance in the area, the nurses emphasize the ease in the use of care technologies, and the obstacles arising from professional conflicts, low recognition and work overload. It is concluded that the residency modality promotes safety for the practice of the specialty, but the identified restrictions impose challenges for the professional qualification and practice, pointing to the need for adapting the teaching program with a view to training specialists with attitudes capable of meeting and overcoming such challenges.


INTRODUCTION
The health professionals' training is a permanent process in which the work is the core of the educational process, a source of knowledge and an object of transformation.Besides that, it fosters the collective and multidisciplinary participation, allows the dynamic development of new knowledge through the exchange of wisdom and experience, research and analytical management of information, as established by the Pan American Health Organization (PAHO) on Permanent Education in Health. 1 Despite being a recommendation to all countries in the Americas, only in 2003 the Ministério da Saúde (MS) created the Secretaria de Gestão de Trabalho e da Educação em Saúde (SGTES-BR) and made policies focused on management, training, qualification and regulation of health workers in Brazil.In the following year, the National Policy for Permanent Education in Health was implemented, through the Regulation GM/ MS No. 198, of February 13, 2004, when the MS started to perform in a more incisive way its constitutional role of ordering the human resources education. 2n the context of reordering the education of human resources in health, it was enacted the Law No. 11. 129, of June 30, 2005, which established the residency training in the health professional area and created the National Commission for Multiprofessional Residency in Health, as part of the Ministério da Educação (MEC-BR).Such governmental act allowed the accreditation of the residency training as a lato sensu nursing postgraduate course as well as to the other health professionals, except Medicine. 3articularly in the Obstetrical Nursing field, the governmental measures to stimulate the education of nurse-midwives, besides aiming at the reduction of its natural deficit in the country, are linked to the actions of the "Rede Cegonha" program, which is intended to assure the right to reproductive planning and to humanized care to pregnancy, birth and puerperium, as well as the right to a safe childbirth and to a healthy growth and development.In the area of this governmental pro-gram, in 2012 the Programa Nacional de Residência em Enfermagem Obstétrica (PRONAENF) was created. 4RONAENF aims at stimulating the education of specialists in the residency method through the support to the qualified insertion of nurses to provide care for the woman's health in the reproductive health, prenatal, delivery and birth procedures, for the puerperium and the family, guided by good practices and scientific evidence, as well as by principles and guidelines set by the Rede Cegonha program and the Sistema Único de Saúde (SUS). 4s it worth mentioning that, in the city of Rio de Janeiro, the stimulus for the education of nurse-midwives in the residency method antecedes the creation of PRONAENF, a result from a partnership between the Secretaria Municipal de Saúde do Rio de Janeiro (SMS-RJ-BR) and the Universidade do Estado do Rio de Janeiro (UERJ) since 2004. 5his previous experience was important in the meetings for the elaboration of the programmatic and curriculum guidelines of PRONAENF, which had the participation of public university professors, nursing entities, such as the Conselho Federal de Enfermagem (COFEN) and the Associação Brasileira de Obstetrizes e Enfermeiros Obstetras (ABENFO), and of technicians from the MS and MEC.
With the conclusion of the guiding document of PRO-NAENF, the SGTES and the Secretaria de Educação Superior of MEC published the RFP No. 21, on September 21, 2012, which resulted in the selection of 18 residency proposals in Obstetrical Nursing, whose first class graduated in March of 2015. 4 Later, the RFP No.28, June 27, 2013, and the RFP No.32, July 24, 2014, selected more proposals and increased the number of residency programs in the country, spread through the five federal regions.Therefore, the residency programs in Obstetrical Nursing came to integrate the Permanent Education Policies for the SUS and spread throughout the country. 6,7he residency is a teaching method based on work as an educational principle and the health institutions are privileged pedagogical spaces, being considered the professional educa-
tacted through this information, with the purpose of inviting them to participate in the research.
Taking into consideration the outdated telephone and electronic data, especially of the first residency classes, there was a need to employ additional strategies, such as to ask the classmates for information, similar to a snowball technique, and a name search on social networks.At last, it was developed a second nominal relation of the nurses who had finished the program and, with these contact information updated, the invitations were made.Because of such difficulty, the data collection occurred between October of 2014 and June of 2015.
The data collection was carried out through the semistructured interview technique, following a script previously tested and made of closed questions, which were about personal and professional characteristics of the participants; and 14 open questions, which allowed us to capture their perceptions of the training during the residency program and the specialized professional practice.
The interviews were recorded on digital audio files and given out of the care environment, in a regular health team's room, in order to avoid interruptions and possible embarrassment of the research participants or patients.
For the result analysis, the thematic analysis technique was used, constituted by the following stages: a) data ordering, which comprised the organization and systematization of the interviews; b) data classification, based on the extensive reading to identify the relevance structures, the central ideas and key-moments of the object of study, enabling a thematic grouping; c) final analysis, which peaked at the elaboration of interpretative synthesis. 12n the end of this process, three categories emerged: the residents' satisfaction with the theoretical-practical content of the service teaching; contradictions between theory and practice in the area of the service teaching; and professional practice challenges in Obstetrical Nursing.
The study respected the formal demands set by national and international research regulatory norms involving human beings and it was approved by the Research Ethics Committee of the SMS-RJ under the Opinion No.70A/2013.The participants' coding was used according to the order of the interviews, as E1, E2, E3 and so on.

RESULTS AND DISCUSSION
The 25 nurse-midwives interviewed were mostly young women, between 25 and 30 years old; they were not civil servants; they had a job contract; and they were working in the public health system and in obstetrics two years ago, at the time of the data collection.After the residency professional qualification, 10 nurses took other specialization courses, main-tion that best provides technical training for specialized care, mainly to women in labor. 5,8owever, studies on residency programs in health and nursing identified that this method has some limitations, such as the influence of traditional educational concepts in the teaching programs; the prevalence of the biomedical paradigm in health practices; the need for pedagogical qualification of the preceptors; and the long workload dedicated to practical activities in the services, intensifying the exposure of the residents to stressful and tiring situations resulting from work responsibilities and demands. 9,10 us, the residency method is a relatively recent teaching experience in the Obstetrical Nursing field, and it is connected to health and professional qualification policies for SUS, but studies show the weaknesses of this teaching process.
In addition to that, it is observed that the number and the distribution of nurse-midwives working in the national health system must be adjusted considering the size and the needs of its population in sexual, reproductive, maternal and neonatal health, in order to improve the quality of the health service, reduce damages, complications and costs related to unnecessary interventions and cesarean sections, and to increase the client satisfaction regarding the care provided. 11ue to these challenges related to the qualification in the residency method and to the professional practice in Obstetrical Nursing in the country, the present research started from the following guiding question: how do the nurse-midwives qualified in the residency method perceive their education and professional practice?
Considering this question, the research intended to describe the perception that the nurse-midwives have of their own education in the residency method and its interfaces with their professional practice.

METHODOLOGY
It is a descriptive research with a qualitative approach carried out withnurse-midwives qualified by a specialization course in the residency method, from 2006 to 2014, whose teaching in practice was given through obstetric services in the public system in the city of Rio de Janeiro.
The study included the nurse-midwives qualified in the residency method who worked in the obstetric care as civil servants or hired nurses.The nurses who left the residency program having less than a year in Obstetrics in period of data collection were excluded from the study.
At first, it was made a survey with the 79 nurses who had finished the program during the proposed period of the research, followed by the establishment of a nominal relation with the telephone and electronic data of each class.Subsequently, each nurse who had finished the program was con-DOI:

Residents' satisfaction with the theoretical-pr actical content of the service teaching
The former residents believe that the course provided had a satisfactory theoretical and practical basis and supplied the necessary skills for a safe professional practice.In this perspective, they highlighted that the residency allowed acquiring a great input of practical experiences, which was translated into a crucial tool for safety perception in the specialized practice, especially in the care provided during a normal labor.

I believe that my training was really good […]. In the first year, we went through the whole pregnancy cycle, the gestational cycle. The theoretical classes gave us the basis we needed and completed the practical field. […] The second year, it's quite valid, because we stayed specifically at the delivery room, and this prepares you a lot.(E.3).
The education in the residency method is developed with the theoretical-practical integration, coordinating the teachinglearning process with the world of work.Thus, the pedagogical structure accommodates the theoretical segment, constituted by courses that provide scientific knowledge appropriation, with an extensive practical segment that allows, through the approximation to professional situations, the acquirement of subjective skills and knowledge resulting from lived experiences. 13n the other hand, the practical teaching is primary for the edification of knowledge, skill and professional attitude, as well as for the theoretical-practical integration, the sharing of knowledge and experiences among the individuals involved in the learning process, and the professional identity construction. 14he practical learning time is admittedly important for the development and improvement of professional skills. 15hen there is an insufficient number of practical experiences through the professional qualification, the nurse-midwives do not feel properly prepared for the specialized practice, mainly for the care provided in a normal labor. 16Therefore, the proper articulation between theory and practice provides a more significant teaching-learning process, offers the necessary confidence for professional practice, in addition to stimulating the critical and reflective posture needed for the autonomy development. 17egarding the learning time in residency service, the nurse-midwives consider that the amount of experiences they had through the course provided a confidence perception for a specialized practice: In residency, you have a workload that makes you confident and, after you graduate, you aren't afraid or anxious, because you're already inserted in the (practice) field (E. 1).
The experience of real situations combines the inductive process of knowledge, poor in generalizations, with the deductive process, mediated by concepts systematized in generally explanatory systems and organized in a socially built logic.The teaching-learning process comprises efforts and attitudes for the production of knowledge from experiences in professional and educational practices in service, whose actions follow technical-rational models of understanding. 18n this perspective, teaching in real situations, which is typical of the residency method, offers opportunities to deepen the technical-scientific knowledge through a training process based on experiences, interpersonal relations and the sharing of knowledge, in which professors and preceptors take the role of facilitator in this interaction of theoretical and practical knowledges. 13esides the appreciation of a lasting contact with different practical situations, the nurses also highlighted the humanized care as a guiding teaching principle in the residency in Obstetrical Nursing:

I guess all the training of the nurse-midwife [sic] is based on a humanized model […]. She is educated by this thought. So, to think of the delivery as a physiological process, which surely doesn't need intervention, and being educated with this view makes us assist [the woman] in a completely different way […]. Actually, I believe all the training was done in this humanized model (E. 16).
The humanization is a value in health care that involves ethics, aesthetics and a health care policy.Ethics, because it implies the attitude of patients, managers and health professionals who are committed and co-responsible; aesthetic, because it is related to the creative process in the production of health and protagonist and autonomous subjectivities; policy, because it refers to the social organizations of care and management practices of SUS. 19In this way, the humanized care enables the articulation of technical and scientific quality with an ethical posture, which respects the need and the singularity of each cared person.
Guided by humanization, the singularities of the professional training in Obstetrical Nursing can also be observed when the concept of demedicalization is incorporated to the nurses' practices, having as guiding principles the respect for the delivery physiology and the non-invasion of the female nature. 20Therefore, when nurses act in accordance to this humanistic and non-medicalized care model, they reach the distinction of their practice before the other obstetric professionals.

clashes even with the medical and the nursing team[…]. I came across interventionist teams, the sort of teams that do routine episiotomy, artificial disruption of membranes, […] gross attitudes, outdated conducts, which aren't advisable by the Ministry of Health anymore (E. 13).
Due to these medicalized conducts, the reality of the hospital obstetric assistance presents itself to women as a space linked to the fear of pain during the delivery, what peaks at the banalization of the cesarean section and at practices that threaten the female dignity. 23o change this reality, there was the reorientation of the Obstetrical Nursing teaching through more focus on the respect to the autonomy and physical integrity of the woman and to the pregnancy physiology, the delivery and birth, besides the promotion of the maternal, fetal, and new-born well-being; from the early diagnosis of complications and the timely decision-making to assure the quality and safety of the care provided. 5,8n contrast to this focus on the teaching, some former residents mentioned content gaps in the residency theoretical teaching program, which demanded a complementation of knowledge and skill necessary toper form proceedings and obstetric maneuvers:

So, for example, the episiotomy, it isn't our routine. Although it isn't something we recommend, do it regularly, and it isn't even learned in theory, but we end up doing it (E. 15).
The professional training is a continuous and necessary process in face of scientific updating and technological innovations in the health area.The nurse-midwives must be capable of acting in emergency situations, for this purpose, the residency teaching program must provide the development of such competences.However, the intervention practices must not be encouraged, but they need to be questioned and discussed due to scientific evidence and to women's sexual and reproductive rights, so that the nurse-midwives may develop a critical conscience and praxis coherent with the principles of humanization.
The paradigmatic conflict between the pedagogical perspective guided by the paradigm of the humanization of care and the predominance of the biomedical model in the services reveals the complexity of the qualification and professional socialization process in Obstetrics, which still retains symbolic elements of women's domination, the nurse From this point of view, it can be seen that the residency teaching in Obstetrical Nursing follows the governmental recommendations regarding the training of health human resources.They stress the importance of the professional training based on the SUS's ethical-political and humanized principles to characterize the care and management processes, as they state that it is necessary to incorporate new methods of care practices aiming at the transformation of the healthcare model, historically centered on the doctor, the illness and the hospital care. 2,3,19

Contr adictions between theory and pr actice in the service teaching
The health training must be founded on a teaching project that fosters the development of skills, the accumulation of knowledge and the acquirement of proper competences to the world of work. 1 In addition, the service teaching comprises a professional socialization process with repercussions on work and on career retention, in which the internship is a transitional period when the aspiring professional works with a professor, preceptor or tutor in a real-work environment, which stimulates the acquirement of a great amount of lessons from the interaction with professionals who develop diverse carepractices. 21espite the positive perception on the residency training, the nurses who had already finished the course found institutional restrictions and paradigmatic conflicts in the conduction of the care practices:

Look, in the maternity [hospital], we know that what prevails is the biomedical model. There were professionals who weren't familiar with the new [humanized] model, they made it hard, the nurse-midwife care […]. When we followed the [humanized] practices, they said it was silly, useless […] (E.4).
This perception is common to all research participants and might be a reflection of the current overview of the Brazilian Obstetrics, which is under a paradigmatic transition process and this causes the coexistence of professional practices and attitudes that follow both the biomedical and the humanized models. 22he effects of this transition process are materialized in a conflict between the theoretical teaching, based on the principles of humanization, and the experiences lived in hospital practice situations, where the medicalization and the obstetric intervention prevail.Such contradiction gets even stronger in the residency method due to the fact that the training happens, mostly, in health services: When I was a resident, I could notice that there's still a long way to get to the [care] humanization.We had We use the [care] technologies, such as aromatherapy, music therapy, penumbra, stool, massage and warm shower.We still don't have a bathtub, but if the patient wants have her own tub, she can bring it.Here, we have nurse residents.So, we have to teach all the [care] technologies, but it depends on the patient's agreement, we offer it, it's up to her to accept it or not.(E.22).
The use of care technologies translates as an important component of the nurse-midwives professional autonomy, who enjoy increasing institutional reliance, as well as among health team members, over their conducts and technical opinions, although conflicts on the obstetric care conduction model remain. 8uch perceptions are seen as new data regarding studies on former participants of specialization courses in Obstetrical Nursing, and they may suggest advancements in the professional practice of these nurses and in the care organization in public maternity hospitals towards a model that is more humanistic, shared and with more solidary, ethical and democratic practices. 5nother professional challenge that the research participants mentioned was the work and responsibility overload: I'm a nurse at the obstetric center and we are responsible for the unit as a whole and for the admission of all women, from moderate to high risk […].I work in this institution and we have Medicine and Nursing Residents […].So, we have to deal with all this, […]all the activities that happen in here are our responsibility, not only the bureaucratic ones, but also the administrative, care and academic ones (E.4).
The nurse-midwife plays an indispensable role in the woman's health care and their work has been increasingly requested in care situations which involve prenatal, delivery and puerperium actions, including the management functions of the services and of the nursing care, the direct supervision of qualifying professionals and the creation and development of health programs related to the obstetric context. 22oncurrently, nowadays the working spaces are marked by the intensification of work, presenting greater pace and density of time, with increasingly constant changes, which demand more learning time for new tasks and a wide range of rules to be followed. 25Consequently, the nurse-midwives face an adverse work situation, which is under a process of deregulation of labor relations, tending to enhance the sexual and social division of the health work, besides weakening the everyday struggle for the acknowledgement of the professional practice value and for the improvement of the work conditions, their functions and attributions in the health area. 20herefore, the professional practice of former residents shows ambivalence between positive and negative aspects.The included, and hegemonic structures in the work organization and institutional culture. 24his transitional phase of the Brazilian obstetric field poses an additional challenge to be solved by the residency method teaching, considering that 80% of the course workload happens in service, especially in hospitals, and it requires monitoring of the care-faculty members for the education of critical and reflective nurses with political attitudes to overcome these adversities and act as transformation agents of this dominant model.

Challenges of the professional pr actice in Obstetrical Nursing
The health education qualifies the professional to reflect critically upon their reality, to establish ruptures on the hegemonic institutional culture and to build new practices and work relationships, aiming at the realization of citizenship rights and, above all, of a professional project of human, ethical and technically qualified care. 5,8esides theses premises, as nurse-midwives still face difficulties to work directly with birth care in the country, given that the obstetric care in Brazil remains centered on the medical professional and is determined by an institutional culture of outdated routines, although changes in this reality are prescribed by health policies. 16uch difficulties are also found in the professional practice of former nurse residents: Here, I'm a nurse midwife [sic] and we try to have this humanized profile.But, inside the hospital environment, it's still very hard and there's always some interference from other professionals (E.21).
The nurse-midwives face challenges in specialized practice, such as a restrict labor market, little professional autonomy, doctors' hegemony and the still prevailing biomedical care model in health care. 16Therefore, there is a group of influential critical factors in the provision and retention of nurse-midwives in the Brazilian health system, especially in hospitals.
Despite this group of restrictive professional factors, these nurses contribute for the institution of humanized care, what has favored public management incentives for the increase of the amount of this kind of specialists in the country.Based on the paradigm of humanization and demedicalization of obstetric care, the non-invasive care technologies concept was proposed, which are the techniques, procedures and knowledge used in the different stages of the gestation, delivery and birth process. 20n this perspective, the former nurse residents mention the lack of difficulty to use these care technologies in the professional practice in maternity homes: positive or enabling aspects are marked by the use of care technologies, in accordance with the humanized model prescribed by the women's health ministerial policy; the perception of relative freedom to act under this care perspective and respect to their specific and distinctive professional knowledge, marked by a humanized, demedicalized and individualized nursing care.
The negative or restrictive professional aspects are the persistence of the symbolic structures of the medicalized obstetric model, particularly at the hospital, which causes conflicts resulting from different views over care conduction and low professional recognition; the work overload related to the responsibilities in management, general care and specifically about Obstetrical Nursing.
Besides that, the supervision of students who are training at the units they work at is another factor that contributes to the work intensification of these specialists, which indicates to be an aspect related to the very expansion of qualification programs in Obstetrical Nursing in public maternity facilities, resulting from stimulation led by permanent health and education policies in SUS.

CONCLUSION
The nurse-midwives have positive perceptions of their residency theoretical and practical training, such as safety and confidence for specialized professional practice.Despite this, they face difficulties during their education, with the contradiction between the emphasis given to the care humanization by the theoretical teaching and the tendency for medicalized practices in service teaching situations.
These nurses use care technologies at their work practice, which denotes the acquirement of knowledge and attitudes associated with humanized care.However, their professional practice still faces typical difficulties of the nursing profession in face of the intensification and deregulation of health work, what requires the adequacy of the teaching program for the development of ethical and political attitudes during the training process so that the nurse-midwives may develop strategies to fight and overcome these challenges.
The limitations of this research are noteworthy, once it was developed from a particular reality and it does not allow generalizations.Nevertheless, its results raise the importance of new studies on the Obstetrical Nursing teaching and its relation with the professional practice in the care of women, their children and family, as well as other methodological models, which may investigate the nurse midwives' care and work characteristics in the Brazilian obstetric care system, and correlate them to professional qualification in the residency method.