NEONATAL PAIN MANAGEMENT IN A MATERNITY HOSPITAL OF USUAL RISK: PERSPECTIVES OF HEALTH TEAM LEADING PROFESSIONALS MANEJO DA DOR NEONATAL EM UMA MATERNIDADE DE RISCO HABITUAL: PERSPECTIVAS DE PROFISSIONAIS LÍDERES DA EQUIPE DE SAÚDE MANEJO DEL DOLOR NEONATAL EN UNA MATERNIDAD DE RIESGO HABITUAL: PE

Objective: to identify the management of neonatal pain from the perspective of health team leading professionals in a maternity hospital of usual risk. Method: qualitative study conducted between September and December 2016 with eight leading professionals of the health team of a maternity hospital in the interior of São Paulo, three nurses, two pediatric physicians, a Nursing technician, a Nursing assistant and a Laboratory technician. Data collection occurred through semi-structured interviews, whose statements were recorded, transcribed and submitted to content analysis, in the thematic modality. Results: verbalizations showed that the evaluation of neonatal pain was performed subjectively, based on aspects observed by the team, such as face alterations, vital signs, movements and crying. There were reports of difficulties in assessing neonatal pain and divergences regarding the time indicated for evaluation. Non-pharmacological methods were cited as strategies that facilitate the management of neonatal pain. However, although the statements were favorable to use them, the knowledge about those techniques was superficial, since speeches included “I don't know” and “I've never read anything about it”, and it was evident the difficulty of applying them. The scores included the need for frequent training/ qualification regarding the evaluation and treatment of neonatal pain, as well as to implement protocols, use scales and sensitize the health team. Conclusion: superficial knowledge of the leading professionals of the health team regarding the evaluation and non-pharmacological management of neonatal pain was evidenced, in addition to the absence of formal protocols and training.


INTRODUCTION
Although neonatal units are considered essential for newborns' care and protection, it cannot fail to reflect on the various singularities of these environments as environmental risk factors for the development of newborns. Many of the treatments provided to newborns include invasive and painful interventions, and may even result in damage to the nervous system that is still in formation. 1 It is known that scientific production on neonatal pain is in constant process of updating. National and international studies on the evaluation and management of neonatal pain identified gaps in knowledge and care practice from the perspectives of pediatricians, 2,3 nurses and Nursing assistants. 4,5 The level of knowledge, attitude, work overload, professional and personal experience are some of the factors that can influence the management of neonatal pain. It is evident that health professionals have very slowly seized the knowledge already produced about the management of neonatal pain, 6 -which configures a subreatment of the theme. 7,8 Some issues of the routine of neonatal units may facilitate the adoption of measures that contemplate pain management, and these facilitators may be related to the very knowledge of health professionals and/or their practice. Moreover, in the context of a maternity of usual risk, in which most of the demands relate to full-term newborns that enables the adoption of non-pharmacological measures during painful procedures with the mother's participation (skin-to-skin contact, breastfeeding and breast milk), we question: "what are the facilitating and/or hindering factors in the management of neonatal pain in this maternity hospital?".
Thus, this study is part of the proposal of atraumatic, developmental and humanized care to the newborn, aiming at transforming the pattern of care, from the perspective of evidence-based practice, and sensitizing Nursing staff with regard to the evaluation of neonatal pain and its nonpharmacological treatment. It is expected to support future research and actions in the health service in favor of improving neonatal care in relation to adequate pain management.

OBJECTIVE
To identify the management of neonatal pain from the perspective of the health team leaders of a maternity hospital of usual risk in the interior of São Paulo.

METHOD
This is a qualitative and exploratory study, with a descriptive approach, conducted between September and December 2016 with eight leading professionals of the health team. The study site was a maternity hospital of usual risk located in the interior of São Paulo, which is a teaching and research center and assists women at usual obstetric risk with about 270 deliveries/month, with approximately 90% of full-term newborns.
The participants were intentionally chosen, and we invited the leaders of the health teams who held some position at the institution and/or who were considered leaders, that is, employees who stood out for the spirit of leadership within their professional category. Thus, semi-structured interviews were conducted with three nurses -1 nurse from UCIN (N1), 1 nurse from the Surgical and Obstetric Center (N2) and 1 Nursing coordinator (NC) -two pediatricians (P1), one of whom is the Pediatrics coordinator and develops pediatric protocols (P2), a Nursing technician (NT), a Nursing assistant (NA) and a laboratory technician (LT).

RESULTS
The statements of the health team leading professionals showed multiple approaches that support the complexity of the theme under discussion. Table 1 shows the distribution of excerpts from the interviews in the five categories and their subcategories, demonstrating the suitability of content analysis (thematic modality) performed.

DISCUSSION
The methodological course we used allowed to apprehend data on the knowledge and practices adopted by the leading professionals of the health team related to the evaluation and non-pharmacological treatment of neonatal pain, as well as to identify their facilitating and hindering aspects.
Regarding the evaluation of neonatal pain, it is still common to perform it subjectively, without the use of scales. The participants revealed that pain assessment was performed only from aspects observed by the team, such as face alterations, vital signs, body movements and newborn crying. The team's difficulty in evaluating neonatal pain was widely mentioned, reporting the lack of knowledge on scales and the absence of their use in the institution. In this context, the barriers mentioned by nurses in the United States and China are related to resistance to change, lack of knowledge, lack of time and lack of confidence in existing tools. 11 Moreover, as for pain management facilitators, it is clear that there is goodwill and interest of the team in performing the best possible assistance to the newborn. However, although the statements are favorable to skin-toskin contact, knowledge about this method is superficial. One of the difficulties highlighted by the professionals interviewed concerns the performance of skin-to-skin contact in the kangaroo position, as well as breastfeeding during painful procedures that require an adequate position, such as punctures for venous access, arterial punctures or PICC insertions. Authors recommend that, for this intervention, physiological parameters should be monitored throughout the procedure, and it is necessary to evaluate the availability The statements were recorded after authorization from the health professionals involved. The full transcription was performed by the same researcher who was in the field, then printed and handed in to the respective professionals for checking and final approval of the transcripts. It is worth mentioning that the professionals interviewed did not request to exclude any of their statements. There were no losses of participants and/or problems during the interviews.
It is important to say that the professionals were interviewed in their working period, in a specific room, taking special care to avoid causing problems to the service and evaluating the needs of the shift, with authorization and consent of their direct superiors. The average duration of each interview was 20 to 25 minutes.
A collection instrument was used to guide semi-structured interviews and consider the saturation assessment of the data obtained to complete the data collection. The questions of this instrument were: what is the perception, in your professional practice, of newborn pain management, in this institution? What are the facilitating and hindering factors for the proper pain management in this institution? When to assess neonatal pain? How to assess neonatal pain? Why evaluate neonatal pain? In your opinion, what changes are necessary to improve the management of neonatal pain in this institution? What non-pharmacological intervention would you use to relieve the pain of your child and/or close relative (NB) undergoing painful procedures? What do you think about skin-to-skin contact in kangaroo position, sucrose and breastfeeding in neonatal pain relief? What do you think about the mother's participation in these measures? How do you do it in the institution? Do you invite the mother be present during blood collection?
The transcription of the semi-structured interviews recordings was submitted to content analysis (thematic modality) and to the theoretical framework exposed. 9 This approach helped identify gaps on the knowledge and practice of health professionals in relation to the management of neonatal pain, and suggestions for care improvement.
Content analysis concerns a set of communication analysis techniques that aims to obtain, based on systematic procedures and objectives of content description of registered messages, indicators that allow inferring knowledge related to the condition of production and reception of these messages. In this context, the thematic analysis technique (thematic modality) consists in the identification of meaning nuclei that make up communication, whose manifestation or repetition has meaning for the analytical objective studied. 10 Thus, the excerpts of the statements obtained were grouped into thematic axes, being distributed between five categories and their subcategories.   be valued and equipped by the institution, as well as receive psychological assistance to learn how to deal with the feelings experienced in practice. This contributes to the professional ability to deal with the work process. 16 The professionals also suggested the need for training/ qualification on the evaluation and treatment of neonatal pain, in the search for necessary changes to improve pain management in the institution. It is inferred that clinical protocols are fundamental for implementing a good management of neonatal pain, as well as for standardizing procedures and conducts, assisting in the organization of units and adequate managing neonatal pain. It is known that the provision of protocols is one of the requirements for obtaining quality titles by the institution. 17 In this sense, the American Academy of Pediatrics recommends that health services have evidence-based protocols for the prevention and treatment of pain in newborns, including careful performance of procedures, routine pain assessment, and the use of pharmacological and non-pharmacological measures for pain relief, surgical pain medications, and procedures for severe pain. 6 Some professionals also recognized a need for sensitizing the health team to promote changes in behavior and actions. It relates to an important theme such as changes applicability in a work environment. It is believed that health professionals' awareness to transform the workplace into a humanized environment depends on individual actions that must stimulate others to carry out the best child care plan.
To program any transformation, the initial step is the professionals' awareness that the treatment of neonatal pain is important and able to be performed with a small touch or attitude such as breastfeeding or calm and comfort them. This change in individual attitude can be mobilized through workshops of humanization and training of the team. 18 It is noteworthy that Nursing professionals play an essential role in the proper management of neonatal pain, with possibilities to avoid it and/or minimize it during painful procedures, since they assist them for longer time within health services. Thus, the findings of this study imply the need to have, among health professionals -here, especially nurses and Nursing students -effective appropriation of updated knowledge about the identification, evaluation, control, management and registration of neonatal pain.
The limitations of the current study are related to the lack of statistical representativeness, since it was carried out only with health team leading professionals of a single maternity hospital in the interior of São Paulo. We suggest, in future research, to include other health professionals to obtain a more comprehensive situational diagnosis on the management of neonatal pain in these categories. of parents to practice skin-to-skin contact, especially among mothers. For newborns with gastroschisis, myelomeningocele and other surgical conditions and/or clinical instability, this intervention is not recommented. 12 We observed in the statements that professionals believe that breastfeeding relieves the pain of the newborn during painful procedures, but at the same time its indication occurs only for certain types of procedures (calcaneus or venous puncture), being the method discarded by the team in other situations. It is then questioned why this strategy is not used in intramuscular injections, such as routine obstetric scans. It is known that the ideal is to put the newborn in immediate skin-to-skin contact, wait 20 to 30 minutes, offer the maternal breast in this period (giving the NB the possibility to suck) and perform the potentially painful routine procedures, thus associating two effective methods in the relief of neonatal pain: skin-to-skin contact and breastfeeding.
A national study reported that breastfeeding combined with skin-to-skin contact can potentiate analgesic effect, contributing to newborns better recovery after painful procedures. 13 It is evident that health professionals recognize breastfeeding and the supply of breast milk as nonpharmacological strategies for neonatal pain relief, which is positive data regarding the knowledge of these methods. This is of great interest in humanization and continuous improvement of neonatal care, especially in maternity hospitals of usual risk.
Research conducted with professionals from 196 hospitals in Australia reveals increased use of measures such as sucrose (53.0%) and breastfeeding (79.0%). 14 The statements confirm the predilection of health professionals for sucrose as a nonpharmacological method of neonatal pain relief, since the maternity hospital where the study was carried out follows the sucrose administration protocol at 25 %. It is noteworthy that, despite the proven efficacy of sucrose at a given concentration, with beneficial effects for the relief of newborn pain, 15 there is still insufficient scientific evidence on the effects of repeated doses of sucrose and on its indiscriminate use, whether in the short or long term.
In the current study, sucrose administration was considered more practical by the team than inviting the mother to breastfeed the NB, for several factors: the mother is a puerperal, and may have difficulty walking to the laboratory; many professionals still believe that the mother does not adequately assist in painful procedures; sometimes breastfeeding does not occur since the newborn is not hungry or is sleepy at that given moment.
The statements also indicate the workflow and the amount of human resources as items that hinders neonatal pain management. In this respect, it is believed that, for a humanized work environment, health professionals need to CONCLUSION This study brings the identification of neonatal pain management from the perspective of health team leading professionals in a maternity hospital of usual risk. Significant deficiencies in relation to the knowledge and practice of those professionals to manage neonatal pain were highlighted, in addition to the absence of formal clinical protocols and training.
It is recommended more appropriation of nonpharmacological measures with the mother's participation, such as skin-to-skin contact and breastfeeding in neonatal pain management among the health professionals interviewed. Moreover, adding the findings to the concepts of humanism, the policies of humanization of care and the developmental care of the newborn, through family-centered care, it is suggested a change in actions and conducts in this health team, which should be stimulated from awareness-raising workshops and professional training, becoming active subjects in the creation and implementation of training, documentation and internal policies for neonates pain assessment and management.
Finally, aiming at ethical, comprehensive and humanized care, we suggest the implementation of clinical protocols, flows for decision-making, audits and constant updates of documents related to the management of neonatal pain in this maternity hospital.