RESEARCH ARTICLES
Nurses’ everyday activities in a child care clinic
Sabiny Pedreira RibeiroI; Daiane Santos OliveiraII; Sônia Lorena Soeiro ArgôlloFernandesIII; Ridalva Dias Martins FelzemburghIV; Climene Laura de CamargoV
INurse. Sanitarian Specialist in Family Health by the Residency Program in Health, State University of Bahia. Salvador, Bahia, Brazil. Email: sabinyenf@yahoo.com.br.
IINurse. Master's Student in Nursing, State University of Bahia. Specialist in Family Health bythe Federal University ofMatoGrosso do Sul. Salvador, Bahia, Brazil. Email: daisanoli@hotmail.com.
IIINurse. PhD in Nursing, Federal University of Bahia. Assistant Professor of the School of Nursing, Department of Community health Nursing. Salvador, Bahia, Brazil. Email: lorenaargollo@gmail.com.
IVNurse.Post-Doctorate in Public Health from the Oswaldo Cruz Foundation, Bahia. Assistant Professor, School of Nursing, Department of Community health Nursing, Federal University of Bahia. Researcher of the Research Group on Children and Adolescent Health. Salvador, Bahia, Brazil. Email: ridalva@gmail.com.
VNurse.Post-Doctorate from the Université Rene Descartes. Assistant Professor, School of Nursing, Department of Community health Nursing, Federal University of Bahia. Researcher of the Research Group on Children and Adolescent Health. Salvador, Bahia, Brazil. Email: climenecamargo@hotmail.com.
ABSTRACT: This qualitative descriptive study guided by Comprehensive Sociology aimed to describe nurses’ day-to-day in a child care clinic and identify the factors that influence the clinic process. From March to April 2011, semi-structured interviews were conducted with eight nurses working in child care clinics at primary health care centers in a health district of Salvador, Bahia. The results demonstrated that everyday child care clinic activities are organized, repetitive, unpredictable, pleasurable, accessible, and permeated by interaction, guidance, and affection, making it possible to follow up the children through team work and with autonomy. Cultural context, equity in care, accessibility, and infrastructure are factors that influence the child care clinic. It was concluded that, in day-to-day child care, nurses establishes actions and interactions with child and family, promoting health, effective care, and respect for ideological, social, and cultural diversities.
Keywords: Nursing; public health nursing; child care; day-to-day activities.
INTRODUCTION
Childcare is one of the main programs of basic healthcare in the Unified Health System (SUS), traditionally defined by a set of techniques that ensure physical and mental development of the child, from the gestational period until 4 or 5 years of age. By means of these techniques it has conditions for the early detection different disturbances in the areas of stature growth, nutrition and child development1,2, contributing to the reduction of high rates of infant mortality observed in Brazil.
Childcare is a prominent task for nursing in their basic healthcare actions. Through consultation in child care, the nurse accompanies the growth and development of children, promotes breastfeeding, nutrition guidance at weaning, controls vaccine-preventable diseases by vaccination, control of diarrheal diseases and acute respiratory infections, solves complications and guides mother/caregiver on the child's health care3,4.
The interest for this study arose in childcare practices, during graduation in nursing at the Federal University of Bahia, which aroused reflections for everyday actions and interactions in childcare as valuable instruments in the health needs of the child and family's involvement. Given these experiences the following was questioned: How is this displayed in the daily routine of the nurses in childcare consultations and what factors influence the day-to-day of this consultation in primary healthcare units?
Therefore, we aim to describe the daily routine of nurses in childcare consultations and identify the factors that influence the day-to-day activities in this consultation. Despite the existence of studies related to the practice of nursing consultations in childcare, it is still limited they that describe or seek to understand the daily routine of this practice with a look at the actions and interactions between the nurse, child and family.
LITERATURE REVIEW
The Brazilian infant mortality showed a marked decline since 1994, when it went from 33.9 deaths per thousand live births to 13.9 per thousand in 20105. Among the causes of this reduction is the reinforcement to breastfeeding mater, that happens mostly in child care, in addition to the vaccination campaigns and improvement of health services2,6. Still, some government policies, focused on child health, had a major impact in reducing child mortality, such as the creation of the Program for Integral Care for Children's Health, in 1984, the formulation of the Strategy for Comprehensive Care for Childhood Illness (IMCI) in 1995, and the Agenda of Commitments for Comprehensive Child Healthcare and Reducing Child Mortality in 20042.
So that the childcare consultation is of quality, it is essential that the healthcare service has an adequate structure, related to the physical area and facilities, availability of materials, equipment and adequate number of nurses with specific training7. The nursing consultation constitutes an activity regulated by law no. 7498/86 of professional activity8.
The nurse, child and caregiver develop daily actions and interactions, which will compose the everyday life in childcare consultations. This is presented by daily interactions, beliefs, values, images, imaginary and symbols experienced daily, which allow or not, the human being to grow and develop throughout life and is manifested by means of speech, laughter and gesture9.
METHODOLOGY
This qualitative descriptive study is guided by the Comprehensive Sociology, which purports to describe the lived in that which it is, being content thus to discern the views of the different players involved9.
The study population consisted of the set of eleven nurses working in childcare in a health district the city of Salvador, Bahia, Brazil, during the collection period, and of these, only eight agreed to participate voluntarily, after presentation of the Statement of Informed Consent Form (ICF).
Data collection was carried out after approval by the ethics Committee of the School of Nursing of the Federal University of Bahia, under protocol no. 036/2010 and counted with the authorization of the Sector of Permanent Education of the Municipal Health Department of Salvador. At all stages of the research were preserved the ethical principles of Resolution no. 196/96 of the National Council10.
Data collection was carried out from March to April 2011, through semi-structured interviews, guided by a script composed of characterization of the subjects and issues elaborated from the objectives. The answers were recorded on a digital device and transcribed.Fictitious designations were assigned the study participants, using the initial letter of the word nurse and numbering in accordance with the order of implementation of interviews (Ex: E1, E2, E3).
In the data analysis, we used the focus on Comprehensive Sociology, as well as in floating readings of data transcribed, selection of testimonies of participants, organization of categories and interpretation of the speeches,the results were grouped in two categories: the everyday life of nurses in consultation in childcare and factors that influence the nursing consultation in childcare.
RESULTS AND DISCUSSION
The daily routine of nurses in childcare consultations
From the testimonies of some nurses, it was possible to describe their daily routine of the childcare nursing consultations.
For some nurses this daily routine is systematized and organized, involving structuring of care, scheduling of appointments, notes and nursingrecords in the monitoring of the child.
We have a specific day for childcare. [...] There is the individual child record, which includes the important information [...]. (E7)
Everything that we do in the consultation must be registered.(E3)
I do all of the records of the children who I consult, it is important to identify any complications. [...] therefore, I have full control of my actions, which are working just fine. (E2)
In this perspective, some nurses, through the organization of records, perform a job not only with clinical actions, but also with a conception of organization and systematization, showing commitment and responsibility in doing this in childcare.
The systematization of nursing assistance enables the identification of problems, interpretation and organization of conducts in the context of professional exercise11. The organization of nursing care, through the records, favors a control of actions undertaken in order to realize its effectiveness, as well as govern a practice that meets the needs of the child and their family12. In the context of childcare, the systematization of care if it shows as a tool to organize the demand, expand access and ensure the quality of care to children and their families2.
The daily routine is repetitive and time consuming, full of routine actions, that are usually practiced and that demand attention and discretion in their implementation and in the records. This refers to the idea that we need to do with quality and not just quantity, that less is more.
It is the step by step, those we always: measure the weight and length, comparing a period with the other; assess the psychomotor development, guiding us on the care. Therefore it takes a long time, to be done with care and recording everything. [...] A consultation only takes twenty to thirty minutes. (E3)
However, each consultation new situations and new doubts are emerging, which makes the daily also unpredictable, allowing new interactions and construction of new relations.
In addition, each month this is repeated. However, there is something new also; new questions, new situations, and we clarify. (E3)
This allusion, always doing the same things corroborates with the idea that time is cyclical, in that repeat situations, in a different way, even though it may seem happen the same way. The history is in cycles, there is a return that integrates changes, developments, the novelties, i.e. a return with something more, something already seen, already known13.
The daily routine in childcare is pleasurable. Attending the child and having a harmonious relationship with the child and family results in a day to day pleasurable and satisfying work, which collaborates with the relationship of trust between those involved.
It is a consultation that I find pleasurable, [...] I like to care for children, and I think that I can establish a good relationship with the child and their family. (E8)
The professional care practices should not be restricted to technical actions, but must be expressed as attitudinal and relational, contemplating elements such as active listening and empathy14. Thus, the nursing consultation is also a space intended for support, discussion and sharing, allowing the strengthening of affective bonds in relationship and providing a care of oneself and the other.
I think that I can have a relationship of affection; I think it's important in childcare, to demonstrate affection and respect for the child, because it raises the confidence of mother and child. (E8)
It is in this pleasurable daily routine, surrounded by displays of affection and respect that the nursing consultation in childcare takes place. The bond between the professional, child and family makes the healthcare actions more effective and assists in participation in the process of taking care of the child15.
In this perspective, the daily routine of the nurse presents an interactional aspect that stands out in conversation, in guidance, linked the educational practices, revealing herself as opportune moment to orient the mother and/or family about issues related to the child's health.
The mother usually has many questions here, [...] the consultation itself is much more conversation, to clarify doubts. (E3)
The work is completely directed to educational practice of mother, guidance on the care of the child.(E2)
Communication is a strand of the nurse in the meetings between the child - subject of attention - and their family, and they are recognized as those who think, feel, act and react in a whole care context16.
Therefore, the role of nurses goes through a series of strategies to engage with users, which may include informal conversations and guidance / clarification of doubts17.
Even in view of nurses, childcare consultation is accessible both for children who are looking for the service, even without prior appointment, as for the responsible that, sometimes, it takes the time to meet some specific need. Such an attitude in the daily routine of these professionals denotes a humanized care, which may reflect in a greater attendance of the mother or caregiver to attend consultations scheduled monthly.
We meets attend on a specific day. Absolutely, comes a child with an unexpected event, which is not scheduled, we attend or welcome them. (E4)
The mother needs something, a contraceptive, for example, and I do these two appointments to prevent it having to return another time. (E8)
My childcare service is greatly sought. There is a good attendance, mothers really come back to do the monthly consultations. (E2)
In this respect, it is evident the concern with reception of the child/family that indicates the care dimension, the worrying with the other. The care, essence of nursing work, is more than an act, it is an attitude. Therefore, it covers more than one moment of zeal; it represents an attitude of concern and accountability18.
The wide demand by childcare service suggests the influence of affective bond established in the consultations in childcare, enabling interest of mothers in return for the follow-up of the child with the nurse. The follow-up of the child, through the frequent returns to the health unit or through the home visit, allows the continuity of actions and qualifies the child care in the context of childcare2.
Everyday life is permeated by monitoring growth and development, which starts from the attention the child still in the belly of the mother, through the first postpartum visit, in which the mother is targeted and evaluated together with the child, until the subsequent consultations scheduled for the health unit.
I took the baby from inside the mother's womb. The first visit that I do at home is the puerperium, [...] and I will accompany the child until they are two years old. (E5)
It is the monitoring of growth and development [...]on the vaccine and in the graph of growth, the people came with the evolution of the child, feeding, if it is appropriate or not. (E3)
Studies indicate the importance of registering the child's weight in their growth and development by assessing their nutritional status. An inadequate nutrition causes problems of growth and consequently restrictions and compromises future for the development of the child19. Thus, the daily routine also covers working in an interdisciplinary health care team.
I speak with the nutritionist and I refer them to her if necessary. Everyone works together, it is very good. (E3)
I have this relationship with the staff of the dentistry; I ask that the mother takes the child there. [...] I always ask for pediatrician doctor’s help here.(E8)
The existence of an interdisciplinary health team facilitates the daily routine in childcare, allowing better quality work to be done. Teamwork aims to achieve impacts on the different factors that affect the health-disease process and presupposes the possibility of practicing a professional reconstructing the practice of the other20.
You detects the problem and have the support of another professional. Then it is important for the issue of you not only to work in childcare. (E8)
The daily routine enables autonomy of prescription guaranteed in protocol. The prescription of medicines by nurses, established in public health programs and in routine adopted by health institution, is recognized by law8.
I can put vitamin A, ferrous sulphate, all the things that the nurse, according to the protocol, can do. (E3)
The prescription, according to the protocol enables a work in childcare in more autonomy, this autonomy understood as freedom, independence and common sense makes professional able to make decisions and perform tasks that enable them to achieve satisfactory results in their work9. However, it recognizes the need for each professional to know his or her role, without prejudice of the other.
Factors that influence the nursing consultation in childcare
The cultural context, equity in care, accessibility and structure and organization of health facilities are factors that influence the day-to-day consultation in childcare, either as facilitators or as hindering, assuming a paradoxical character.
Here is afro-descendant region has a lot of holy mother daughter, and we respect that [...] the reality is our Africandance, we learn how to dance and dance to foster this child. (E5)
The cultural context, customs and traditions are configured as facilitating factors, to the extent that it seeks to understand and incorporate these aspects in health education activities. The knowledge of superstitions and popular practices is essential for professionals to familiarize themselves with the groups with which they work and learn to deal with the cultural value of each individual21. This means extending the professional approach in childcare consultation in valuing the popular knowledge and does not reduce it solely to knowledge scientifically produced22.
However, some popular practices based on old ideas, beliefs or myths, such as the fact that only breast milk does not sustain the child, it show how factors that hinder the consultation in child care.
The exclusive breastfeeding up to six months is a practice that we have been struggling [...], and while doing so, the grandparents say that breast milk alone does not sustain the child. It is not easy! ( E6)
Not always, the popular knowledge related to the health of the child is seen as something that should be incorporated into the professional practices. Some nurses have difficulties in dealing with this knowledge, when it goes against the scientific knowledge that underlies their practice. Thus, a work seeks to change the habit or practice. The change of habits related to health between users is a difficult process, because they are rooted in the sociocultural aspects, transmitted between different generations within the family or in the community23.
Equity in healthcare is a factor that influences the consultation in childcare. The fairness concerns the means necessary to achieve equality, being related with the idea of social justice. So that one can exercise fairness, there have to be favorable environments, access to information, experiences as well as opportunities on which to make choices for a healthier life24.
When there is balance in family, structure can work positively fairness, when it seeks to treat the child individually, recognizing the family values and traditions, fostering the empowerment of individuals.
The mother and father are scavengers, so I try to treat the child without prejudices, and show the mother that the children may be scavengers too, if they wish, but they must organize themselves in a neighborhood cooperative. (E5)
In contrast, fairness is shown as a complicating factor when family dysfunction demand attention, a greater concern of nurses in childcare practice.This attitude if worrying about, being attentive, represents an attitude of accountability, which is the care18.
We are concerned with the origin of the child. [...] There are children here very dysfunctional family: children of divorced parents, siblings from several parents. They are influences that we really have to be more aware of. (E5)
Accessibility was perceived as a factor that influences the consultation. Access to the free user demand has professionals and service as well as the user's interest in seeking this service and the bond that is formed with the community contribute to the consultation in childcare being that it is developed more easily.
The ease with which the patient has access to the professional [...] it is a facilitating factor. Even though they are not scheduled, they can be attended and so we can create with this family a relationship [...], which facilitates because the user believes in you. (E8)
The mothers are interested in searching for the answer, seeing their growth, if it is appropriate. (E1)
The term accessibility is understood as an indicator of quality of service and may be translated by the opportunity from easy access and resoluteness of health. Meanwhile, the search for care models that contemplate access and articulation of the primary attention to other levels of care, remains as a challenge to the scope of the integrality25,26.
The lack of community interest in participating in educational activities and the phenomenon of violence are accessibility aspects that constitute obstacles in the consultation.
What makes it difficult is the issue of violence. The mothers who live on that side has difficulty to come due to the conflict. (E2)
I have difficulty to gather the community for educational activity. (E7)
When there is an adequate physical space, a surplus of material resources and qualified human resources to the structure and organization of health units become facilitating factors of nursing practice in childcare, which enables a service in a healthy environment.
Having a good physical space to meet, I do not think that there is a great difficulty.(E8)
In terms of material, I have everything. [...] I'm not missing anything there. (E2)
Professionals in the vaccination room [...] when they see that the baby and mother needs is confusing [...] they refer them to me and increase the flow, this makes it much easier. (E3)
On the other hand, the existence of an inadequate space, deficit of some On the other hand, the existence of an inadequate space deficit of some material resources, and manpower deficiency or lack of trained professionals are aspects of structure and organization that hinder the consultation in childcare.
One professional stays with out attending because there is not a sufficient number of doctors. This interferes. (E2)
Sometimes the smallest things are lacking, a child tensiometer. (E5)
The lack of a doctor on the team is another factor that interferes. (E7)
To greatly improve I had to have an understanding about what is childcare on the part of the reception. (E3)
It is essential that the health services have appropriate structures regarding the physical area, facilities, availability of materials and equipment and sufficient number of professionals with specific training to meet the demand with quality and resolution7.
CONCLUSION
Nursing as a scientific and humanistic profession focused on the principle of humane care, works in childcare for prevention, recovery and promotion of child health, meaningful and satisfying way. Through this study, it was possible to bring understanding about the day-to-day activities of nurses participating in this research, organizing the results into two categories: the everyday life of nurses in consultation in childcare and factors that influence this consultation.
Such a daily routine is revealed by a set of routine and systematic actions, while that shown in dynamic and unpredictable, based on interaction, mentoring, monitoring the growth and development of the child and forming bonds. In this daily routine, it is possible to develop a work enjoyably with demonstration of affection and respect for the child and their family, supported in the multidisciplinary team and with autonomy of prescription, second institutional protocols.
The cultural context, fairness in care, accessibility and structure and organization of the health service are factors that influence the daily lives of the consultation in childcare, sometimes facilitating sometimes hindering the day-to-day activities. However, the factors that hinder are not sufficient to prevent the consultation in childcare happen satisfactorily, resulting in promotion, prevention and recovery of health.
This study was also relevant to unveil aspects of this daily routine essential to the comprehensive health care of children. However, it has limitations in revealing an everyday referred to only in the speeches of the participants, it was not possible at the time of data collection, contrasting with non-participant observation of the consultations.
REFERENCES
1. Ferreira ABH. Dicionário Aurélio Básico da Língua Portuguesa. Rio de Janeiro: Nova Fronteira, 2011.
2. Ministério da Saúde (Br). Departamento de Ações Programáticas e Estratégicas. Agenda de compromissos para a saúde integral da criança e redução da mortalidade infantil. Brasília (DF): Ministério da Saúde; 2004.
3. Prefeitura do Município de Londrina (PR). Autarquia Municipal de Saúde. Saúde da criança: protocolo. Londrina (PR): Secretaria Municipal de Saúde; 2006.
4. Figueiredo GLA, Mello DF. A prática de enfermagem na atenção à saúde da criança em unidade básica de saúde. Rev Latino-Am Enfermagem. 2003; 11: 544-51.
5. DATASUS. Departamento de Informática do Sistema Único de Saúde [site de Internet]. Estatísticas vitais. [citado em 21 jun 2013] Available at: http://www2.datasus.gov.br/DATASUS/index.php?area=0205.
6. Fundo das Nações Unidas para a Infância. Situação mundial da infância 2008. Brasília (DF): Escritório da Representação do UNICEF no Brasil; 2007.
7. Saparolli ECL, Adami NP. Avaliação da qualidade da consulta de enfermagem à criança no programa de saúde da família.Acta Paul Enferm. 2007; 20: 55-61.
8. Presidência da República (Br). Lei n. 7.498, de 25 de junho de 1986: dispõe sobre a regulamentação do exercício da enfermagem, e dá outras providências [documento da internet]. Brasília (DF); 1986 [citado em 23 mar 2013]. Available at: http://www.abennacional.org.br/download/LeiPROFISSIONAL.pdf.
9. Maffesoli M. O conhecimento comum. São Paulo: Brasiliense; 1988.
10. Ministério da Saúde (Br). Comitê Nacional de Ética em Pesquisa em Seres Humanos. Resolução nº 196, de 10 de outubro de 1996: diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. Brasília (DF): Conselho Nacional de Saúde; 1996.
11. Barros DG, Chiesa AM. Autonomia e necessidades de saúde na sistematização da assistência de enfermagem no olhar da saúde coletiva. Revescenferm USP. 2007; 41: 793-8.
12. Lima GT, Silva MFOC, Costa TNA, Neves AFGB, Dantas RA, Lima ARSO. Registros do enfermeiro no acompanhamento do crescimento e desenvolvimento: enfoque na consulta de puericultura. Rev RENE. 2009; 10: 117-24.
13. Maffesoli M, Rouanet SP. Moderno x Pós-Moderno. Rio de Janeiro: The StateUniversityof Rio de janeiro, Cultural Department; 1994.
14. Formozo GA, Oliveira DC, Costa TL, Gomes AMT. The interpersonal relations in health care: an approach to the problem. Revenferm UERJ. 2012; 20:124-7.
15. Rangel RF, Fugali MM, Backes DS, Gehlen H, Souza HT. Avanços e perspectivas da atuação do enfermeiro em estratégia saúde da família. Cogitareenferm. 2001; 16: 498-504.
16. Martinez EA, Tocantins FR, Souza SR. As especificidades da comunicação na assistência de enfermagem à criança. Rev Gaúcha Enferm. 2013; 34:37-44.
17. Monteiro AI, Santos ADB, Macedo IP, Gurgel PKF, Cavalcante, JMP. A expressão da autonomia do enfermeiro no acompanhamento do crescimento e desenvolvimento da criança. Revenferm UERJ. 2011; 19: 426-31
18. Boff L. Saber cuidar: ética do humano - compaixão pela terra. Petrópolis (RJ): Vozes; 1999.
19. Veleda AA, Soares MCF, Cézar-Vaz MR. Fatores associados ao atraso no desenvolvimento em crianças, Rio Grande, Rio Grande do Sul, Brasil. Rev Gaúcha Enferm. 2011; 32: 79-85.
20. Araújo MBS, Rocha PM. Trabalho em equipe: um desafio para a consolidação da estratégia de saúde da família. Ciênc Saúde Coletiva. 2007; 12: 455-64.
21. Vasconcelos VM, Frota MA, Martins MC, Machado MMT. Puericultura em enfermagem e educação em saúde: percepção de mães na estratégia saúde da família. Esc Anna Nery. 2012; 16:326-33.
22. Barbosa MARS, Teixeira NZF, Pereira WR. Consulta de enfermagem: um dialogo entre os saberes técnicos e populares em saúde. Acta Paul Enferm. 2007; 20: 226-9.
23. Siqueira KM, Barbosa MA, Brasil VV, Oliveira LMC, Andraus LMS. Popular Beliefs regarding health: ownership of socio-cultural knowledge. Textocontexto - enferm. 2006; 15: 68-73.
24. Ministério da Saúde (Br). Núcleo Técnico da Política Nacional de Humanização. HumanizaSUS: documento base para gestores e trabalhadores do SUS. Brasília (DF): Ministério da Saúde; 2006.
25. Freitas PH, Piovezan R, Colomé JS, Vianna M, Carpes AD. Educação em saúde na rede de atenção básica: problematizando a acessibilidade de usuários do SUS[internet]. In: 3º Jornada Interdisciplinar em Saúde; 2010 junho 8-11; Santa Maria, Brasil. Santa Maria: Centro Universitário Franciscano. [citado em 11 abr 2013] Available at: http://www.unifra.br/eventos/jis2010/Trabalhos/188.pdf .
26. Cursino EG, Fujimori E. Integralidade como uma dimensão das práticas de atenção à saúde da criança: uma revisão bibliográfica. Rev enferm UERJ. 2012; 20:676-80.