Perception of Nurse Midwives Regarding Their Professional Identity: a Descriptive Study

ISSN: 1676-4285

Perception of nurse midwives regarding their professional identity: a descriptive study

Marina Caldas Nicácio¹, Andressa Lohan dos Santos Heringer¹, Mariana Santana Schroeter¹, Adriana Lenho de Figueiredo Pereira¹

1 State University of Rio de Janeiro

ABSTRACT Aim: To describe the similarities and differences between the professional practice of nurse midwives in the birth center and in the hospital, identifying whether the specifics of this practice influence the perception of their professional identity. Method: This was a descriptive, qualitative research conducted with nurse midwives in a birth center and a maternity hospital in the city of Rio de Janeiro. The interviews were analyzed using the thematic content analysis technique. Results: Two categories were established: similarities and differences in professional practice, and perceptions of professional identity: acts of belonging and assignment. Discussion: Professional socialization was determined by experiences in the limited scope of nursing. Perceptions of the professional identity do not change because the place of performance is the hospital or birth center. Conclusion: The different characteristics of these institutions do not influence perceptions of the professional identity of nurse midwives.

Descriptors: Obstetric Nursing, Professional Practice. Nursing care.

Nicácio MC, Heringer ALS, Schroeter MS, Pereira ALF. Perception of nurse midwives regarding their professional identity: a descriptive study. Online braz j nurs [internet] 2016 Jun [cited year month day]; 15 (2):205-214. Available from: http://www. 205 objnursing.uff.br/index.php/nursing/article/view/5203 INTRODUCTION This is not just about identities at work, but forms of identities within which training is as important The hospital is the main scenario of the pro- as work and corporate knowledge is as structural fessional practice of nurse midwives in normal as the actor’s position. Identity is detached from birth care in Brazil. The birth center is a public the way workers express this interaction. health institution that is physically distanced Identity and difference are strictly depen- from the hospital. Nurses take full responsibility dent on representation, a form of attribution of for the institution and there are no doctors in the meaning and a meaning-making process. This team of professionals. In situations of maternal, process is influenced by history and culture; fetal or neonatal risk, patients are transferred to norms, traditions, and rules of the institutions; the main maternity hospital. speech or dialogue with other actors in the The institutional characteristics of the birth professional field and experiences in affiliation center involve facilitating the development of groups. Thus, this identity construction is for- professional autonomy and the possibilities of mulated and reformulated in response to social nursing care(1). In the hospitals, nurses expe- interaction in a particular professional context(5). rience professional conflict and obstacles to Identity is set in the perception of itself (real providing humane care due to the predomi- identity) and of what is assigned or proposed by nance of the biomedical model in care routines others (virtual identity); that is, the acts of belon- and actions centered on the physician. Despite ging and attribution are the result of continuous governmental initiatives to increase the perfor- and constant movement in the socialization mance of these professionals in the country, the process, both that which arises from the personal specialized qualification required still needs im- trajectory (biographical) and from social inte- provement in order to overcome the influences ractions during training and work (relational). of this existing model and play an active role in Thus, despite the sense of individuality, identity transforming the prevailing obstetric model(2). is correlated to the context of work, to everyday In addition to these weaknesses, there experiences, interaction and recognition of other are frequently “accumulation” or “change-of- social actors(4). -function” issues that challenge the professional In order to identify himself, the individual practice of nurse midwives, such as relocation to uses acts of belonging, that is, meaning catego- other nursing functions in the institution, which ries that express “what kind of man or woman causes work overload, frustration, demotivation, you want to be.” The virtual identity is defined conformism, and submission. This set of factors by a relational process and the categories that has been listed as one of the possible causes for define what kind of man or woman you are; that the development of a hybrid professional iden- is, the attribution acts(4). tity: a mix between “being a nurse” and “being From this perspective, the experiences of a midwife”, which is often cited as one of the nurse midwives in their professional practice can reasons why these nurses experience obstacles be differentiated when they exercise their labor to performing their specific duties in hospitals(3). activity in an environment with unique and dis- The sociologist Claude Dubar(4) suggests tinct features, for example, the birth center and that the construction of the professional identity the hospital. As a result, the meanings of their is inseparable from plans for training and em- professional identities in these situations can ployment and various professional relationships. also be differentiated. Considering this presup-

Nicácio MC, Heringer ALS, Schroeter MS, Pereira ALF. Perception of nurse midwives regarding their professional identity: a 206 descriptive study. Online braz j nurs [internet] 2016 Jun [cited year month day]; 15 (2):205-214. Available from: http://www. objnursing.uff.br/index.php/nursing/article/view/5203 position and the theoretical concepts described The nurse midwives participating in the above, the following question was established: study were randomly selected: an active nurse do the specifics of the professional practice was interviewed on each day shift, shifts from of the nurse midwife in the birth center and Monday through Friday, at both institutions. the hospital influence the perception of their At the hospital, all five duty nurses were inter- professional identity? To answer this question, viewed. On one of the day shifts, the nursing staff the current research was developed, aiming to was incomplete since there was only one profes- describe the similarities and differences between sional present. The same quantity of interviews the professional practice of nurse midwives in was carried out in the birth center. the birth center and the hospital, and identifying The inclusion criteria were as follows: a whether the specifics of this practice influence nurse midwife working in direct assistance to the perception of their professional identity. normal childbirth, regardless of employment bond. Exclusion criteria were as follows: nurse midwives who worked in this role, but also filled METHOD the position of head of the obstetrical center or direction of the institution. This work uses a descriptive and qualitati- Interviews were conducted in-depth from ve approach. The research was conducted in a July to August 2012. We used an interview guide maternity home and a hospital; both institutions consisting of 30 open questions. The first part of belong to the public health network and provide this instrument consisted of questions relating an environment for service education for obste- to training and professional career; in the second trical nursing residents. part, the issues were related to professional The hospital was a municipal maternity practice in obstetric nursing in the investigated hospital, which primarily serves women whose institutions. obstetric profile is classified as normal risk. In The interviews were analyzed using thema- 2011, nurses at the hospital attended 1,384 live tic content analysis, which outlines the following births (LB) by normal delivery, corresponding to stages: 1) pre-analysis; 2) material exploration 47.1% of the 2,937 births performed vaginally. and treatment of results; and 3) inference and Whilst the research was being conducted, the interpretation. To preserve the anonymity of institution had 11 nurse midwives, a diarist, and the participating nurses, a code was adopted 10 physicians on duty distributed across day and to refer to the place where the obstetric nurses night shifts. exercise their professional activity and they were In the birth center, there are currently 18 numbered in the order of the interviews: Birth nurse midwives, and two day laborers who Center N1, Hospital N2, and so on. exercise managerial positions and the vice The study was approved by the Council direction of the institution. The other nurses of Ethics in Research of the Municipal Health are selected for day and night shifts to provide Secretariat of Rio de Janeiro (SMS-RJ), opinion care to women and families in the prenatal, No. 316A/2011. normal delivery and postpartum and newborn It is noteworthy that the study has limits infants whose evolution progresses within the in terms of the scope of its results on percep- physiological parameters. In 2011, a total of 215 tions of the group investigated and, therefore, LB were assisted. the distinctive characteristics of the practice of

Nicácio MC, Heringer ALS, Schroeter MS, Pereira ALF. Perception of nurse midwives regarding their professional identity: a descriptive study. Online braz j nurs [internet] 2016 Jun [cited year month day]; 15 (2):205-214. Available from: http://www. 207 objnursing.uff.br/index.php/nursing/article/view/5203 nurse midwives in the profession in particular following statements: and bounded contexts. Three activities have emerged in the shift: a labor, a prenatal consultation, RESULTS and a transfer to the hospital. I said I would handle the transfer and the The average age of the 10 interviewed other colleagues wanted me to do nurses was 42.5 years, ranging from 28 to 51. In other tasks. (Birth Center N4) relation to the time they graduated in nursing, two nurses had been graduated for less than 10 [...] Sometimes the [delivery] room years, three nurses for 17 years, and five had 20 is used as an office. When we have to 30 years of experience. The average period women hospitalized in labor and pos- of working in obstetrical nursing was 15 years, tpartum, the prenatal consultations get ranging from 4 to 27 years. Six nurses obtained delayed. (Birth Center N3) their titles through qualifications in obstetrical nursing, and the others through lato sensu post- [...] We have to do several things and -graduation. also the part that is the nursing’s The analytical path generated two thematic responsibility in the obstetric center. categories: the first was Similarities and diffe- (Hospital N6) rences in professional practice, and the second was Perceptions of professional identity: acts of [...] With the antepartum full depart- belonging and assignment. ment, you can’t provide individuali- zed attention. You have to meet this Similarities and differences in professional [woman in labor] first and then the practice other one. Sometimes you have to give attention to all at the same time. The common features of professional (Hospital N8) practice are the performance of care, typified as technical care, obstetric nursing techniques and The work at the hospital was characterized procedures, and relational care such as attitudes by disagreement over the conduct of obstetric of welcoming, listening, talking, supporting, care and the limitations of professional auto- encouraging the participation of the compa- nomy, as can be seen in the following state- nion, and the link between mother and baby. ments: It was only in the birth center that we had the opportunity to set up recording units related to You learn something in terms of [hu- educational activities, undertaken in individual manized care] theory, which can be ap- sessions and with groups of pregnant women. plied. But it is very complicated to use; The nurses mentioned factors involved in it is a constant struggle. (Hospital N9) professional practice, such as work overload, high demand for care for the limited number [...] If you need to apply oxytocin be- of professionals, and the accumulation of func- cause labor is taking too long, is not tions in both institutions, as expressed by the evolving, you apply it and ask the doc-

Nicácio MC, Heringer ALS, Schroeter MS, Pereira ALF. Perception of nurse midwives regarding their professional identity: a 208 descriptive study. Online braz j nurs [internet] 2016 Jun [cited year month day]; 15 (2):205-214. Available from: http://www. objnursing.uff.br/index.php/nursing/article/view/5203 tor to prescribe it. [...] At the same time, both institutions, the interviewees stated that when [the pregnant woman] arrives they are women and nurses who perform care. from the admission department, she Such perceptions can be observed in the follo- already comes with oxytocin prescri- wing statements: bed, and you cannot avoid it. So this lack of autonomy is what bothers me. I am a daughter, a mother, a wife and a (Hospital N7) nurse. (Birth Center N4)

[...] When we came to the delivery […] A nurse, a woman and mother of room, we were the “Indian shaman”. [...] two children. (Hospital N8) (Hospital N9) I’m the same nurse I’ve always been. For Despite this confrontational environment, me, caring is the most important. So I there is a consensus in terms of professional am a caregiver. (Hospital N7) practice acknowledgment: Assignment acts develop from social rela- They [doctors] recognize my work as tionships with other subjects. In the birth center, valid and confident. (Hospital N8) the nurse midwives perceive themselves as professionals who share the same vision about The birth center differs from the hospital. the care model and struggle to overcome the The care behaviors are established by consensus adversities of the profession: and there is freedom of action, as mentioned in the following statements: We look like a big family. This facilitates everything; we speak the same langua- Everyone follows the same [care] pro- ge. The purpose and the end are the tocol. If we need to change something, same. (Birth Center E4) we discuss until we find the best solu- tion. (Birth Center N1) [...] Being here means breaking various barriers and facing various situations. [...] There is a freedom of action, of (Birth Center E3) being able to implement, create, ex- periment, and encourage active labor. [...] You have to prove that you know (Birth Center N4) all the time; show that you know what you’re doing (Birth Center E1) [...] Here we have an autonomy that I think no one has. (Birth Center N5) [...] We have trouble even with our class [nursing]. Many do not accept our way Perceptions of professional identity: acts of be- of working [at the birth center]. We don’t longing and assignment have difficulty in dealing only with the doctor. [...] So far we have managed to Acts of belonging are related to percep- win great battles and we say that “we kill tions about oneself, a person’s own identity. In a lion a day.” (Birth Center N5)

Nicácio MC, Heringer ALS, Schroeter MS, Pereira ALF. Perception of nurse midwives regarding their professional identity: a descriptive study. Online braz j nurs [internet] 2016 Jun [cited year month day]; 15 (2):205-214. Available from: http://www. 209 objnursing.uff.br/index.php/nursing/article/view/5203 At the hospital, the nurse midwives DISCUSSION consider themselves a distinct group due to the paradigmatic tendency of the training The experiences lived by the subjects in- they had in their specialty and the distrust volve a process that is dynamic, individual and they face with regard to their professional collective, subjective and objective, biographical competence: and structural, and resulting from the socialization process, which expresses the culture, the We have several types of nurse mi- roles, values and other meanings that determine dwives here. A group that began in their identity(4). biomedical vision and suddenly was Care is an existential, relational and contex- placed in the world of physiological tual phenomenon that involves ethical attitudes [delivery]. And there is that group and humanist values. In the specific field of that has already learned in this more nursing, care is regarded as the essence of the humane, more physiological model. profession(6) and the epistemic center in the (Hospital N7) theory and practice of the area(7). Nurse midwives express these theories about themselves as [...] Some professionals [physicians a distinctive way of being, knowing and acting and nurses] do not believe in the work within the health professions. of obstetric nursing. When we do our One study of nursing practice in the obs- work, they see that it works, that it is tetric center has identified that there is work possible. Then it becomes a little easier overload due to the increased demand for care for us to cope with. [...] If you do not and the lack of professionals, which causes phy- believe, you give up. So it’s not an easy sical exhaustion, psychological distress, and job profession. (Hospital N6) dissatisfaction(8). These work characteristics are observed in all areas of operation of the nursing Because, well, of the 40 something staff, and are related to the influence of political doctors that we have here, you can cost containment and the limitation of public risk 10, a fourth, that respects you as a resources for health(9). professional. So it’s a very difficult team There are also gender inequalities in to work with because the competition everyday relationships of nursing work, whi- is too intense; the competition for po- ch underlie professional conflicts and power wer, of who gives more orders. So it’s struggles in the hospital. One study found that difficult. (Hospital N8) nurses have increased workload compared to their working time. These professionals have Despite these difficulties experienced, all higher stress rates, fatigue and work overload the nurse midwives interviewed expressed a than their male counterparts(10). desire to remain in the profession and in the It is noteworthy that the birth center nurses specialty. also described excessive workload in terms of This set of results was synthesized in the care demand, revealing that they have common thematic scheme of the research presented in issues regarding work in the hospital. However, Figure 1. the fact that this institution is a female domina- ted environment, where care is managed and

Nicácio MC, Heringer ALS, Schroeter MS, Pereira ALF. Perception of nurse midwives regarding their professional identity: a 210 descriptive study. Online braz j nurs [internet] 2016 Jun [cited year month day]; 15 (2):205-214. Available from: http://www. objnursing.uff.br/index.php/nursing/article/view/5203 Figure 1 - Thematic scheme of the research by category, prepared by the authors. Rio de Janeiro, 2014.

Similarities and di erences of professional practice

Similarities Di erences

• Technical and relational care Hospital: dissensus in obstetrical conduct, • Institutional challenges professional conicts; avoids direct confronta- • Job satisfaction tion, but perceives professional recognition Birth center: educational care; consensus in care behaviors and professional autonomy

Perceptions of professional identity

Acts of belongingness Assignment acts

Woman, mother, the one who Hospital Birth center takes care, nurse; loves what she does, and ghts for Nurse midwifes: professional Nurse midwifes: mutual respect professional practice competence, human assistance and adherence to the and training inuenced by the institutional philosophy ⇓ biomedical model Team members: cooperative Aims to stay in her profession Doctors: competitive, uncoop- work. and in her specialty erative and interventionist Reference maternity profession- Nursing sta : good relationship, als: distrust in terms of the but there is still distrust of technical competence of the competence of the nurse nurse midwife and by the fact midwife. that the institution is distant from the hospital conducted by nurses, can lead to more symme- country from the 1940s, represented as a symbol trical working relationships since there is not of modernity, civility, and social advancement at the same gender division of labor observed in this time. This process was consequent to the the hospital. The singularities of nursing work at regulation of the state on maternal and child the birth center should be investigated further. health, which boosted the supply of public and As women nurses in the field of obstetrics, insurance medical services for prenatal care and professional socialization has been influenced childbirth in the country(11). by the historical process of this particular field. The professionalization of the nurses inter- Since the beginning of civilization, daily care has viewed had occurred exclusively in the field of been allocated to women. Female participation nursing and their move to obstetrics was in the has also been crucial in the history of patient context of hospital care of the 1990s, which was care and nursing, as well as in obstetrics, which already under the influence of the Humanization was particularly marked by feminine home care. of Childbirth social movement. Considering Throughout the twentieth century, Brazi- that midwifery training was interrupted in the lian obstetrics suffered from the progressive pro- last decades of the twentieth century and only cess of institutionalization. The hospital began to resumed from 2005(3), it is assumed that nurses prevail as the labor and birth environment in the had no interaction with the professionals in the

Nicácio MC, Heringer ALS, Schroeter MS, Pereira ALF. Perception of nurse midwives regarding their professional identity: a descriptive study. Online braz j nurs [internet] 2016 Jun [cited year month day]; 15 (2):205-214. Available from: http://www. 211 objnursing.uff.br/index.php/nursing/article/view/5203 workplace. Therefore, the professional socializa- conflicts between the care model that they seek tion of the interviewees was clearly marked by to adopt and the hegemonic obstetric model in the labor field of nursing. the health system, as well as the perception of It is important not to confuse socialization mistrust of health professionals in terms of their with schooling. Blurring the two does not help professional competence. to understand the mechanisms of building Such problems are similar to those ex- oneself by means of work activity. Work can perienced by other nursing professionals in provide training, can be a source of experience, general, relating to having little social visibility, of new skills and knowledge for the future, but limitations in terms of professional autonomy it is also under the influence of the vicissitudes and low recognition of the scientific basis of the of the economic system, cultural traditions, and profession(16). Despite this problem, the nurses the social policies of each country(4). interviewed manifest coping attitudes and stru- In this sense, the work experience of nur- ggle to overcome these challenges. ses participating in the study was confined to It should be noted that some nurse midwi- public institutions of obstetric care, where the ves consider that their expertise is recognized by political, legal, and organizational planning is the medical team at the hospital. This fact may under the auspices of the health policy of the denote that the obstetrical field is undergoing a Brazilian state. paradigmatic transition in knowledge and care The results suggest that the hospital is the practices, which advances towards the principles most difficult environment for the professional of humanization and “medicalization” of normal practice of obstetric nursing, where the interven- delivery assistance. With this advance, the mo- tion procedures and biomedical technologies dification of social relationships are enhanced are most valued and doctors are the most in- through more symmetrical relationships be- fluential professionals in the conduct of care. This tween the professionals and the women, and setting adversely influences the performance of between doctors and nurses(17). midwives and nurse midwives in comparison The struggle of these nurse midwives to to the home space and normal birth centers(12). ensure their professional practice in obstetrics At the hospital, there is a tendency to adopt and the implementation of humanized care has a more interventionist approach and apply been investigated in national and international restrictions in terms of the decision-making of scientific literature(18-19-20). This literature deals the hospital professionals, which has caused cri- with the transformations of public policies in ticism from recent social movements of women obstetrics and the resulting impact on the inclu- and the search for other environments for the sion of such professionals in the labor and birth birth of their children(13-14). scenarios, as well as the strategies adopted to The birth center is found to be a better overcome the challenges and constraints faced place for the nurses to exercise autonomy in the in the obstetrical service in the country. conduct of obstetric care. This ability to use their Study participants identified themselves knowledge and skills to assess and meet the as nurses and they had significant experience needs of customers determines the perception in the framework of nursing and the Brazilian of autonomy(15). However, the nurses in the birth health system. Whether it occurs in the hospital center experience professional challenges simi- or at the birth center, labor practice is related lar to those reported by hospital nurses, such as to the public health system, which is the locus

Nicácio MC, Heringer ALS, Schroeter MS, Pereira ALF. Perception of nurse midwives regarding their professional identity: a 212 descriptive study. Online braz j nurs [internet] 2016 Jun [cited year month day]; 15 (2):205-214. Available from: http://www. objnursing.uff.br/index.php/nursing/article/view/5203 of the construction of personal and collective professional practice in obstetric nursing, espe- subjectivities in the professionalization process cially in different areas of the hospital. of Brazilian obstetric nursing.

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Nicácio MC, Heringer ALS, Schroeter MS, Pereira ALF. Perception of nurse midwives regarding their professional identity: a 214 descriptive study. Online braz j nurs [internet] 2016 Jun [cited year month day]; 15 (2):205-214. Available from: http://www. objnursing.uff.br/index.php/nursing/article/view/5203