ORIGINAL

Planning and strategies for the management of high-risk prenatal care: a phenomenological study

Fabiana Fontana Medeiros1, Izabel Dayana de Lemos Santos1, Juliana Vicente de Oliveira Franchi1, Sebastião Caldeira2, Rosângela Aparecida Pimenta Ferrari1, Alexandrina Aparecida Maciel Cardelli1

1 State University of Londrina, Londrina, PR, Brazil

2 State University of Western Paraná, Cascavel, PR, Brazil

ABSTRACT

Objective: To understand the meaning of planning actions in high-risk prenatal management and the expected professional improvement strategies. Method: A qualitative study was carried out with 13 managers providing indirect care in a high-risk prenatal care setting, between January and March 2020, through face-to-face interviews and analysis in the light of social phenomenology. Results: Four concrete categories of experience emerged: Actions developed in care planning, Indispensability of professional improvement, Challenges in management towards professional training, and Expected actions through the responsible bodies and sectors. Conclusion: The planning of actions in high-risk prenatal management was aimed at training the primary health care team. Among the strategies for a professional qualification, the importance of financial investment from higher levels than the manager's qualification is highlighted, as well as the expansion of actions in continuing education in primary care and specialized services, aiming at care improvements.

Descriptors: High-Risk Pregnancy; Health Services Administration; Professional Training; Social Phenomenology.

INTRODUCTION

Pregnancy is defined as a physiological phenomenon. However, this phase can represent a critical situation caused by changes in a woman's life, including physical, mental, and social changes, as well as fetal changes, resulting in risk to maternal or fetal health, characterizing a high-risk pregnancy(1). Prenatal care (PC) has the essential function of planning assistance to prevent, diagnose and treat undesirable events and, thus, avoid future complications for the woman and the fetus(2).

PC in Brazil is ensured by Rede Cegonha, which supports the organization of the maternal and child health care network, defining guidelines for the early initiation of PC, risk stratification, and healthcare in a specialized service(3). Therefore, the management of such actions is the responsibility of the managers of high-risk prenatal care (HRPC), who plan and implement care actions.

Despite PC advances, national and international studies have shown weaknesses(4-5). When considering the planning of actions as a management tool, allowing decision-making on priorities that directly interfere with the organization of the public healthcare network, the management of health services is considered a fundamental element in the resolution and effectiveness of public health policies(6).

In this sense, actions aimed at human resources in health, management, education, and policies materialize in improvements in the quality of PC, contributing to the reduction of maternal mortality(7).

Despite the importance of the manager in the quality of care, it is unprecedented in the literature to investigate managers working in indirect assistance at HRPC, which is a knowledge gap. Understanding the reality experienced by managers in the planning of HRPC may provide evidence for the development and implementation of effective policies aiming at care improvement.

From this perspective, the present study asked: How do managers experience the planning of indirect care in the HRPC? What strategies could be implemented for care improvement?

Thus, the objective was to understand the meaning of planning actions in high-risk prenatal management and the expected professional improvement strategies.

METHOD

This is a qualitative study anchored in Alfred Schütz's Social Phenomenology, which comprises the subjective experience in people's daily lives, permeated by the relationships that constitute the social world. Man manifests his experience according to past and present experiences (reasons why) and plans to achieve his goals (reasons for), based on intersubjectivity, giving rise to interaction in a social context, defined through the physical and sociocultural environment, experiencing everyday situations(8).

Comprehensive sociology is perceived from the analysis of interpretation of the phenomenon, from the perspective of valuing the social dimension, through everyday experiences, with the possibility of understanding, from the experiences of health professionals, seeking reasons to justify each action performed(9).

In that regard, the phenomenological perspective contributes to an effective perception of the experiences in the health-disease process of human beings and those living in health care scenarios, aiming to understand people within the social world in HRPC management(10).

The study used social phenomenology to understand the meaning of planning actions, and strategies managers use in high-risk prenatal care. Through the theoretical and methodological framework used, the reasons for the human activity that occurs in the world of life were sought, in the face of managerial limits, related to insufficient knowledge and failure to typify professional improvement(10).

The ethical precepts that govern research with human beings were complied with, and the participants signed an Informed Consent Term. The study was approved by the Ethics Committee in Research Involving Human Beings of the State University of Londrina, according to opinion No. 3.660.461/UEL, on October 24, 2019, and CAAE No. 21597619.5.0000.5231.

The study was carried out in the participants' work environments, these being the Municipal Health Authority of Londrina, PR, Brazil, which manages and coordinates the services in Primary Health Care (PHC) in the municipality; the State Health Department of the 17th Health Regional of Londrina, PR, Brazil, which manages the RAS of the State; the Specialty Outpatient Clinic of the State University of Londrina, PR, Brazil, a reference for outpatient monitoring of high-risk pregnancies linked to the University Hospital; and the Intermunicipal Health Consortium Paranapanema in Londrina, PR, Brazil, a reference for outpatient care of pregnant women at intermediate and high risk, acting as a management and articulation tool in 21 municipalities in the state of Paraná.

The selection of participants was intentional, and professionals with a minimum experience in the management position of 60 days were included in the study. The search for participants was carried out through prior contact with the administrative team to identify the participants. Later, an interview was scheduled with the manager at a more convenient time for the interviewee.

Before the beginning of the interviews, the researcher introduced herself to the interviewee, clarified the research objective, and informed the scientific trajectory of the studied theme.

The number of participants was not defined a priori. The inclusion criteria were considered for the sample composition and the guarantee of participation of the managers of all the institutions surveyed. Four participants did not meet the inclusion criteria, and two did not accept to participate. Therefore, six participants were excluded, resulting in the participation of 13 managers.

Data collection was carried out by the main researcher, who was carrying out a doctorate study and delved into the scientific method and theoretical-methodological framework.

The interviews were conducted between January and March 2020, guided by the following questions: What actions do you develop in the HRPC follow-up? How do you perceive your training in the professional practice experience in caring for pregnant women with high-risk pregnancies? What do you expect from the bodies/sectors responsible for this follow-up for the continuity of your care actions in the HRPC?

The interviews were carried out in the manager's room, at the workplace, using a voice recorder after the participant's permission. The interviews lasted an average of 50 minutes. When considering the richness of the experience of the participating managers, the 13 interviews were included in the study, with no sample losses.

Data collection ended when data saturation was achieved, no new themes emerged, the proposed objective was achieved, and answers to the research questions were provided(11).

The transcribed data were returned to the respective participant for knowledge and possible comment on the testimonies, but there was no change request.

The interviews were coded using the letter M, the initial of the word "Manager", followed by Arabic numerals, according to the order of the interviews (M1 to M13) to guarantee the anonymity of the participants.

The testimonies' organization, categorization, and analysis were conducted based on the theoretical and methodological principles of Alfred Schütz's Social Phenomenology, through accurate reading of each statement, reaching the units of meaning of the lived experience; grouping of significant aspects to the composition of the categories; analysis of the categories, listing the "reasons why", representing the actions experienced and expressed; and the "reasons for", constituting future actions, resulting in the categorization of data and the understanding of the phenomenon in the light of Alfred Schütz's Social Phenomenology(12). A correction was made in the transcription of the participants' speeches regarding the Portuguese language's cultured norm without changing the original meaning.

RESULTS

The study participants comprised eleven female and two male managers aged between 36 and 62. The average training time was 22 years, with nine managers having training in nursing, two in medicine, one in pharmacy, and one in foreign languages. As for the educational level, nine had a lato sensu postgraduate degree, and four had a stricto sensu postgraduate degree. Concerning employment, ten managers were civil servants, and three were in commissioned positions.

In light of Alfred's Social Phenomenology, four concrete categories of the lived experience were identified, three related to the "reasons why" of the planning of actions in HRPC management: Actions developed in care planning; Indispensability of professional improvement; and Challenges in management towards professional training, composing the past and the lived present. Furthermore, a category referring to "reasons for" covering the expectations of managers regarding the qualification of this segment emerged: Expected actions through the responsible bodies and sectors.

Actions developed in care planning

Regarding the actions developed in the manager position, it was typical to carry out training of the multi-professional team on maternal and child mortality indicators through supporting workshops, case discussions, and professional support based on doubt-resolving and guidelines updating.

We have been working a lot on workshops about matrix support, with specific themes, according to the maternal and infant mortality committee indicators, from the physician, nurse, nursing assistant, community health agent, administrative staff, oral health team, and the NASF team. We have also encouraged case discussions within the unit to improve our services (M2).

We have a professional to answer questions and guide professionals on the cutting edge, to provide this support (M3).

We have clinical supervision, where professionals from the specialized outpatient clinic listen to the primary care professional. This makes the professional following a given case share his experiences with us, providing a direction regarding healthcare. He is also allowed to express his anguishes and needs (M7).

When there are new protocols, strategies, and ordinances, we disclose them to the municipalities through training and solving some questions from the municipalities as they contact us for clarification (M9).

Indispensability of professional improvement

It was evidenced that the undergraduate course is a basis for the position held in management, with the need for continuous professional improvement, through the search for updates in guidelines, training, lato sensu and stricto sensu studies, and participation in scientific research groups. The performance in direct assistance to pregnant women with high-risk pregnancies also allowed acquiring knowledge for the position held in management.

My specialization degree in public health and auditing was fundamental; It gave me all this set of knowledge to be in management (M6).

I participate in a doctoral research group, strengthening my concerns about the managerial role. It has helped me to make my reflections (M7).

Training provides the basis. We always need to update ourselves. I think my practice of working from edge to edge makes much difference when you are in the management and coordination, because you know exactly what it is like at the front line and understand the professionals' reality (M9).

In practice, we see different cases of prenatal care, and you end up looking in the literature and reading the protocol. I also had some training to work at the Mortality Committee, but I think most of my knowledge comes from daily searches (M10).

The manager's training in medicine proved to be an intermediary tool in communication with other medical professionals, despite nursing being praised in competence for management.

As a doctor, I realize they respect a person more if he is a doctor. Sometimes, a nurse speaks something, and my advisor says the same thing. She won't be heard if I am not the one talking among the doctors. But in my management practice, I didn't behave like a doctor but like a nurse. Nurses understand much more about management, and doctors are not trained in management or supervision. We are not trained for this (M8).

Challenges in management toward professional training

The absence of forums aimed at scientific research results, the rotation of the PHC team, changes in guidelines, and the scarcity of professional training weaken the production of knowledge and the continuity of the implemented actions.

We do not have forums for listening and understanding the research results from studies conducted at the various universities that carry out detailed research in prenatal care. I do not know of any forum that can integrate universities with services and discuss this issue of prenatal care in a systematic way (M7).

You change many professionals in the municipalities, in primary care, so sometimes you do a whole training job, and some of the professionals don't stay, or what you trained can no longer be done, something else comes along that takes everything away. What you've done, everything you've ever done is no longer that way (M9).

We have few local, regional, and state training, and many things are cluttered with knowledge. There are always new things, for example, the service brings something new, but I have never seen this in my life, or they bring doubts that you have never thought about or read, or a new guideline (M11).

The importance of managers faced with the weaknesses for professional improvement being trained to manage the health-disease process was revealed, not letting political interests influence effective health actions.

There are municipalities that, in two years, changed their health secretary five times. This is difficult because you cannot discuss that subject with that person. After all, they are thinking about the political part. For example, some people say that every healthcare unit has to do the risk classification, while others say no, that the service will be on a first-come, first-served basis because the population will revolt if we do it like that. This manager is not thinking about health. He is thinking about whether he will have a vote or not (M9).

We need to have people with management skills; sometimes, political managers are not prepared, and the manager must be aware of the health-disease process (M10).

Expected actions through the responsible bodies and sectors

Managers expect financial investment from the higher level aimed at management training, which is fundamental to the position and expands the training of PHC and specialized care professionals with systematized meetings.

We need investment for professional training. If we access the UNA SUS website, we have access to a series of courses, but not all professionals have this habit of accessing the Internet and searching for this information, so, sometimes, things could be better targeted towards the managers to apply with their professionals (M2).

We need people with a managerial vision. If you have a good management plan, you can move forward, so the public power must train the people who are ahead (M10).

Training would be a fundamental strategy for our service and the staff who assist these pregnant women in specific services so that the same knowledge may be learned. I think that training should occur more frequently (M11).

DISCUSSION

In the context of the meaning of the "reasons why", managers develop actions related to the improvement of the multi-professional team, which must be trained to provide differentiated care in the HRPC, requiring the acquisition of knowledge by professionals acting in executive and healthcare actions.

Permanent education is considered essential for the professional improvement of health actions and a strategy for reorganizing the functioning of services and the work process. In Brazil, the National Policy for Permanent Education in Health (PNEPS in Portuguese) was instituted in 2004. However, this strategy presents difficulties in its operationalization related to insufficient financial resources, lack of political will, lack of personnel, or even lack of training of higher bodies to create inter-institutional or sectoral arrangements(6).

Based on maternal and child mortality indicators, the speeches showed specific themes for professional training through workshops on matrix support and case discussions. A study that investigated the planning of health care for chronic health conditions described the importance of matrix support in the professional training of the PHC team, and also identified the use of matrix support by the professionals working at specialized services, occurring in person or at a distance, weekly, applied in the format of case discussions focusing on problematization, planning, programming, and execution of collaborative actions between specialized and primary care. The authors emphasize the richness of matrix support as professional support to the PHC team and for improvements in the RAS(13).

Given the context above, the importance of the maternal and infant mortality committee is highlighted as a guide for the themes to be worked on in the matrix support workshops. The maternal and infant mortality committee plays a substantial role in identifying weaknesses and guiding HRPC actions. In this sense, the quest to reduce maternal mortality indicators is a worldwide concern. Several initiatives are underway to face the challenge of maternal mortality. In the United States, the Prevention of Maternal Deaths Act, created on December 21, 2018, authorizes federal funding to support state and local multidisciplinary committees focusing on comprehensive assessments of maternal deaths and support through information on prevention activities(14).

Aiming for greater performance by the maternal and infant mortality committee, greater investments are needed to expand information and access to discussions held with the committees to disseminate information to staff. The importance of the performance and awareness of the committee members regarding the importance of professional training is highlighted.

The findings also show the need for professional support aimed at queries and updating guidelines, as well as the training and specializations as continuous strategies for the management position, aiming at professional improvement and, consequently, updating the managers for disseminating knowledge to professionals who work directly in the HRPC.

There is a need to strengthen health work with the performance of primary and essential care. In this sense, using health care indicators represents a strategy for qualifying PHC and strengthening the team's work process. We reinforce the importance of health professionals with qualified training, education, and permanent supervision specific to the demand of primary care, giving rise to qualification with reciprocal intentions for continuity of care, access to services, and comprehensive care(15).

The strategic actions for training and professional support can contribute to the quality of healthcare through the improvement, adaptations, and formulations of protocols that must be followed in the HRPC, in addition to the integration and participation of the team in the planning of gestational care, as well as the reciprocity of intentions aggregated through the knowledge, acquired that permeates the biographical situation of the professionals involved.

Nursing training proved favorable to the management position, which knows training on team management and actions for gestational planning. In this sense, when, at the same time, the professional has targeted training and professional practice, these contribute an important aspect to a reflective look at the management of care planning for pregnant women with high-risk pregnancies.

Nursing training represents preparation for generalist professional practice, requiring specializations and continuous professional development and improvement training(16). Professional experience adds safety to obstetric practice, allowing the professional to correlate the knowledge acquired in theory, improving skills, acquiring dexterity and reflective capacity on lived experiences(17).

Despite the nursing training being favorable for the management position, the difficulty in communication between the professional nurse manager and the doctor who works in practice was highlighted, evidencing obstacles in interpersonal communication and challenges faced in the performance of the nurse manager.

A study in Malaysia identified an authoritarian attitude of the medical professional toward the nurse, evidencing barriers to professional communication. In this sense, there is a social and professional view that the nurse is on a hierarchical level inferior to that of the doctor. However, these two professional categories must act in the search for care improvement. It is emphasized that the two professions are exclusive and do not present resolution without effective and collaborative communication(16).

The discussion on nurse-manager communication versus communication with medical professionals is a scientific gap, with the need to break paradigms and go deeper.

In order to favor professional improvement, the role of the manager in a scientific research group was also highlighted, allowing the manager to reflect on the needs of the service. The importance of the manager to delve into the research results is evident, aiming at scientific deepening and, consequently, the strengthening of the management practice, an essential strategy in the improvement of the acquisition of the baggage of knowledge.

In this sense, the present study emerged as a challenge for implementing listening forums for managers about research results. The importance of the universities to create spaces for sharing research results with service managers is highlighted, as this survey is essential for the proposal of care improvements, in addition to being an opportunity for the improvement of the manager.

Also, the turnover of workers in the PHC was considered a limit to the continuity and improvement of the set of knowledge. In this context, we emphasize the importance of the public servant's bond for the continuity of health education actions, aiming at improving the professional knowledge acquired throughout life by predecessors, thus achieving reciprocity of intentions in the healthcare context, thus considering the meaning of care for high-risk pregnant women through the typification of professional improvement. Another study showed the relationship between employment and professional instability and insecurity, which are responsible for the high turnover of professionals(18).

It is understood that the need to promote public tender is a gap to be filled to supply the precariousness of work and adequate remuneration, aiming at establishing the professional's bond with the public service and the continuity of professional training actions.

The findings also show the expectations of managers (reasons for), expected through higher levels, for the development of actions aimed at professional improvement, evidencing the need for financial investment aimed at training of managers, this being a need for a professional qualification, as well as for positions held by political managers, identifying the essentiality of public power in providing training to the new position assumed, intending the manager's understanding of the continuity of processes, decision making, and implementation of new policies to meet the needs.

Continuing education represents a strategy that can reorient professional training, enabling the re-elaboration of the set of knowledge in the face of the specifics of practice, with an impact on the change of professional conduct, thus promoting the development of the team and the reorganization of health services(19).

Thus, one of the strategies that could be implemented worldwide for a professional qualification in HRPC care would be continuing education, based on the Rwanda Human Resources for Health Program, launched in 2012. The country has adopted government-led professional training, which provides professional health training through a partnership with academic institutions, minimizing the shortage of qualified health workforce and strengthening the capacity of graduate health schools. However, there is a need for significant investment in local faculty recruitment and career development, adequate resources for management and administration, infrastructure, equipment, long-term financing flexibility, and stakeholder commitment(20).

One of the essential elements for implementing policies aimed at permanent professional training is the recognition of this need by public policymakers and higher bodies regarding the effective implementation in health institutions. This is one of the paths for professional improvement and the qualification of the service provided, consequently, for the reduction of maternal and infant mortality indicators.

In this regard, continuing education at a distance, also known as e-learning, used worldwide, can be a strategy for the professional improvement of managers and direct assistance professionals, using the internet as a tool, offering professionals the opportunity to maintain their working hours and engage in the learning environment in the best way and at the most convenient time(21).

In addition to investments in continuing education, investments in improvements related to infrastructure, coordination of health services, working conditions of professionals, and technologies for distance education are recommended. The study also highlights the need to intensify the interaction between the health system and educational institutions and encourage interprofessional collaboration. It is noteworthy that all these actions must be directed towards a scenario of political-administrative stability, providing motivation and confidence to health professionals(21).

Study limitation

As a limitation of the present study, we highlight that it was carried out in a single region of Brazil with a specific sample of managers. However, the results are significant and can serve as guidelines for managers and policymakers regarding strategies to improve high-risk prenatal management.

CONCLUSION

The results of the present study revealed the need for actions necessary to implement professional training in the HRPC, which comprehends professional training of the PHC team, having as teaching strategies the workshops on matrix support, case discussions, and professional support through solving doubts and updating guidelines.

The manager's training was considered the basis for the position held, with the need for continuous professional training to improve the set of knowledge through research, training, direct assistance, immersion of the manager in lato sensu and stricto sensu programs, and participation in scientific research groups. Among the challenges in the management of professional training are the lack of spaces aimed at the manager regarding the dissemination of research results, the high turnover of PHC professionals, the changes in guidelines, the practice of filling positions by political managers without knowledge of the health-disease process, and the lack of actions aimed at professional training.

As for the strategies expected from higher bodies, the need for financial investment aimed at the qualification of the manager was revealed, as well as the expansion of actions in continuing education for teams working in primary care and specialized services to improve the quality of care.

Further studies are suggested to investigate the subject in question, directed to HRPC management bodies in other regions of the country, seeking in-depth and effective interventions in the quality of care.

*Paper extracted from the doctoral dissertation “Avaliação da assistência, acesso e planejamento do serviço pré-natal de alto risco na atenção primária à saúde e ambulatorial especializada: estudo misto”, presented to the State University of Londrina, Londrina, PR, Brazil.

CONFLICT OF INTEREST

The authors have declared that there is no conflict of interest.

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Submission: 10/15/2021

Approved: 07/27/2022