Nursing consultation with newborns in a capital city of the Legal Amazon: the need for teaching and learning about the theme

The Nursing consultation corroborates health promotion and protection of the population. However, current research shows that this strategy does not always reach its full potential. Thus, this study aimed to identify components that interfere with the practice of Nursing Consultation with the newborn (NB) in Primary Health Care (PHC). To this end, 11 nurses from Family Health Care teams in the municipality of Palmas, Tocantins, Brazil, were interviewed from June to November 2019, and the collected information was submitted to Content Analysis. The results show that the Research, Society and Development, v. 11, n. 2, e30111225881, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i2.25881 2 practice of the NB Nursing Consultation is permeated by several challenges, such as difficulties in finding the NB and weaknesses in clinical assessment and in the implementation of the Nursing Process (NP). The components lack of knowledge and technical skills to assess the child, and insipient and unsystematic execution of the steps of data collection and implementation of the NP, negatively, interfere in the practice of Nursing Consultation.


Introduction
In recent years, several countries have shown a significant drop in infant and child morbidity and mortality rates (Dandona et al., 2020;Burstein et al., 2019;UNICEF, 2018;UNICEF, 2019). However, despite the advances in the protection of children's health on the world stage, research shows that mortality in this group is still high and its profile significantly influenced by socio-demographic inequalities (UNICEF, 2018;Tashiro et al., 2019). It is recorded that 58% of infant deaths that occurred between 2000 and 2017 could have been prevented in the absence of these differences (Burstein et al., 2019).
The first 28 days of life of the child are presented as the period of greatest vulnerability to survival, with a global mortality rate of 18 per thousand live births. It is estimated that 2.5 million newborns (NBs) died in the first month of life in 2018, with approximately seven thousand deaths per day (UNICEF, 2019).
In Brazil, social indicators show that children in the Legal Amazon, States of Acre, Amapá, Amazonas, Mato Grosso, Pará, Rondônia, Roraima, Tocantins and part of Maranhão, have a higher risk of dying before one year of age and of not completing Elementary School, and the main deprivation to which Amazonian girls and boys are subjected is the lack of access to adequate sanitation conditions (UNICEF, 2018).
In this scenario, the Nursing Consultation (NC) and the role played by nurses working in Primary Health Care (PHC) stand out as having the potential to improve children's indicators (Furtado et al., 2018). The NC represents an important resource for the development of a practice guided by the principle of integrality and based on scientific evidence, as well as enabling a systematic and quality professional practice (Hanzen et al., 2019;Kahl et al., 2018).
The NC should be performed considering the Nursing Process (NP), a strategy structured into five steps, which are data collection (anamnesis and physical examination), the Nursing Diagnosis, the planning, the implementation and the evaluation. These steps should occur in an interrelated, interdependent and recurrent manner, and the first of them, data collection, subsidizes the others (Cofen, 2009).
Despite being an instrument that qualifies the practice of nurses, studies show that, many times, professionals are not sufficiently prepared to implement the NP, which may compromise, satisfactorily, the result of the interventions performed by them (Santos et al., 2020;Borji et al., 2018).
When considering that professionals working in PHC must be prepared to assist children and contribute to the qualified care, as well as to the protection and promotion of the health of this clientele (Tubbs-Cooley et al., 2020;Silva et al., 2018), this research aimed to identify components that interfere in the practice of NC to the NB in PHC.
Thinking about effective responses for the different realities of the Amazon requires an extraordinary effort, which implies the ability to dialogue, build and develop proposals in an inclusive and sustainable way, as well as knowing and recognizing this territory as a space of social, cultural and economic relations of a significant diversity of groups and environments (UNICEF, 2018). Thus, it is believed that the results of this research collaborate to give visibility to the existing gaps in Nursing care to the NB in the context of a Brazilian capital of the Legal Amazon and to strengthen evidence regarding the need and importance of a systematized, qualified, safe and cross-cultural Nursing practice.

Methodology
This is a descriptive and exploratory research with a qualitative approach, carried out with nurses from Family Health Care teams who work in Community Health Centers (CHC) of Palmas, Tocantins, Brazil, a Brazilian capital located in the Legal Amazon.
The inclusion criteria for participation in the study were: nurses who had been working for at least one year, in the municipality's Family Health team. Those who were not providing direct care to the community during the data collection period were excluded. The participants' statements are identified by the letter "N", followed by an alphanumeric system.
The selection of participants occurred through an electronic lottery, for which the researchers coded the CHCs in a digital platform. One unit was drawn at a time and its respective nurses were invited to participate in the study. There was no refusal and data collection was closed when the data saturation was reached, as recommended by the specialized literature (Nascimento et al., 2018). In total, 11 nurses from five CHCs were interviewed.
Data collection took place from June to September 2019, through an individual semi-structured interview, which included the following questions related to the nurse's practice in the consultation with the newborn: "if any, tell me about factors that interfere in the performance of the Nursing Consultation with the newborn" and "if you do, describe to me, in detail, how your consultation with the newborn occurs".
The interviews took place in the health units, in a room that allowed comfort and privacy, at a time and day previously agreed upon with the participants. They were recorded on digital media, conducted and transcribed by the researcher responsible for the study.
The data was submitted to Content Analysis, through the following procedures: pre-analysis (comprehensive reading, seeking to systematize the initial ideas); exploration of the material (aggregation of the ideas already systematized in content units), and treatment and interpretation of results (formation of categories and contextualization) (Bardin, 2016).
It is recorded that this research is part of the umbrella project "Standard operating procedure for newborn consultation in primary care: elaboration process", met the ethical precepts of NHC Resolution No. 466/2012 and was approved by the Ethics Committee for Research in Human Beings, CAAE 96933918.6.0000.5519.

Results
The results of this research reveal that the practice of nurses working in PHC, during consultation with the NB, is permeated by challenges related to the routine of families and limitations in knowledge, in the ability to assess the child and to satisfactorily implement the NP, which are contemplated in the category "Factors that interfere with nursing care in consultation with the newborn", presented below.

Factors that interfere with Nursing care in the newborn consultation
The Difficulties in finding the NB presents itself as a factor that hinders the implementation of NC to this clientele, especially in the first seven days of life of the child. The fact that nurses, commonly, do not locate families at their home addresses, after discharge from the maternity hospital, was expressed in the interviewees' statements.
Many times, we are not able to perform the correct follow-up of the newborn, because many puerperal women do not return to their home address after they have had a baby. They end up going to their mother's house, for example. (N1) They practically leave the maternity ward waiting for someone to travel, which makes it difficult to perform the consultation of the newborn [...] there are even women who go and stay 60 days away. (N2) This is not always possible, sometimes, the mother, as soon as she leaves the maternity ward, goes to a farm, some farm or some small town, to be close to her relatives. (N3) We can't because the mother already leaves the maternity hospital and goes straight to the house of some relative who will help in the care of the child, and she only returns home after, I don 't know, 30 or 40 days. (N5) It is noted that health professionals do not perform actions capable of ensuring the consultation of NBs in the first days of life. This scenario compromises the identification and management of factors that put at risk the health of the binomial.
Limitations in the knowledge and skills for consultation with the NB were also recognized by the interviewed nurses as barriers to satisfactory care practice, as indicated by the reports below.
We could have some refresher courses in this area, with the Ministry of Health staff, with you guys that are there in these colleges. Because theory is different from the practice that we experience on a daily basis, but we need to get more training, and look for strategies to overcome these abysses that we find in the reality of the UHS.

It is difficult because of my low ability to deal with the newborn. After two years it is even better, I don't know if this is because the childcare part is not systematized here in the unit. (N8)
The nurses recognize the existence of weaknesses in NB care and even indicate strategies to remedy them, specifically through training that includes the topic and provides opportunities to clarify doubts.
In addition to the limitations regarding the evaluation of the NB, difficulties were also observed in the proper use of the Child Health Handbook during professional practice, due to lack of skills, knowledge and/or for not recognizing its importance for the protection and promotion of the NB's health, as shown in the following statements. Sometimes, I ask for the child's card just to see the issue of the vaccination schedule, but, otherwise, I don't even ask, and to be honest, the mothers don't even bring it, because they know I don't use it. (N11) The lack of use of tools that favor the protection and promotion of children's health is observed, as recommended by the Ministry of Health, such as the Child Health Handbook.
Weaknesses in the implementation of the data collection stage of the NP are present in the practice of the interviewed nurses. Although it is possible to observe that the history of the NB/mother/family and the physical examination of the child are collected, these elements were not systematically and completely performed, as evidenced by the statements below.
We do the anamnesis and physical exam. We collect the history that the maternity staff gives us, both the discharge summary and the delivery information, and the extra information that is reported by the mother, like when some It was noticed that, during data collection, no psychosocial issues related to the binomial were addressed, such as maternity, bonding, support network, and mental health of the mother, among others. And in relation to the physical examination of the NB, it is observed that it was performed in an unsystematic and superficial way.
It was found that, in data collection, there was only a survey of biological aspects of the binomial, and that they were covered insipiently. This finding highlights weaknesses in the construction of a comprehensive Nursing care, human and directed to the promotion and protection of the health of the NB, as well as its family.
Regarding the physical examination performed during the NB's NC, it was possible to identify that it is not implemented in a structured and organized way, and that there are inadequacies and inconsistencies when employing the propaedeutic steps of inspection, palpation, percussion and auscultation, as revealed in the speeches below. When it is here in the unit, which has more structure, we do those reflex tests, I forget the name now, but it can be done and also when we open the system, everything appears. (N8) It is noted that the physical examination does not occur by systems, is not organized according to the anatomical structures, and is not performed according to the cephalocaudal anatomical organization. It is also pointed out that the propaedeutic steps were not carried out in their entirety and, many times, not systematically. Such aspects compromised the quality of the information and could impair the identification of Nursing Diagnoses and decision-making.
Weaknesses were also observed in the survey of the NB's history and in the implementation of the physical examination. Such conducts contribute to important bio-psychosocial issues not being identified and considered in the nurses' work plan, and may reflect in fragmented and unqualified care.
The statements indicate that nurses perform the NC to the NB, but, it does not meet the assumptions of the scientific literature, especially with regard to the implementation of all stages of NP. There was no mention of the stages of Nursing Diagnosis and Assessment in the interviewees' reports. This fact highlights weaknesses in the implementation of the NCS/NP and attention to legal requirements of the profession.

Discussion
As a strategy for the protection and promotion of health, the evaluation of the child in its first week of life is presented, as an opportune period for the health professionals to guide families on immunization, neonatal screening, establish a support network, diagnose physiological changes, early, identify and act on difficulties related to breastfeeding and general care (Soares et al., 2020).
However, some factors can act as barriers to evaluating the NB after discharge from the maternity ward (Soares et al., 2020;Furtado et al., 2010). In this research, the non-location of families was presented as a component that interferes with the practice of NC for this clientele. Thus, there is a need for strategies that promote coordination between maternity hospitals and PHC units, in order to promote access to health services and comprehensive care to children and families.
A study conducted in a municipality in the Legal Amazon showed that adequate care to the NB contributed to reducing the neonatal mortality coefficient, highlighting the need for improvement in prenatal care and structuring of the health care network in order to ensure quality care, integrated and continuous to the mother/child binomial (Moreira et al., 2017).
Articulating the relationships between the health support and assistance sectors and promoting the exchange of actions and inter-sectoriality are extremely important, because, besides corroborating the integral care to the NB and the families, especially those that depend on social policies, needing the State's equipment and other initiatives, they also favor better maternal and child health indicators (Furtado et al., 2010).
In this study, the inadequate use of the Child Health Booklet also operated as a component that interferes with the quality of NC. Difficulties in the completion and operationalization of the booklet compromise the completeness of health care to the NB, since it impairs the multidisciplinary work, the continuity of care at different levels of care and follow-up the evaluation of the child (Amorim et al., 2018).
Overcoming the precariousness in the records and management of the Child Health Handbook requires the training of health professionals who can operate this instrument and recognize its importance in child health surveillance. In addition, it is necessary to empower parents or guardians to carry and demand its use in the different health services (Amorim et al., 2018).
Regarding NB NC, authors indicate that it is performed by nurses working in PHC (Hanzen et al., 2019;Vieira et al., 2019). However, its implementation does not always meet the assumptions of the scientific literature, as observed in this and in other studies (Vieira et al., 2019;Gaíva et al., 2018). Weaknesses in the knowledge and skills to assess the NB are components that reflect, negatively, on the quality of NC.
Research with nurses showed that, in the NC, the evaluation and the surveillance of child development were partially carried out in most of the consultations, and only the mother's perception of the developmental milestones was used, without testing the presence in the child's examination (Gaíva et al., 2018).
Another investigation found that nurses do not report, in detail, how they evaluate the child's neuro-psychomotor development and even confuse their evaluation with the child's general condition and growth measurements, not contemplating actions that include the evaluation of milestones and risk for developmental delay (Vieira et al., 2019).
In this context, it is essential to qualify PHC professionals to make them aware of the importance of proper surveillance of child development, contributing to provide, children and families, with quality care (Vieira et al., 2019;Lucena et al., 2018).
Thus, the relevance of actions aimed at improving the knowledge and skills of nurses for the practice of NC is presented (Santos et al., 2020), in order to favor the proper implementation of the pediatric physical examination, and the satisfactory evaluation and monitoring of the child's growth and development (Gaíva et al., 2018). It is emphasized that improving technical and scientific knowledge is a fundamental aspect for determining which interventions are necessary at the time of NC (Hanzen et al., 2019).
Among the strategies directed towards the qualification of nursing clinical practice in PHC are the incentive to use clinical Nursing protocols in the different points of the health care network, the implementation of a unified registration system, the elaboration of Nursing diagnoses and care plans, and the strengthening of practice based on scientific evidence (Kahl et al., 2018).
In this perspective, the NP is presented as a possibility to qualify the NC, because it contributes to the scientificity of the work and favors systematized and the safe care (Hanzen et al., 2019;Santos et al., 2020;Rosa et al., 2020). However, as observed in this and another study (Santos et al,, 2020), the NP has not been used satisfactorily, during NCs.
It is pointed out that the inappropriate use of the NP may reflect in failures in the nurses' assistance, since it compromises the provision of evidence-based care and the resolution of health needs (Santos et al., 2020;Rosa et al., 2020;Adamy et al., 2020).
Thus, it is essential that nurses have a broad theoretical and practical knowledge of all the steps that make up the NP, and that the institution where the care is provided makes its execution possible, in order to contribute to the assertiveness of the professional's position and efficient direction of their actions (Santos et al., 2020).
For this, it is recommended that training and continuing/permanent education on the NP be carried out in order to enable the nursing team to systematize their actions, qualifying care, avoiding unnecessary burdens and offering humanized, quality and safe care, based on scientificity (Adamy et al., 2020).
By considering the aspects presented above, the NC configures itself as a health instrument capable of effectively contributing to the protection and promotion of maternal and child health (Hanzen et al., 2019;Vieira et al., 2019). However, it is necessary to overcome weaknesses, such as those presented in this study.
Among other aspects, NC should contemplate actions that encompass health promotion, prevention, treatment and recovery, employing the scientific knowledge of the profession in clinical practice (Vieira et al., 2019).
As a limitation of this research, it presents the data collection carried out with professionals from only one Brazilian municipality. However, the visibility of aspects of the work process that act as barriers in the NB's NC in PHC in the context of a capital of the Legal Amazon region is pointed out as an innovative character. Thus, the findings may contribute to qualify Nursing care in the country.

Conclusion
The components that interfere in the NB's NC, in PHC, in the context of a capital city of the Legal Amazon, are the fact that children are not found at home after being discharged from the maternity hospital; the lack of knowledge and skills for clinical assessment of the NB; and failures in the execution of all stages of the NP.
Considering the urgent need for strategies that protect infant health in Brazil, especially in the Legal Amazon, joint actions between the maternity ward and health units are essential in order to favor the planning and implementation of actions capable of ensuring, quality and timely health care to the NB and their family.
The stages of data collection and implementation occur in an incipient and unsystematic way. There were numerous weaknesses in the execution of the physical examination of the NB, especially related to lack of organization of the information collected, evaluation of anatomical structures in a disorderly manner and inadequacies and inconsistencies when employing the propaedeutic steps.
Furthermore, data collection and implementation only considered biological aspects of the binomial, showing that nurses' care is based on the biologicist model of care, and that the bio-psychosocial demands are not always considered in the work plan of these professionals.
It is concluded, that although nurses perform the consultation with the NB, it does not meet the basic assumptions of the scientific literature, especially with regard to the implementation of all stages of the NP, quality of information collected and skills for satisfactory clinical evaluation of the NB.
Permanent training of nurses working in the Family Health teams is recommended in order to qualify the assistance to RNs and their families, and to improve maternal and child health indicators in the regions of the Legal Amazon.