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Innovative model for the development of specific skills of nurses in neonatology


How to cite this article:
González-Carrillo E, González de la O G, Moriel-Corral LB. Modelo innovador para el desarrollo de competencias específicas del personal de enfermería en neonatología. Rev Enferm Inst Mex Seguro Soc. 2016;24(1):11-8.

Innovative model for the development of specific skills of nurses in neonatology

Eliazar González-Carrillo,1 Guadalupe González-de la O,1 Leticia Bernardina Moriel-Corral1

1Facultad de Enfermería y Nutriología, Universidad Autónoma de Chihuahua. Chihuahua, México

Correspondence: Guadalupe González de la O

Email: ggonzale@uach.mx

Date received: September 3rd, 2015

Date judged: October 30th, 2015

Date accepted: November 30th, 2015


Introduction: Nursing models are structures that allow give the person specific care, individualized and based on scientific evidence, development and application of them is a challenge within health institutions, because it requires a continuous process update.

Objective: To design and implement a competency model models supported by Patricia Benner and Alfonso Silíceo nurses for service in neonatology specialty hospital.

Methodology: Descriptive study in neonatology service in which strengths and weaknesses identified in the care and evidenced felt needs and 24 nurses from all shifts, on a scale of 1 to 10, the powers of environment were measured care, nursing care and care airways in the preterm infant stages of pain. The collection methods were participant observation, observation guide, questionnaire and checklist.
Results: Regarding the evaluation of the three powers environment care, nursing care and care airways in the preterm infant stages of grief, the average was 6.3 in knowledge, skills and attitudes 7.0 7.4, which makes it obvious one deficit in the domain of professionals and specific skills to deliver preterm newborn care.
Conclusions: The implementation of innovative model for specific competencies for nurses who provide care to the preterm newborn care situation is proposed.

Keywords: Pediatric Nurse Practitioners; Education; Professional competence; Neonatology


Care as an object of study of the nursing discipline means getting the experience of being in an environment directed towards the care of the individual, family, or community, considering their values, beliefs, feelings, and emotions, as well as biology. Human care begins when the nurse interacts through empathy, understanding, and living the care situation; this includes not only functions of a vertical professional-person relationship, but the ability to perceive and accept the human being in its different dimensions.1

According to the vision of Benner and Wrubel, who have described care as a primary, human experience that determines what happens between the nurse and the individual and what is important for them, the nursing discipline must be consistent with the epistemological framework and with knowledge as the main feature that is generated from the development of the very disciplinary core in response to the needs of professional practice.2

Care is an inter-subjective process of conscious commitment that harmonizes with universal love, and therefore has a high healing potential, but to provide it the nursing staff must combine the required skills during practice, skills meaning a number of capabilities that can be learned, have gradations, are evaluated in practice, have a dynamic character, are often interdisciplinary, and that constitute a synthesis between different types of theoretical, practical, contextual, and attitudinal knowledge.3

Speaking of skills, in 2007 Silíceo conceptualized them as a structured cognitive system closely linked to the goals, projects, values, hopes, and fears of each individual; skills require knowledge, ability, talent, and emotionally positive attitudes.4

This author proposes two models of skill development within organizations, and he is supported by some techniques such as neurolinguistic programming, and Milton Erikson’s method, which refers to the use of levels of logic to identify areas that people want to change, detecting representative systems with which they have perceived and built their own world of possibilities, constraints, and empowerment.

With another argument, this author defines skills as the set of competencies required for the exercise of a professional activity, such as behaviors, faculty of analysis, decision-making, and information transmission, among others, which are included for the full exercise of the occupation. He also mentions that the elements of the skills degrade in functions over the course of the process, and are comprised of the set of attributes, ranges of application, evidence of knowledge, and performance domains and criteria; all these components provide students with cognitive, procedural, and attitudinal tools to conduct themselves independently, solve problems, make decisions, communicate with technical language, use technology, and interact with heterogeneous groups.5 

Therefore, this project aims to present a model of development of specific competencies for nursing staff of the neonatology service, which cares for the preterm newborn, and also proposes how it is possible to develop nursing practice in this format after analyzing the current situation, with which the prevailing care model is formulated in the first place.

A model has been created for the development of skills in the nursing staff in secondary care health institutions, especially in the neonatology service, based on the traditional model that is currently operating and the limited intervention participants have in the construction of knowledge. 

The proposal shows a series of steps to follow in searching for an approach to the development of skills in neonatology service nursing staff, allowing them to provide specific care to preterm children based on scientific and individualized evidence, articulating objectives, methodology, a framework that supports it, defining elements, evaluation, and assessment instruments. It consists of five stages: from the statement of the problem, reviewing the state of the art, the model and the description of items, the approach to implementation, and challenges to be overcome for adoption.

The health institution where the study was conducted has the most specialties in care of children, it is of medium capacity and is always full, it provides care for enrollees, the general population, and seguro popular (public insurance). It is the only one with the infrastructure and equipment for diagnosis and treatment. The nursing department at the Hospital Infantil de Especialidades is responsible for the supply of human talent; the staff consists of 220 members including staff and contractors, with different training from technical level to professional level.
The neonatology service has 9 hospital beds and the statistics of the service were analyzed, finding 163 neonates admitted and 159 discharged in 2007, with an occupancy of 91%, with an average of 19.9 days spent, with a total of 34 deaths annually corresponding to a rate of 28.1%, prematurity being the leading cause of mortality, which is high according to the indicator of 7.7 per 1000 live births; nosocomial infections are at 3.9%, indicating that the nursing staff, as part of the health team, have a direct impact for these effects to occur, and that competent practice guarantees optimal care.

The neonatology service has five nurses per shift, with a nurse-patient ratio of 1.8 per preterm infant, a technical nurse with post-technical training in intensive care, three with degrees in pediatric nursing, five registered nurses, four nursing assistants, and nursing technicians.

There is a document in the hospital unit describing the nurse positions with the specifications of general tasks for preterm newborn care, requiring specific care with a high degree of complexity and experience.

The nursing staff working in the service belongs to categories ranging from beginner to expert; the heterogeneity in knowledge and experience makes autonomy and decision-making when providing care difficult, so the question arises about whether there is a deficit in the domain of professional and specific skills in the nursing staff, and if staff need to develop skills to provide care to the preterm child.

The need was thus identified to develop a model of skill for neonatology service nursing staff allowing them to provide care that is characterized by being comprehensive, human, specific and individualized, and based on scientific knowledge for care of the preterm newborn.


The project was conducted in the city of Chihuahua, Chihuahua, Mexico, in the neonatology service of a specialty hospital of the Instituto Chihuahuense de Salud (ICHISAL).

The first step was to explore the context to then make a descriptive and cross-sectional study. The universe consisted of 24 nurses in four shifts, with sampling for convenience, because the total of nurses was considered as the sample. Inclusion criteria were: all nurses on all shifts, and only nurses on medical leave or on vacation were excluded, which in this case were two.

Fieldwork begins with an exploratory diagnosis showing the felt and demonstrated needs of the nursing staff caring for the preterm newborn, a questionnaire was prepared on the three main elements of skill, a checklist for each one of them, an observation guide, participant observation, and a field diary. Researchers remained in the service for three days each week from February to April, rotating through the four shifts using the instruments and obtaining information to then make the corresponding analysis. These activities gave the data for the model of prevailing nursing care based on the analysis of strengths and weaknesses, giving rise to the proposed care model. 

Two questionnaires were developed to obtain information on knowledge and skills and an observation guide to record attitudes on a qualitative ordinal scale of Excellent (10), Good (8), and Fair (6). It was considered Excellent if the nurse speaks to the newborn, pets them, moves them carefully, and gently provides comfort; it was considered Good, if they talk to the infant, move them carefully, and provide comfort; and Fair if they speak while moving them and provide comfort.

The field diary recorded the number of times the nurses attended clinical sessions and training courses, if they performed teaching in service activities, or if they had a teaching program.

Microsoft Excel was used to capture data and for descriptive analysis, and the study population was characterized by the variables of sex, class, shift, and the knowledge, abilities, attitudes, and values ​​of the elements of the skill were rated from 1 to 10.

Participants voluntarily accepted collaboration and were informed through a meeting to obtain approval and support in the presence of senior management. Their integrity and confidentiality were protected with respect for ethical principles. The storage of individual and group data adheres to the ethical and legal considerations under the Ley General de Salud for research involving human beings, specifically, with no risk to participants.


Of all nursing staff, 70% are female and 30% male, 40% nurses with post-technical training in pediatrics, 20% with bachelor's degrees in nursing, 30% interns and nursing assistants, and 10% management of the service.

Assessing the care environment of the preterm infant (CEPI) the average rating was 6.3, the care of the airways of the preterm infant (CAPI) was 6.4, and the care of the preterm infant in pain phases (CPIPP) was 6.6. 70% of nurses showed good skill, 20% fair, and 10% excellent; attitudes and values ​​were good in 70% and excellent in 30%, it is shown that the knowledge base has a lower score in relation to skills (Figures 1 and 2).

Figure 1. Knowledge and ability of nurses in newborn care. CEPI = care environment of the preterm infant. CAPI = care of the airways of the preterm infant. CPIPP = care of the preterm infant in pain phases

Figure 2. Attitudes and values of neonatology service nurses. Source: Guía de observación adaptado de Ramió, Valores y actitudes profesionales.11

Model for the development of nursing skills in neonatology

The model (Figure 3) consists of two separate circles, and three blocks: the first represents the organization and service, which are the context in which nursing practice happens, the second corresponds to the nurse who is at the center as the main element and the subject of skill development. Within the box are the five levels proposed by Patricia Benner’s model, indicating the hierarchies that every nurse can acquire through solid preparation plus the experience gained in the workplace, and the third block represents care, which is where the model leads to.

Figure 3. Innovative model for developing specific skills of neonatology nurses. Source: design and construction of model based on results, participant observation, field notes, and literature review.

In the left circle is the term development with two arrows opposite each other, at the top are the core skills, which refer to attitudes and values ​​that correspond to knowing how to be, and the bottom are ancillary skills that correspond to knowledge and ability, i.e. knowledge and know-how.

The right circle contains within it the components of the situation of preterm newborn care: care chain, positioning, non-nutritive sucking, and handling; all are linked by lines that define the route, there are also two extensions of the circle, one containing the care situation with a relationship to the elements and the other containing the domains of care.

Model evaluation happens in four phases: first by estimating the development of skills, abilities, attitudes, and values ​​in service nursing staff; in a second stage, evaluating the application of the model in preterm infant care and modifying service indicators; in a third stage, evaluating nurses on the skills developed, and finally showing the application of the model in the following aspects: educational intervention, evaluating the teaching-learning process, changes in methods and techniques, and finally the degree of nurses’ empowerment from the model in objective and subjective aspects.

The values ​​in the innovative model for skill development are human dignity, truth, justice, equality, and altruism; the attitudes are humanism, honesty, integrity, tolerance, and vocation (Table I).6-11

Table I. Definition of professional values, attitudes, and conduct of neonatology nursing staff
Values Attitudes Professional conduct
Human dignity6
This is an intrinsic value of the moral person that has no equivalents, and belongs to all people by the mere fact of belonging to the human species.
Humanism Individual care
Gentle treatment
Talking affectionately
Caring for their environment
Defined as the correspondence between the spoken statement and objective data of the reality that surrounds us.
Honesty Performing care professionally, autonomously, and responsibly not requiring supervision
This value is primarily essentially human and social, because it only pertains to the actions of humans; it implies a deontic relationship, i.e. it implies "ought to be" and precisely characterizes the actions of "to be" and "ought to be".
Integrity Using resources rationally, supporting the newborn that does not have what it needs to receive care
This is an ideal to be attained, regarding the rights that humans must have to be recognized as equals regardless of age, sex, and economic, political, ideological, and religious differences.
Tolerance Providing care based on individual needs respecting origin and socio-economic status
These are benevolent social tendencies of the human being or behavior which consists of disinterested care for another person even if such action harms their own interest.
Vocation Showing commitment and initiative when providing care.

Strategies for implementing the model


  • Knowledge construction was performed by applying the educational program to develop specific and transversal skills such as nursing care under an integrative model, teamwork, educational skill, capacity for abstraction, and analysis of scientific nursing papers, and showing attitudes and values ​​during the care process with the newborn and their parents.
  • Skill development was based on the theory of constructivism.
  • The level or degree of skill was established as: low, medium, and high according to the results of the diagnostic evaluation.
  • The program was organized constructively, in order to optimize resources and obtain the maximum benefit for the nursing staff and the service.
  • Different teaching strategies were used to develop skills and achieve the teaching-learning process.
  • After finishing the educational intervention, the service was supervised permanently to assess changes in the care provided to preterm infants, using the evaluation guidelines and indicators established by health regulations.

Skills are defined as the integration of different types of cognitive, procedural, emotional, and attitudinal capacities, which have a praxiological component, structured and built by the person during their training and development, enabling professional performance and achievement of expected results.12 Regarding the skills required of the neonatology service nurse for care of newborns in critical condition, mastery of the overall implementation of specific skills in different situations that arise in the context of care is crucial, in addition to performing the nursing process and participating in teamwork, the role of partner, effective communication, clinical judgment, and clinical investigator, among others.

Patricia Benner13 reports that the qualified nurse requires a solid training base that allows them to acquire skills based on experience faster and more safely. No nursing models were found adopting this philosophical model, only some research on assessing the skills that nurses should show when providing care to the preterm newborn in critical condition, one of them by Urbina, Rivera, and Bacallao14 in which they conclude that the main trends, approaches, concepts, and classifications of labor competencies agree that the way forward is related to the exploration of knowledge, abilities, and attitudes, through the evaluation and design of educational interventions for the continuous improvement of nursing staff.

It is essential for nursing in the neonatology service to carry out their practice within a clear and explicit frame of reference to facilitate care and for their actions to impact the development of the preterm newborn in care, since the knowledge of different concepts of nursing practice is a factor of major importance to ensure solid risk-free care.15

Adopting a model that has as reference Patricia Benner’s philosophical model in the healthcare field is a difficult challenge, a slow and complex journey, and it requires will, perseverance, and determination, which not all nurses are interested or motivated to carry out, but taking it on will advance the practice, giving a different image of the nurse whose actions, methodologically performed and scientifically grounded, show a professional profile in everything the concept entails.

This model of care is applicable in any unit with similar issues, because it describes step by step how it can be developed within any institution with similar problems, and how it can be evaluated by instruments designed for the purpose; it also allows an approach to the development of competencies for neonatology service nurses because it has explicit objectives, methodology, a framework that supports it, elements, and tools for evaluating each skill.

Silíceo in 2003,4 mentions that the technique of skill development within institutions can be facilitated using structured experiences and case management, but that the most important tool is positive feedback and skill reinforcement, which happen right in the workplace, and they argue that a skilled person needs ability, talent, and an emotionally positive attitude, but it is not easy to identify in what proportion, since many people without much talent have brilliant achievements, and others with enormous talent, almost casually and unintentionally give great solutions. Therefore, skills consist of knowledge, abilities, and tested attitudes, and their inroads to productivity and quality have made skills as such occupy an important place in the development of staff working in an organization of any nature.

The profession of nursing has many challenges and questions, such as the need to improve the acts of care to identify problems resulting from professional practice, to respond to social demands, and when performing care based on a care model, strengthening disciplinary knowledge resulting in quality and developing a professional daily practice.

This project is ethically based on the fact that nurses working in neonatal intensive care need to make decisions centered on the care they provide, so they must have knowledge, abilities, attitudes, and values ​​that underpin their actions, considering parents in the process of care.16 Another aspect taken into account is the code of ethics for nurses in Mexico, which among its principles states: "justice in nursing care refers not only to the availability and use of physical and biological resources, but to the satisfaction of basic care needs in the biological, spiritual, emotional, social, and psychological realms, which translates into humane treatment".


To the master teachers who with their teachings were guides to carry out this work, to the health institution for approving the project and providing the facilities, and to the nurses who always showed willingness to develop the model of care.

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