THE PARTI CI PATI ON OF PARENTS I N THE CARE OF PREMATURE CHI LDREN I N A
NEONATAL UNI T: MEANI NGS ATTRI BUTED BY THE HEALTH TEAM
1Josefina Gallegos Mar t ínez2 Luciana Mar a Mont i Fonseca3 Car m en Gr acinda Silv an Scochi4
Martínez JG, Fonseca LMM, Scochi CGS. The participation of parents in the care of prem ature children in a neonatal unit: m eanings attributed by the health team . Rev Latino-am Enferm agem 2007 m arço-abril; 15(2): 239-46.
This qualit at iv e st udy aim s t o ident ify and analy ze t he m eanings t he healt h t eam at t r ibut es t o t he par ent s’ par t icipat ion in t he car e of pr em at ur e childr en hospit alized at a public hospit al. Dat a w er e r ecor ded and collect ed t hrough sem i- st ruct ured int erviews perform ed wit h 23 professionals. The result s show t hat parent s’ part icipat ion in t he care of t hese children is st ill in an init ial st age at t he hospit al’s neonat al unit . However, t here is int erest from t he healt h t eam t o im plem ent it because it s im port ance is recognized in im proving t he clinical st abilit y , t he gr ow t h and dev elopm ent pr ocess of pr em at ur e childr en. I n addit ion t o allow ing for m ot her - child int eract ion and affect ive bonding, it prepares t he m ot her for t he child’s discharge. The presence of t he m ot her h elps t h e n u r sin g t eam by giv in g m at er n al car e t o t h e h ospit alized ch ild. On t h e ot h er h an d, t h e par en t s’ presence int erferes in t he environm ent of t he neonat al unit . I t affect s t he work dynam ics and creat es insecurit y am on g t eam w or k er s, w h o feel su per v ised. Besides, t h er e is con cer n r egar din g h ospit al in fect ion . Th u s, in accor dance w it h ot her st udies fr om differ ent count r ies, t hese m eanings ent ail r eflect ions on t he need t o base t he prem at ure care in t erm s of collect ively building a care philosophy t hat rest ores concept s of hum an right s, cit izenship, bonding and m ot her- child at t achm ent , pediat ric psychology and also expands t he concept of t raining for a par t icipat iv e healt h educat ion.
DESCRI PTORS: infant , new bor n; infant , pr em at ur e; infant , low bir t h w eight ; fam ily; neonat al nur sing
PARTI CI PACI ÓN DE MADRES/ PADRES EN EL CUI DADO DEL NI ÑO PREMATURO EN LA
UNI DAD NEONATAL: SI GNI FI CADOS ATRI BUI DOS POR EL EQUI PO DE SALUD
El est udio t iene com o obj et iv o ident ificar y analizar los significados at r ibuidos por el equipo de salud con relación a la part icipación de la m adre/ padre en el cuidado del niño prem at uro hospit alizado en un hospit al público. Se t rat a de un est udio con enfoque cualit at ivo. Los dat os fueron recolect ados a t ravés de la ent revist a sem i- est r u ct u r ada y gr abada de 2 3 pr ofesion ales. Los r esu lt ados m ost r ar on qu e, aú n est a par t icipación es incipient e dent ro de la unidad neonat al hospit alaria, no obst ant e exist e int erés por part e del equipo de salud en im plem ent arla, reconociendo su im port ancia al favorecer en la est abilidad clínica del prem at uro y en su proceso de cr ecim ien t o y desar r ollo; per m it ien do de est a f or m a, la in t er acción m adr e- h ij o y el est ablecim ien t o del v ínculo afect iv o, así com o el ent r enam ient o m at er no par a la fut ur a alt a. Se per cibió que la m adr e ay uda al equipo de enferm ería brindado cuidados al niño y realizando cuidados propios de su función m at erna. Por ot ro lado, la pr esen cia de los padr es m odifica el am bien t e den t r o de la u n idad n eon at al, pu es in t er fier e con la dinám ica de t rabaj o, genera inseguridad en el equipo por sent irse fiscalizado, así m ism o, exist e la preocupación por in f eccion es h ospit alar ias. Est as sit u acion es en con f or m idad con ot r os est u dios en div er sos países, n os llevan a reflexionar sobre la necesidad de fundam ent ar la asist encia al prem at uro hacia la const rucción colect iva de una filosofía de cuidado que rescat e concept os con relación a los derechos hum anos, ciudadanía, vínculo y apego m adr e- hij o, psicología pediát r ica y de est a for m a, am pliar el concept o de ent r enam ient o en educación par t icipat iv a en salud.
DESCRI PTORES: r ecién nacido; pr em at ur o; r ecién nacido de baj o peso; fam ilia; enfer m er ía neonat al
PARTI CI PAÇÃO DAS MÃES/ PAI S NO CUI DADO AO FI LHO PREMATURO EM UNI DADE
NEONATAL: SI GNI FI CADOS ATRI BUÍ DOS PELA EQUI PE DE SAÚDE
Esse est udo t em com o obj et iv o ident ificar e analisar os significados at r ibuídos pela equipe de saúde acerca da part icipação da m ãe/ pais no cuidado ao filho prem at uro hospit alizado em um hospit al público. Trat a-se de um est udo com delineam ent o na abordagem qualit at iva. Os dados foram colet ados at ravés de ent revist a sem i- est rut urada e gravada de 23 profissionais. Os result ados m ost raram que est a part icipação ainda é incipient e na unidade neonat al do hospit al, m as há int eresse da equipe de saúde em im plem ent á- la, reconhecendo a sua im port ancia ao favorecer a est abilidade clínica do prem at uro e seu processo de crescim ent o e desenvolvim ent o, possibilit ar a int er ação m ãe- filho e o est abelecim ent o do v ínculo afet iv o, bem com o o t r einam ent o m at er no par a a alt a do filho. Per cebem os ainda, que a m ãe aj uda a enfer m agem nos cuidados do filho hospit alizado, ex ecut ando cuidados de m at er nagem . Por out r o lado, a pr esença dos pais m odifica o am bient e da unidade neonat al, pois int erfere com a dinâm ica do t rabalho, gera insegurança na equipe que se sent e fiscalizada e há pr eocupação com as infecções hospit alar es. Assim , esses significados em consonância com out r os est udos em diferent es paises, nos levam reflet ir na necessidade de fundam ent ar a assist ência ao prem at uro em t erm os de const r uir colet iv am ent e um a filosofía de cuidado que r ecuper e conceit os sobr e dir eit os hum anos, cidadania, vínculo e apego m ãe- filho, psicología pediát rica e am pliar o conceit o de t reinam ent o para a educação part icipat iva em saú de.
DESCRI TORES: r ecém - nascido; pr em at ur o; r ecém - nascido de baix o- peso; fam ília; enfer m agem neonat al
1
St udy ext ract ed from Doct oral Dissert at ion; 2 RN, M. Sc., Professor at Universit y of San Luis Pot osi, e- m ail: j [email protected] x; 3 RN, Doct oral St udent , e-m ail: lue-m ont [email protected]; 4 RN, Full Professor, e- m ail: [email protected]. Universit y of São Paulo at Ribeirão Pret o College of Nursing WHO Collaborat ing Cent re for Nursing Research Developm ent
I NTRODUCTI ON
T
e ch n o l o g i ca l a d v a n ce s i n n e o n a t a l ca r e hav e incr eased t he sur v iv al of y ounger and y oungerchildr en, w eighing bet w een 5 0 0 and 7 0 0 g, w ho can sur vive at t he gest at ional age of 24 w eeks( 1).
B e s i d e s p r e m a t u r e i n f a n t s ’ b i o l o g i c a l
v u ln er abilit y an d low bir t h w eigh t , t h e r isk s cau sed
by t he t herapeut ic process at neonat al int ensive care unit s, t he use of highly com plex pr ocedur es and t he
lon g h osp it alizat ion p er iod t u r n t h ese b ab ies m or e
su scept ible t o in f ect ion s an d ot h er diseases. Th ese sit uat ions incr ease t he fam ily ’s social and em ot ional
c o s t s e v e n m o r e , a s t h e y i n v o l v e g r e a t h u m a n
suffering and, t hus, t urn prem at ure birt h and low birt h weight int o a public healt h problem( 2).
Hist orically, child care has been t he m ot her ’s
r esponsibilit y. How ev er, in t he hospit alizat ion pr ocess of sick childr en, t he fam ily has been ex cluded fr om
car e, a conduct j ust ified by t he k now ledge av ailable at each m om ent in hist or y. Befor e t he Second Wor ld
War, t he m ot her w as separ at ed fr om t he pr em at ur e in f an t , as t h e m ot h er w h o u sed t o b r east f eed h er
pr em at ur e child st ar t ed t o be consider ed as a t hr eat
t o t he child’s fr agilit y and as a sour ce of infect ions. Hence, she was im peded t o m aint ain cont act and could
only see her child t hrough windows( 2). Aft er t he Second Wor ld War, t he effect s of m at er nal separat ion and/ or
privat ion on t he child’s developm ent and personalit y(
3-4)
st art ed t o be st udied, and t he t radit ional care m odel,
cent ered on t he sick baby, st art ed t o be t ransform ed int o a new m odel t hat allows for t he m ot her’s/ fam ily’s
p ar t i ci p at i o n i n car e, b ased o n n ew p h i l o so p h i es, concept s and car e m odels( 2).
However, despit e t his new m odel, advances in
l i t e r a t u r e a n d t h e d e v e l o p m e n t o f h u m a n r i g h t s legislat ion for children, in our realit y, t he sit uat ion of
prem at ure infant s has not changed a lot . Nowadays, in m ost Mexican hospit al, t he parent s’/ fam ily’s visit t o t he
n ew b or n s is st ill r est r ict ed an d con t r olled b y r ig id st andards, while t he m ot her’s part icipat ion in care for
t h e p r em at u r e b ab y is st ill lim it ed . Th e sep ar at ion bet ween t he m ot hers and fam ilies and t he prem at ure
infant s at t ended in t he hospit als of San Luis Pot osí, which is st ill present at m ost neonat al unit s, despit e knowledge
pr oving t he advant ages of t heir par t icipat ion in car e,
an d despit e t h e t r an sf or m at ion s an d in n ov at ion s in m any services in Brazil and ot her count ries, m ot ivat ed
us t o carry out a st udy about t his t hem e.
Co n si d er i n g t h a t h ea l t h p r o f essi o n a l s a r e p ot en t ial ag en t s of ch an g e in h ealt h ser v ices, t h e
realizat ion of t his st udy is j ust ified in order t o ident ify
t heir per cept ion about t he par ent s’ inser t ion in car e
for t heir child at neonat al unit s. Thus, we highlight t he
im port ance of knowledge product ion in Mexico, wit h a
view t o cont ribut ing t o t he t ransform at ion of care.
This st udy aim s t o ident ify and analy ze t he
m eanings of m ot hers’/ fat hers’ part icipat ion in care for
their prem ature hospitalized child, attributed by the health
team of a neonatal unit in San Luis Potosí, Mexico.
METHODOLOGY
We car r ied out a descr ipt ive and qualit at iv e
st u d y. Th is ap p r oach w as ch osen b ecau se it is t h e
m o st ap p r o p r i at e t o d i sco v er an d u n d er st an d t h e
m e a n i n g s o f h u m a n a ct i o n s a n d r e l a t i o n s, w h i ch
st at ist ics do not r eveal( 5).
The st udy was carried out at a neonat al unit
of a p u b lic h osp it al in t h e cit y of San Lu is Pot osí,
Mexico. This car e inst it ut ion is funded by t he feder al
and st at e governm ent s and care is paid for by client s.
I t is a r egional, secondar y car e hospit al, w it h som e
t er t iar y - lev el funct ions, and at t ends t o t he r ur al and
ur ban low - incom e and m iddle class populat ions fr om
t he cit y, fr om San Luis Pot osí St at e and fr om ot her
neighbor ing st at es. Et hical consider at ions ar e based
on ar t icle 3 of t he Mex ican Gener al Healt h Law , and
on art icle 100 of t he sam e Law wit h respect t o research
in v olv in g h u m an bein gs. Th e pr oj ect w as appr ov ed
by t he inst it ut ion’s Et hics and Resear ch Com m it t ee.
St u d y p a r t i ci p a n t s w e r e 2 3 h e a l t h t e a m
pr ofessionals, nine of w hom had a t eaching diplom a
in nursing, while one was a general nurse ( N1... N10) ;
f o u r n u r s i n g a i d s ( N A 1 . . . N A 4 ) ; o n e e m e r i t u s
n eon at olog ist , t w o ad j u n ct n eon at olog ist s an d on e
n eon at olog ist sp ecialized in ear ly n eu r ost im u lat ion
( NE1... NE4) , t wo resident pediat ricians ( RP1 and RP2)
and t wo social workers ( SW1 and SW2) , who accept ed
t o par t icipat e in t h e r ecor ded in t er v iew an d sign ed
t he infor m ed consent t er m .
Dat a w er e collect ed t hr ough sem ist r uct ur ed
i n t e r v i e w s , w h i c h c o n t a i n e d t h e i n t e r v i e w e e ’ s
id en t if icat ion d at a an d w er e g u id ed b y t h r ee op en
quest ions: Tell m e what you t hink about t he m ot her ’s
p ar t i ci p at i o n i n car e f o r h er p r em at u r e ch i l d at a
n eon at al u n it . ¿How does t h e m ot h er par t icipat e in
car e f or h er pr em at u r e ch ild at t h is n eon at al u n it ?
¿What do you suggest t o favor m at ernal part icipat ion
h osp it al, b et w een Sep t em b er 2 0 0 3 an d Sep t em b er
2 0 0 4 , dur ing t he int er v iew ees’ w or k shift , and t ook an av er age of 45 m inut es.
Th e t h eo r et i ca l r ef er en ce f r a m ew o r k w a s
co n st i t u t ed b y t h e a p p r o a ch o f p r em a t u r e ca r e t ransform at ions, hist orical landm arks for care and t he
m other’s participation in care for the prem ature infant at
t he neonat al unit . The m et hod used w as qualit at iv e,
them atic content analysis. The presence of certain them es indicat es t he m ot ivat ions, opinions, at t it udes, values,
beliefs and tendencies, that is, the reference values and
behavioral m odels present in discourse. Based on t he t hree operat ional st eps, i.e. pre- analysis, explorat ion of
t he m at er ial and t r eat m ent and int er pr et at ion of t he
obtained results, we discovered the units of m eaning that constituted this com m unication( 5).
RESULTS
All h ealt h p r of ession als con sid er t h at it is
im port ant for t he m ot her t o part icipat e in care for her prem at ure child at neonat al unit s, and som e highlight
t hat t he fat her should also par t icipat e:
... I t hink t hat yes, t hat it is very im port ant t hat t he
fat hers com e, well, t he m ot her, but I t hink t he fat her t oo... ( N4)
... t he fat hers’ part icipat ion is essent ial in t he newborn’s
evolut ion, for a long t im e we t alked about t he m ot her- child dyad,
now it ’s about t he m ot her- fat her- child t riad. ( NE1)
We apprehended t he following m eanings: The
m o t h e r ’ s/ f a t h e r ’ s p r e se n ce f a v o r s t h e p r e m a t u r e infant ’s clinical st abilit y and gr ow t h and developm ent
p r o c e s s ; Pa r t i c i p a t i o n a l l o w s f o r m o t h e r - c h i l d i n t er a ct i o n a n d a f f ect i v e b o n d i n g ; Th e m o t h er i s
t r ain ed f or t h e ch ild’s disch ar ge; Th e m ot h er h elps
t he nur se t o t ak e car e of t he hospit alized child and Th e m at er n al pr esen ce of t h e par en t s m odif ies t h e
envir onm ent at t he unit .
The m ot her s’/ fat her s’ pr esence fav or s t he pr em at ur e infant ’s clinical st abilit y and gr ow t h and developm ent
p r o cess
Healt h professionals highlight t hat t he parent s’ st i m u l u s i n car e f o r t h e p r em at u r e ch i l d l ead s t o
gr eat er w eight gain, fav or ing t he child’s gr ow t h and
con t r i b u t i n g t o t h e p r em at u r e b ab y ’s n eu r ol og i cal d ev elop m en t :
... when t he m ot her t akes care of t he baby, t he baby
grows bet t er and fast er and, so, t hat is t he first part , when t he
m ot her t akes care... t o leave t he hospit al fast er... ( NE4)
. . . y es, t her e ar e adv ant ages, som e childr en st ay
hospit alized for 3 m ont hs... t hey are m ore react ive and t heir
int ernal psychology already st art s t o open up and, at t his m om ent ,
t hey are already aware of who is beside t hem , and t hat is an
advancem ent ... bringing t he m ot her close t o t ouch him and t his
cont act is very im port ant for his neurological form at ion... ( RP2)
Fur t her m or e, it is highlight ed t hat pr ox im it y t o t h e m ot h er / f at h er of f er s p osit iv e st im u li t o t h e p r em at u r e i n f an t ’s st ab i l i t y an d cl i n i cal ev ol u t i on ,
reduces hospit alizat ion t im e and decreases t he baby’s new hospit alizat ions, t hus m inim izing car e cost s:
... and t he second reason is not t o be hospit alized again
when t hey leave, t o evolve bet t er when t hey go hom e... we have
recent dat a in which we ( observe) t hat t he t im e in hospit al is
short ened... bet ween 10 and 15% ... ( NE4)
... spending is less ( $) ... ( NA3)
Par t icipat ion allow s for m ot h er - ch ild in t er act ion an d af f ect iv e bon din g
All in t er v iew ees h igh ligh t t h e aspect of t h e relat ion bet ween t he prem at ure infant and t he parent s, especially t he m ot her. This int eract ion occurs t hrough t act ile ( t ouching and car essing) and audit iv e st im uli
( t alking and singing) . Hence, t his frequent cont act and t h e r e l a t i o n s h i p b e t w e e n m o t h e r a n d c h i l d a r e im por t ant for t he est ablishm ent of affect ive bonding:
... so as t o get t o know her child... anot her im port ant
t hing is for her t o t ouch him ... we have seen t hat t he fact of
t ouching him , of st im ulat ing him , of t alking t o him , is very useful
for t he baby’s furt her form at ion... t his st im ulus by t he m ot her is
very im port ant , t o t ouch him , t o caress him , t o t alk t o him , t o
sing t o him ... ( RP2)
... t his int eract ion bet ween t he m ot her and t he infant
because t he m ot her passes t ranquilit y, passes good vibrat ion,
caresses him , gives him , t he baby should not be separat ed from
t he m ot her, bonding wit h t he m ot her st art s t here, at t hat m om ent ,
wit h caresses... t he t wo can ent er equally at t he int ensive care
unit , fat her and m ot her who t ouch him , who caress him , even
when he is receiving vent ilat ion... ( NE3)
The t eam , m ainly t he doct ors, m ent ion som e e f f e ct s o f a n o n h a r m o n i o u s m o t h e r / f a t h e r - ch i l d r elat ion an d of b ad ly est ab lish ed b on d in g , su ch as child v iolence and em ot ional pr iv at ion:
... t he first ( problem ) is t he syndrom e of t he m ist reat ed
child, t his first consequence is as if it were an abandonm ent ,
t hey leave him and t he m ot her does not com e back; when t hey
have him ( at hom e) he is subj ect t o m ist reat m ent … The second
( problem ) is t he abandonm ent of feeding, t hat t hey don’t give
him food – poor t hing, and t he t hird ( problem ) is t he abandonm ent
of psychom ot or developm ent , t hat he does not evolve adequat ely
The m ot her is t r ained for her child’s dischar ge
Accor d in g t o t h e in t er v iew ees, t h e p ar en t s w ant t o t ak e car e of t heir child, but t hey ar e afr aid
b e ca u se o f h i s sm a l l si ze a n d t h e t e ch n o l o g i ca l appar at us inv olv ed in car e:
. . . v er y oft en , t h e fat h er s par t icipat e slow ly , an d
som et im es t hey go and see t hem ( baby) but it scares t hem
because t he baby is very sm all... t hey don’t want t o hold t he
baby’s lit t le hand, t hey don’t want t o hurt or fract ure t hem ... ( N8)
... I t hink t hat yes, it ’s a lim it ing fact or – t he t echnology
– because when t he m ot hers see t hem full of m achines, t hey
don’t want t o t ouch t hem eit her, t hey’re afraid, t hey t hink t hat
som et hing’s gonna happen t o t hem ... ( N2)
When int er act ing w it h t he healt h t eam , t he par ent s seek infor m at ion about t he child’s condit ion,
car e an d t h e p r ev ision of d isch ar g e. Th e p ar en t s’ quest ions are m ainly direct ed at t he nurses, but it is t he doct or who gives inform at ion about t he diagnosis.
... t here is not hing writ t en, only t he resident or t he
m edical head can give inform at ion, because t here were several
problem s, so it was form alized... because, in fact , saying not hing
m ore t han “ he’s st able” ; “ he’s delicat e” ; “ it ’s very serious” , not
m aking prognoses “ t hat t he baby’s very sm all” , “ t hat it depends
a lot on t he baby if he get s discharged or not ” and “ t hat it ’s very
individual for each baby” I say it like t his “ m aybe a m ont h, a
m ont h and a half, it depends on t he weight gain and, for t hem , 1g
is very im port ant ... ( N1)
… it are t hey ( nurses) who have m ost cont act wit h
t raining t he fat hers because som et im es one ( doct or) does not
give t hem anyt hing else but general inform at ion and one orient s
t hem t o t he nurse and she’s t he one who is t here m ore about t he
det ails... if you need som eone, it will bet t er be a nurse, she needs
t o be dedicat ed t o a pat ient so as t o be able t o give at t ent ion t o t he
fat her … ( NE2)
Th e ca r e p r o v i d e d b y t h e m o t h e r a t t h e neonat al unit is relat ed t o a form al or inform al t raining
p r ocess. Th e m ot h er s lear n ab ou t car e, esp ecially feeding and, depending on t he child’s clinical st at us, t hey pr ov ide som e special car e, it depends on t hem at hom e. This t raining is m ainly given by t he nurse.
… I believe t he nurse part icipat es m ore, because it are
nurses who t each t hem m ore, such as how t o breast feed t hem ,
how t o rem ove t he nipple from t he baby’s m out h, and so t hese
ladies feel m ore secure t oo … ( RP1)
… par t icipat e in feeding, because if t he infant can
already be breast feed or fed by suct ion... when changing diapers,
clear in g t h e g en it als… an d if t h e b ab y is d isch ar g ed w it h
m edicat ion, as t his will also be part of t he orient at ion she needs
t o receive, what t ype of m edicat ion she’ll t ake hom e and also t he
vaccinat ion schedule she has t o t ake, t hat would be a separat e
piece of inform at ion, ext raordinary. ( N5)
Social workers locat e t he m ot her who at t ends
t he neonat al unit and pr ov ide food, accom m odat ion and t ranspor t aid if necessar y.
... if it ’s due t o a lack of m oney, we cont act her and
reach an agreem ent , a deal ( wit h t he parent s) , we give financial
suppor t ( $) , w e suppor t her her e, w e look for donat ions for
t r anspor t t ick et s and ex plain t he fam ily m em ber not t o be
concerned, t hat we will provide support in m oney or t ransport
t icket s... ( SW1)
... t he parent s leave, and leave t he babies for 8 or even
15 days and doct or X get s annoyed: “ t hey no longer leave m e,
t hat t his lady ( m ot her) does not com e... j ust look at what happens
wit h t his lady who is abandoning t his boy” and wit h any t eam
m em ber or wit h t he social worker, who is t rying t o localize t hem
( t he parent s) t o com e, even if t wo t im es per week... ( NA5)
Th e m o t h e r h e l p s t h e n u r se t o t a k e ca r e o f t h e hospit alized child
Nu r si n g sh a r e s ca r e r e l a t e d t o t h e e a r l y
st im ulat ion and feeding of t he pr em at ur e baby w it h t he m ot her. Som e nur ses per ceiv e t his par t icipat ion
as a help t hat r educes t he w or k ov er load:
… for early st im ulat ion, t he doct or com es every day in
t he m orning, she also gives t hem exercises, so t hat t hey ( t he
parent s) also exercise t heir m out h so as t o st art st im ulat ing,
now resides t hat we ( nurses) reinforce t hem in case of any doubt
because t hey ask us anyway … how t o st im ulat e t hem , how t o
est ablish cont act , t hey st art t o t alk t o t hem , t he baby is m ore
react ive, he’s hearing t he voices, t hey m ove, t his helps him a lot ,
because even if w e ( t he nur ses) w ant ed t o t alk t o t hem , or
st im ulat e all of t hem , som et im es we don’t have enough t im e …
and t hey ( m ot hers) help us if we have a lot of work, because t hat
is also an advant age, t hey help us t o feed him … ( N6)
… som et im es t here’s a work overload for nursing and
t he fact t hat t he m ot hers help us t o give t he bot t le and knows
how t o give it , t his gives t he nurses t im e t o cont inue care … ( N8)
Th e m at er n al pr esen ce of t h e par en t s m odif ies t h e
envir onm ent at t he unit
Despit e acknowledging t he im port ance of t he
parent s’ insert ion in t he neonat al unit , t he int erviewees
also ap p oin t a d isad v an t ag e, b ecau se t h e p ar en t s’ p r esen ce m od if ies t h e en v ir on m en t . Th is asp ect is
p ar t icu lar ly m en t ion ed b y n u r sin g , st at in g t h at t h e
par en t s in t er f er e in t h e w or k dy n am ics an d do n ot focus care on t he child:
… t he only disadvant age I ’d see is t hat t he m ot her is
not prepared for it , t hat she does not receive t raining before she
t hat , inst ead of wat ching t he baby, she looks at what we are
doing, t he m achines, and she observes ot her t hings … ( N5)
... t here is a problem , t hat t hey ( parent s) w ant t o
int erfere out side visit ing hours, t hat is t he problem we face in
neonat ology, for exam ple, we arrive aft er 6 or before 4, which is
t he t im e when we are only t aking care of t he children, feed t hem ,
deliver care, so t hat at 4: 30 pm t he parent s are t here, and t hat is
t he problem , t hat t hey want t o int erfere at any t im e... som e
babies are really delicat e and we cannot t ake care of t hem because
t he parent s are t here and do not let us deliver proper care... ( NA2)
Th is sit u at ion cr eat es in secu r it y ab ou t t h e
r ealizat ion of t he pr ocedur es in fr ont of t he par ent s
a n d e v e n f e a r o f p o s s i b l e q u e s t i o n i n g s o r denouncem ent s by t he client s:
... and, in som e situations, the m other m ay not like what
she (the nurse) is doing with another or even with her own baby, and
that’s when denouncem ents com e up (to the governm ent or hum an
rights); she is entitled to, but it is a lim iting factor for us to perform
as we constantly do at the service... (N8 )
The par ent s’ educat ion lev el also affect s t he
r el at i o n w i t h t h e n u r se, w h o f eel s i n t i m i d at ed b y q u e s t i o n s a b o u t t h e b a b y w h e n a s k e d b y m o r e
pr epar ed per son s, w h o m ay ev en be im peded fr om ent ering t he neonat al unit . Ot her difficult ies relat e t o
com m u n icat ion w it h less edu cat ed par en t s, w h o do
not under st and t he or ient at ions t hey r eceiv e:
... t he m ot hers ask lit t le, it are bet t er prepared people
who ask m ore, once a m an asked m e about t he Apgar, so I said t o
m yself, “ oh m an, why does he com e here and t alks t o m e about
t he Apgar” and, well, he was a t eacher. And I t hink t hat , when
prepared people com e, we st op, including m e, and som et im es we
don’t even let t hem pass because we decide “ no, t hat one asks t oo
m any quest ions.” Som e t im e ago, a m an asked about oxygen
sat urat ion, t hat is, can you im agine! And m y colleagues did not
let him ent er because he asked quest ions, but t he m aj orit y does
not ask and, if t hey ask, t he quest ion is ¿have you given a bat h
already? or ¿have you changed t he diaper already?... ( NA1)
... it ’s harder wit h people com ing from t he rural zone,
t hey don’t underst and what we are saying... ( NA2)
Special at t ent ion is giv en t o t he t eam ’s lack of preparat ion t o deal wit h t he m ot her and t he fam ily
at t he unit , as t he professionals’ t raining in general is
f o c u s e d o n p h y s i o p a t h o l o g y. H e n c e , s o m e
int erviewees m ent ion t he need for recycling, alt hough
t he courses m inist ered in- service do not allow for wide
par t icipat ion by t he t eam :
... we use her ( early st im ulat ion doct or) for support
because she’s t he m ost involved, she has t aken courses, she’s
prepared, we ( resident s) have alm ost no preparat ion, not in t his
specific area, only what we see, t he focus is m uch m ore direct ed
at t he physiopat hological aspect and early st im ulat ion... ( RP1)
... one ( nurse) is not accust om ed t o chat wit h anyone,
one creat es a rout ine, from hom e t o work and pure rout ine. I t ’s
really difficult here ( in- service t raining) , everyone adapt s t hings
t o his schedule, for exam ple t hose from t he m orning shift t ake
courses, because yes, t hey t ake t hem ( courses) , in fact I don’t
even com e, because t hey give t he courses in t heir schedule…
t here’s a lot of t raining m issing for us at night ... ( NA4)
Som e pr ofessionals ar e st ill concer ned about in f ect ion s gen er at ed by allow in g v isit or s’ en t r y in t o
t h e n eon at al u n it . On t h e ot h er h an d , t h is r u le is r e f u t e d b y a d o ct o r w h o d e m o n st r a t e s u p d a t e d
k now ledge about t his pr oblem :
… when I st art ed t o work in neo ( neonat al unit ) , we
were prohibit ed t o let t he parent s ent er, only we ( nurses) and t he
doct ors were t here and t here was less infect ion ... t hat is, t hey
saw t he babies t hrough t he window... because, as t hese people
do not live near, t hey com e from far, t hey’re st aying at t he host el,
in t he st reet ... so it ’s im port ant t hat , t he m ot her com es in, she
washes her hands, but it ’s not t he sam e t hing...t he neonat al unit
is a delicat e room because of t he kind of pat ient ! ( em phat ically) ;
so I t ell t hem , wash your hands very well, put on t he gown and
get in, I leave and I m ake sure t hat t hey wash t hem selves well,
but t he ot her day t he m ot her sees m e and says “ here’s t hat
annoying one, I ’d bet t er not get in” ( int o t he neonat al unit ) …( NA1)
... t hat was quest ioned at first , everybody said t hat ,
when t he parent s ent ered, infect ions would increase and t hat
scared us, and t hat is what happened, not hing happens…of course,
according t o t he rules, when t he m ot her or t he fat her has an
infect ion, t heoret ically t hey can’t ( ent er) , but if t hey wash t heir
hands, use t he gown – in t he USA t hey no longer use gowns- but
we do use t he gown, when he ( t he baby) is ill, because som et hing
( prot ect ive) t o t he m ot her and not hing happens... and all serious
infect ion peaks t hat occur, t hey’re not because of t he parent s,
t hey’re due t o ot her t hings... ( NE4)
DI SCUSSI ON
All in t er v iew ees in d icat e t h e im p or t an ce of
t he m ot hers’ and fat hers’ part icipat ion in care for t he prem at ure baby at neonat al unit s, in line wit h previous
st udies( 6- 7) and r ecom m endat ions for it s im plant at ion at n eon at al u n it s, st ar t in g fr om in t en siv e car e u n t il
dischar ge fr om hospit al( 8- 9).
Th e b en ef i t s o f t h e m o t h er s’ an d f at h er s’
par t icipat ion ar e w idely ack now ledged, including t he
child’s w eight gain, decr eased hospit alizat ion t im e( 6), affect ing t he baby’s behavioral and cognit ive conduct s
and t he m odeling of brain archit ect ure( 7) and beneficial i n t h e t r e a t m e n t a n d r e c o v e r y o f h o s p i t a l i z e d
dem onst r at ed t hese clinical effect s, such as r educed
vent ilat ion dependence, im proved weight gain, earlier s t a r t o f n o n n u t r i t i v e s u c k l i n g , s e l f - r e g u l a t i o n ,
n e u r o b e h a v i o r a l i m p r o v e m e n t , d e c r e a s e d
hospit alizat ion t im e and low er car e cost s( 9).
I n g e n e r a l , r e s e a r c h a b o u t t h e f a m i l y ’ s
insert ion in care for t he hospit alized child has focused
on m at er nal par t icipat ion. This is under st andable as,
h i s t o r i c a l l y, w o m e n h a v e a s s u m e d t h e r o l e a s r esponsible for fam ily car e.
A st u d y a b o u t p a t e r n a l e x p e r i e n ce s a t a
pediat r ic int ensiv e car e unit appr ehended t hat , w hen p ar t icip at in g in car e f or h osp it alized ch ild r en w it h
c o n g e n i t a l h e a r t d i s e a s e s , t h e f a t h e r l i v e d t h i s
ex per ience and per ceiv ed him self as decision m aker, as support t o his wife and child, and t ried t o conciliat e
t h i s ex p er i en ce w i t h h i s d ai l y w o r k r eal i t y. Th ese
m ean in g s r ef lect ed t h e m an ’s r ole in societ y as in possession of pow er and r esponsible for t he fam ily ’s
m ain t en an ce( 1 1 ).
Tr an sf o r m at i o n s i n so ci al g en d er r el at i o n s
have been evidenced. Nowadays, we know t hat fat hers can adopt m at er nal behav ior s, due t o t heir capacit y
t o r egr essiv ely ident ify w it h t he baby( 4).
Nur ses do not fill up t he space nex t t o t he ch ild an d f at h er s ar e en t it led t o be pr esen t du r in g
t heir child’s hospit alizat ion( 11).
I n child care, t he fam ily- cent ered care m odel
has been em phasized. I t involves a set of philosophies, pr inciples and pr act ices, w hich put t he fam ily at t he
ce n t e r o f ca r e , u n d e r st a n d i n g i t a s t h e p r i m a r y st rengt h and support resource, which is im port ant for
decision m aking in child car e( 12).
Healt h pr ofession als sh ou ld offer con sist en t
support and care qualit y st andards, based on respect ,
r esponsibilit y and t he fam ily ’s needs( 9).
Wit h respect t o t he m eanings t he int erviewees
at t ribut ed t o t he m ot hers’/ fat hers’ part icipat ion at t he neonat al unit as favor ing t he infant ’s clinical st abilit y
an d g r ow t h an d d ev elop m en t p r ocess, w e ob ser v e t hat t hey ar e in accor dance w it h t hose at t r ibut ed by
nurses involved in care for t he hospit alized child, who have been int er view ed in som e ot her st udies( 6, 10).
A q u a n t i t a t i v e s t u d y o f n u r s e s a t s o m e hospit als and m at ernit ies in São Paulo Cit y found t hat
a l l i n t e r v i e w e e s r e p o r t e d t h a t i t i s i m p o r t a n t f o r
m ot her s t o par t icipat e in car e for pr et er m new bor ns, in dicat ing t hat t h ey pr ov ide t he fir st st im u li for t he
childr en’s beneficial and fast ev olut ion. The childr en present great er weight gain and recover fast er, which
s u p p o r t s t h e i r p h y s i c a l , m e n t a l a n d a f f e c t i v e
d ev el o p m en t . Th e sep a r a t i o n o f t h e m o t h er - ch i l d binom ial w as m ent ioned as a fact or t hat affect s t he ch i l d ’ s p h y si ca l a n d m e n t a l g r o w t h . Th e n u r se s m ent ioned w eight gain and t he possible r educt ion of
hospit alizat ion t im e as adv ant ages( 6) .
This aspect is also obser v ed in a qualit at iv e st u d y t h at an aly zed t h e m ean in g of ex t en d in g t h e m ot hers’ part icipat ion in care at a pediat ric room
ing-i n u n ing-i t o f a p u b l ing-i c h o sp ing-i t a l ing-i n Ca sca v e l , Pa r a n á , accor ding t o nur sing pr ofessionals. The int er v iew ees e m p h a s i z e d t h a t t h i s p a r t i c i p a t i o n o f f e r s g r e a t benefit s, including t he child’s fast er r ecov er y( 10).
Wit h respect t o t he m eaning at t ribut ed t o t he m ot her s’/ fat her s’ par t icipat ion as fav or ing int er act ion and t he est ablishm ent of m ot her- child bonding, st udies an d t h eor ies su st ain t h e im por t an ce of t h e m ot h er
and fat her relat ing wit h t he child, wit h a view t o t he d e v e l o p m e n t o f a h e a l t h y p e r s o n a l i t y a n d t h e f or m at ion of a solid b ase f or m ot h er - ch ild b on d in g and at t achm ent( 3).
Th e im p or t an ce of m ot h er - ch ild in t er act ion has been highlight ed in order t o prevent t he dam age cau sed b y ear ly sep ar at ion , w h ich can b e m or e or l e s s s e v e r e , r a n g i n g f r o m t h e m i s t r e a t e d c h i l d
sy ndr om e t o abandonm ent , and due t o it s r elev ance for t he est ablishm ent of bonding and at t achm ent( 3,9,13). Warm t h, int im acy and a const ant relat ion wit h t h e m o t h er o r an o t h er p er so n r ep l aci n g h er o n a
p er m an en t b asi s ar e co n si d er ed essen t i al f o r t h e newborn’s and young child’s m ent al healt h. This care av oids t he m at er nal pr iv at ion pr ocess( 3).
We believe t hat t he care t he m ot her gives t o her child and t he fat her s’ v isit s t o t he neonat al unit
correspond t o t he bond t he parent s want t o est ablish wit h t heir child, t hrough t heir proxim it y, t hus t rying t o t r a n sm i t t h e i r l o v e t o t h e i r b a b y. I n t h i s se n se , according t o t he m ot hers, when t hey are present , t heir ch ildr en f eel m or e pr ot ect ed, secu r e, con f iden t an d car ed for( 10).
The fam ily should be pr esent at all neonat al unit s, part icularly t hose at t ending a high- risk client ele, considering t he increasing survival of m ore im m at ure
babies who require long hospit alizat ion periods. I n t his sense, it is highlight ed t hat fam ily- cent ered care rest s
D u r i n g h e r p a r t i c i p a t i o n i n c a r e f o r t h e
prem at ure child, t he m ot her is t rained at t he neonat al unit . Thus, she receives inform at ion and advice about
hygiene and feeding care. Specialist s and researchers
have discussed t he relevance of t he advice t he m ot hers/ fat her s r eceiv e dur ing t he pr em at ur e child’s st ay at
t h e n eon at al u n it , pr esen t in g r ecom m en dat ion s an d
guidelines for it s syst em at ic developm ent( 6,9- 10,12- 13).
I n t h is st u dy, n u r ses ar e m en t ion ed as k ey pr ofessionals in t r aining t he par ent s. The m ot her is
t r ained and deliv er s m at er nal car e t o her pr em at ur e
ch i l d , e sp e ci a l l y t h o se r e l a t e d t o f e e d i n g , a t t h e m ot her ’s br east or t hr ough a for m ula.
Ho w e v e r, t h i s t r a i n i n g a n d i n f o r m a t i o n i s
c r e a t e d f r o m t h e p r o f e s s i o n a l s ’ p o s i t i o n i n t h e t ech n ical an d social d iv ision of w or k . Hen ce, w h en
t he doct or inform s t he m ot her/ parent s about t he child’s
c o n d i t i o n , t h e d i a g n o s i s , t r e a t m e n t a n d c l i n i c a l ev olut ion, t his is because t hey hav e t ak en cont r ol of
t he work process at t he neonat al unit as a whole. I n n u r si n g w o r k , t h e n u r se co o r d i n a t es, g u i d es a n d
supervises t he nursing st aff and ot her em ployees, as w ell as t he or ganizat ion of t he envir onm ent( 14).
I n t h e con t ex t of t h e t ech n ical an d social
d i v i si o n o f w o r k , t h e p a r en t s p l a y a p a ssi v e r o l e t o w a r d s t h e p r o f e ssi o n a l s a n d t h e y m a y n o t b e
experiencing t heir part icipat ion as a right( 15), but as a set of act ions im posed by healt h pr ofessionals.
We believe t hat Mexican neonat al services are gradually acknowledging t he im port ance of t his t raining
wit h a view t o t he cont inuat ion of care at t he baby’s
hom e. However, at t he neonat al unit under st udy, t he m ot hers/ fat hers receive generic advice, depending on
t he baby’s disease, oft en at t he m om ent of discharge. The planning of discharge should include t he
par ent s’ educat ion, w ho can be inv olv ed as soon as t h e baby is adm it t ed, st ar t in g t h eir par t icipat ion in
car e f or t h e ch ild at t h e n eon at al u n it . On e of t h e posit iv e effect s t his ent ails is t he acquisit ion of sk ills
t o cont inue care at hom e( 13).
Reflecting about this new paradigm and in line
with current recom m endations, we believe that prem ature
infants, when they leave the neonatal unit, are still in risk sit uat ions. These children face great er risk of dying or
sequelae and, aft er discharge, m ay need som e special care which the parents have to learn.
The way t his part icipat ion has been occurring, i . e. w i t h ou t t h e m ot h er ’s p ar t i ci p at i on i n d eci si on
m ak in g, does n ot con t r ibu t e t o t h e con st r u ct ion of sh ar ed car e am on g m ot h er s an d n u r ses, d ist an ces
t h em an d st r en gt h en s t h e ex ecu t ion of f r agm en t ed
care, divided in part s, according t o t he value at t ribut ed
t o each car e act , as t he m ot her par t icipat es in m or e dom est ic car e, w h ich ar e less v alu ed becau se t h ey
pose less int ellect ual r equir em ent s( 10).
I n t h is r elat ion w it h t h e h ealt h t eam , t h e m ot h er s can eit h er h elp or in t er f er e, depen din g on
t heir at t it ude t owards t hese sit uat ions. Alt hough t hey
a r e co n si d e r e d a s co l l a b o r a t i v e a g e n t s i n w o r k ,
depending on t he m om ent s and r out ine act iv it ies at t h e ser v ice, t h e p ar en t s’ p r esen ce at t h e n eon at al
u n i t m o d i f i e s t h e e n v i r o n m e n t a n d , i n c e r t a i n
si t u a t i o n s, t h e i n t e r v i e w e e s e x p r e sse d t h a t t h e y i n t e r f e r e i n t h e d y n a m i cs o f w o r k , m a i n l y w h e n
procedures such as m edicat ion, clinical t est s and ot her
m or e com plex t r eat m ent pr ocedur es ar e car r ied out . Accor d in g t o t h e n u r ses, t h e m ot h er s sh ou ld h elp
w i t h o u t b e i n g i n v a s i v e( 1 0 ). Th i s m e a n s t h a t t h e
m o t h e r s/ f a t h e r s ca n r e m a i n a t t h e u n i t w i t h o u t b r ea k i n g ser v i ce r u l es, w i t h t h e t ea m , esp eci a l l y
n u r si n g p r o f e ssi o n a l s, e st a b l i sh i n g t i m e s f o r t h e par ent s’ access t o t he neonat al unit .
Th is r ev eals a d u alit y in t h e in t er v iew ees’ percept ion. They consider it is relevant for t he parent s
t o part icipat e, but t he nurse can be one of t he m ain barriers against t his perm anence, because t he nurses
r eliev e t h at t h e par en t s ar e a sou r ce of st r ess an d u s e t h e i r v a l u a b l e t i m e( 8 ); h e n c e , t h e p a r e n t s
collabor at e but som et im es also int er fer e in w or k .
The nurse’s concerns about infect ions caused by the parents’ and relatives’ entry into the neonatal unit
l ack a m o r e el ab o r at e sci en t i f i c f o u n d at i o n . Th e transform ations in care for the prem ature infant brought
about by the incorporation of psychological questions into car e pr act ice hav e lead t o t he par ent s’ m or e act iv e
insertion in care for their child, including care at intensive car e unit s( 2). Ot her fam ily m em ber s, w ho used t o be
im peded fr om get t ing int o neonat al unit s, st ar t ed t o relat ed wit h t he infant during his long hospit alizat ion,
whenever necessary and individually planned. Results of
m icrobiological and epidem iological research evidence that this practice has not caused any increase in hospital
infections. Hence, the foundations of infection prophylaxis have been reviewed, and the focus of restrictive isolation
m easures m oved to the use of discardable m aterials and procedures to disinfect equipm ent and caregivers’ hands.
FI NAL CONSI DERATI ONS
Th e m o t h er s’ / f at h er s’ p ar t i ci p at i o n at t h e
i n t e r e st e d i n i m p l e m e n t i n g i t , a ck n o w l e d g i n g i t s
im por t ance because it fav or s t he pr em at ur e infant ’s clinical st abilit y and growt h and developm ent process
and also allow s for m ot her - child int er act ion and t he est ablishm ent of affect ive bonding, as well as m at ernal
t r aining for t he child’s dischar ge.
I n par t icipat ing, t he m ot her helps nur sing in
car e f or t h e h osp it alized ch ild , p r ov id in g m at er n al ca r e . On t h e o t h e r h a n d , t h e p a r e n t s’ p r e se n ce
m odifies t he env ir onm ent at t he neonat al unit , as it i n t e r f e r e s i n t h e d y n a m i cs o f w o r k a n d cr e a t e s
in secu r it y in t h e t eam , w h ich f eels con t r olled an d
concer ned about hospit al infect ions.
Anot her advancem ent in care at t he neonat al
unit we st udied in Mexico refers t o t he fact t hat som e p r of ession als also in d icat ed t h e im p or t an ce of t h e
fat her’s insert ion in care for t he prem at ure child. This m akes us t hink of changes in t he m ot her’s role as t he
only caregiver for t he fam ily’s healt h, and t hat t hese t r an sfor m at ion s der iv e fr om t h e n ew car e dem an ds
posed by t he or ganizat ion of cur r ent fam ily syst em s, in com binat ion w it h changes in t he social cont ext .
Therefore, t here is an urgent need t o im plant
per m an en t edu cat ion of t h e n eon at al t eam , bey on d educat ional t echniques, also including cont ent s about
c a r e f o c u s e d o n d e v e l o p m e n t ; a t t a c h m e n t a n d affect iv e bonding bet w een m ot her, child and fam ily ;
int erpersonal relat ion, client welcom ing, am ong ot hers, wit h a view t o im proving t he m ot her’s and t he fam ily’s
t raining for care delivery at hom e. Moreover, t here is a need for a broader underst anding of t he preparat ion
for t he baby’s discharge, wit h a view t o following t he b a b i e s ’ g r o w t h , t h e i r a d e q u a t e a n d h e a l t h y
d ev elop m en t an d a p ar t icip at or y h ealt h ed u cat ion
p r o cess.
Hence, w e need t o t hink of t r ansfor m at ions,
h o w e v e r, s t a r t i n g f r o m t h e p r o f e s s i o n a l s ’ o w n reflect ions, t rying t o look at t he realit y of t he subj ect s
w ho ar e ex per iencing t hese sit uat ions – t he par ent s of t he baby hospit alized at t he neonat al unit , who also
hav e som et hing t o say. The fam ily ’s par t icipat ion in car e for t he pr em at ur e baby has t o be inser t ed int o
t he inst it ut ional philosophy, a gap appoint ed b y t he
in t er v iew ees.
Recebido em : 25.8.2005 Aprovado em : 25.9.2006
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