Intervention of occupational therapists with accompanying mothers in hospital pediatric wards¹

Abstract

Introduction

Occupational therapists have consolidated their assistance in hospital settings through their work in various sectors of these institutions with diverse populations. The pediatric ward is one of the scenarios where these professionals act, providing services to hospitalized children and adolescents, as well as to their companions: their mothers.

Objective

To present the intervention of occupational therapists with accompanying mothers in pediatric wards and these professionals’ perception of the mothers’ contribution in this context.

Method

This is a descriptive, exploratory, qualitative study. 14 occupational therapists working with accompanying mothers in pediatric wards participated in this study. The data were collected through a self-administered questionnaire containing 39 questions available via Google Forms^®, coded using the ATLAS.ti^® 8.0 software, and analyzed by Content Analysis in its thematic modality.

Results

The data showed that occupational therapists assess the difficulties and needs of accompanying mothers during the hospitalization of their children, set goals that encompass the woman or the dyad, and perceive the contributions arising from their practice. The data also pointed out the models, techniques, resources, and theoretical frameworks used by these professionals in their interventions with the accompanying mothers, as well as the places made available by these institutions for this practice.

Conclusion

Occupational therapists fully help accompanying mothers during the hospitalization of their children. The results illustrate the occupational therapy intervention process with this population, from the evaluation, intervention, to the results observed by the professionals.

Keywords:
Child Hospitalized; Hospitalization; Mothers; Women’s Health; Occupational Therapy

Resumo

Introdução

Terapeutas ocupacionais têm consolidado sua assistência nos contextos hospitalares atuando em diversos setores dessas instituições com populações diversas. A enfermaria pediátrica é um dos cenários de atuação desses profissionais, que prestam seus serviços às crianças e adolescentes hospitalizados, assim como as suas acompanhantes, as mães.

Objetivos

Apresentar a intervenção de terapeutas ocupacionais com mães acompanhantes em enfermaria pediátrica e a percepção desses profissionais sobre sua contribuição nesse contexto.

Método

Trata-se de estudo descritivo, exploratório, de abordagem qualitativa. Participaram 14 terapeutas ocupacionais que atuavam com mães acompanhantes em enfermaria pediátrica. Os dados foram coletados por meio de questionário autoaplicável contendo 39 questões disponibilizado via Google Forms^® , codificados com auxílio do software ATLAS.ti^® (versão 8) e analisados por análise de conteúdo na modalidade temática.

Resultados

Os dados apontam que as terapeutas ocupacionais avaliam as dificuldades e necessidades das mães acompanhantes durante a internação dos seus filhos, traçam objetivos que englobam a mulher ou a díade e percebem as contribuições decorrentes da sua prática. Os dados apontam ainda modelos, técnicas, recursos e referenciais teóricos utilizados pelos profissionais nas intervenções com as mães acompanhantes, além dos locais disponibilizados pelas instituições para essa prática.

Conclusão

Terapeutas ocupacionais auxiliam de forma integral as mães acompanhantes durante a internação dos seus filhos. Os resultados ilustram o processo de intervenção da terapia ocupacional com esse público, perpassando pela avaliação, intervenção e resultados observados pelos profissionais.

Palavras-chave:
Criança Hospitalizada; Hospitalização; Mães; Saúde da Mulher; Terapia Ocupacional

Introduction

Child hospitalization is considered a stressful experience for the patient and their family - the, sometimes, painful procedures performed during treatment, the uncertainty regarding their effectiveness, the prognosis of the disease and the fear of the unknown contribute to this perception. Therefore, it is necessary that the family be considered in the assistance, not restricting the focus of care to the patient (Kudo et al., 2018).

In Brazil, Law nº 8.069/1990, which establishes the Child and Adolescent Statute (ECA), guarantees the child and youth population the right to have a companion, parent or guardian full-time during hospitalization (Brasil, 1990). However, the literature points to the prevalence of mothers assuming the role of companion during pediatric hospitalization (Pyló et al., 2015).

Several factors contribute to maternal overload during the child's hospitalization: the environment, the lack of availability of other people to take turns during care, physical and mental exhaustion, full-time stay in the hospital and the desire to be at home. In addition to these, other factors are pointed out, such as inappropriate furniture for resting, negligence in self-care, concern with the clinical status of the ill child and with the other children who stayed at home (Bezerra et al., 2021). Other factors may result from the period of hospitalization of the child, such as the possibility of unemployment of the parents or guardians and the difficulty of restocking personal items for use in the hospital environment (Joaquim et al., 2017a).

Thus, the immersion of the mother in the hospital is permeated by uncertainties, difficulty in adapting to the new environment, expectations regarding the cure, experience of negative feelings (anguish, sadness) and distance from people and places that are significant to them, requiring the elaboration of a strategies that can help this population during their stay in the hospital, both by occupational therapists and by other members of the health team (Almeida et al., 2016).

It is the competence of the occupational therapist in a pediatric ward to assist the patient and their family (Kudo et al., 2018). However, there is a need for more studies that deepen the understanding about the intervention of occupational therapy in this context, considering the specific needs of mothers during the hospitalization of the child, and because the studies available in the literature addressing interventions with mothers were carried out in other hospital units, such as the Neonatal Intensive Care Unit (Joaquim et al., 2014; Silva et al., 2018; Correia et al., 2019).

The importance of clarifying and detailing the intervention of the occupational therapist with the accompanying mothers is highlighted, elucidating the objectives of the intervention, the theoretical contributions, the evaluation process and the resources used. In this sense, the objective of this article is to present the intervention of the occupational therapist with accompanying mothers in a pediatric ward and the professionals’ perception of their contribution in this context.

Method

Descriptive, exploratory study with a qualitative approach. The participants were 14 occupational therapists who work in a hospital context, included because they are part of the pediatric ward team and work with accompanying mothers. Professionals who performed strictly administrative functions or did not perform assistance in pediatric wards were excluded.

Data collection took place between August and September 2020, with the publication of the research on Facebook® through the researcher's personal page and the private group "Occupational Therapy in Hospital Contexts". Another place of dissemination was the WhatsApp® instant messaging application, selecting groups related to occupational therapy that the main researcher was a member of, as well as through individual messages to occupational therapists who worked in a pediatric ward. The invitation to participate in the research was prepared in text and folder formats that contained the following data: name of the researcher, name of the advisor, research title, objective, target audience, approximate duration of the questionnaire, information on the content of the questions and the link to access the Free and Informed Consent Form (ICF) and the instrument.

Data were collected through a self-administered online questionnaire available in the free form tool Google Forms®. The 39-question questionnaire, validated by three judges, with open (22) and closed (17) questions, sought to know the profile of the participants and their intervention with accompanying mothers. All participants who agreed to participate in the study completed the questionnaire responses, and the collection was closed using the data saturation technique, which employs the researchers' perception to interrupt the insertion of new participants, considering that the data obtained present redundancy or recurrence of content (Fontanella et al., 2008).

The authors followed the norms of Resolution nº 466/12 of the National Health Council (CNS) - National Research Ethics Committee (CONEP), which regulates research involving human beings, with approval of the Research Ethics Committee of the Federal University of São Carlos under opinion No. 26205819.8.0000.5504. The participants' identities were preserved and their answers will be presented by the letters OT (occupational therapist), plus the Arabic number corresponding to the order in which the professional answered the questionnaire (from OT01 to OT14).

Quantitative data were organized and treated by descriptive statistics using the Excel® program (2016 version). Qualitative data were analyzed using Content Analysis in thematic mode (Gomes, 2007). The treatment steps were, initially, the exhaustive and comprehensive reading of the responses to the questionnaire and, subsequently, the inductive coding of the record units with the help of the ATLAS.ti® software (version 8). The coding process was reviewed by the researcher-supervisor to ensure the rigor of the analysis (Moreira, 2018). Next, the categorization, inferences and interpretative synthesis were performed (Gomes, 2007). The analysis of qualitative data generated three thematic categories; however, this study will present the results of only one of these categories: “Intervention processes in assisting accompanying mothers”.

Results and Discussion

The data present the profile of the participating occupational therapists (Table 1). Most of these professionals are biologically female (n=13), white (n=11) and concentrated in the age group up to 39 years; the predominance of females was verified in other studies with professionals who worked in a pediatric hospital context (Estes & Pierce, 2012; Lima & Almohalha, 2011; Idemori, 2015). As for training time, the number of professionals with 12 to 19 years of training prevails (n=5), corroborating those found in the literature (Lima & Almohalha, 2011; Matos, 2020). Occupational therapists with postgraduate degrees (n=12) also prevail, specifically in the Sensu Lato modality (n=8).

Table 1
Profile of occupational therapists participating in the study.

Variables		N=14
Biological sex	Female	13
	Male	1
Age	Up to 29 years	6
	30 to 39 years	5
	40 to 49 years	3
Training time	02 to 04 years	4
	05 to 09 years	3
	12 to 19 years	5
	More than 20 years	2
Post-graduate	Yes	12
	No	2
Postgraduate modality	Sensu Lato	8
	Stricto Sensu	4
Distribution of professionals by region	Southeast	9
	Northeast	4
	North	1
Provision of service	Public	12
	Private	1
	Public-private	1
Performance in a hospital context	Less than 1 year	2
	01 to 03 years	4
	07 to 08 years	3
	11 to 19 years	4
	More than 20 years	1
Work in a pediatric ward	Up to 01 year	5
	03 to 08 years	5
	11 to 19 years	3
	More than 20 years	1
Exclusive performance in the pediatric ward	Yes	2
	No	12

The data also show that most participating occupational therapists are from the Southeast region (n=9), work in the public health service (n=12), with an indefinite contract (n=7) and a workload of 30 hours/week, corroborating with Farias and Bezerra (2016). It should be added that the time working in a pediatric ward was between 03 and 08 years, with only one professional having more than 20 years of experience. In this sense, the time of practice is a relevant factor for the development of the occupational therapist's clinical reasoning, as evidenced by the review by Britton et al. (2015). The results indicate that most participants in this study do not only provide assistance in the pediatric ward (n=12), but simultaneously provide assistance in other sectors of the hospital institution (Lima & Pereira, 2020; Silva et al., 2020).

Table 2 presents the characteristics of interventions by occupational therapists with accompanying mothers.

Table 2
Characteristics of interventions with accompanying mothers.

Access to the patient	Interconsultation request	4
	Active search for occupational therapist	13
	Clinical discussion	7
	Spontaneous search for family member	2
	Demands identified during patient care	12
Service frequency	Daily	9
	Weekly	3
	Others	3
Forms of service	Individual with the mother	9
	Mother-child dyad	14
	Group of accompanying mothers	8
	Other family members	7

Regarding the forms of access, occupational therapists have accessed patients through active search (n=13), and this behavior was found in studies carried out in Intensive Care Units (Bombarda et al., 2016; Coelho et al., 2020). The results reveal the prevalence of daily consultations (n=9), showing that occupational therapists routinely provide assistance to accompanying mothers during their children's hospitalization. In contrast, the literature shows that this assistance occurs weekly (Alves et al., 2008; Mouradian et al., 2013; Joaquim et al., 2014, 2016; John et al., 2018). The studies found mention group interventions, which may be the reason for weekly interventions.

As for the forms of care, there are more responses for mother-child care (n=14), as indicated by Perilla (2019). Occupational therapists can jointly assist the patient and the caregiver/family member and, in addition, mother-child care can strengthen the dyad (Lima & Almohalha, 2011).

The American Occupational Therapy Association (2020) defines, through the Framework of Practice: Domain and Process, that the occupational therapy intervention process encompassess assessment, intervention and results. As this is the initial stage, the assessment of accompanying mothers in the pediatric ward of the study has been carried out through listening, seeking to understand maternal needs. Occupational therapists also detect the demands during the work routine in the sector while caring for patients and in the clinical discussions of the team, as demonstrated by the following reports from the participants.

I try to treat based on the demand presented on the day [...] (OT11).

we speak informally and, during the dialogue, I raise some issues that need to be worked on. (OT13).

the demands are identified during the follow-up of the child or during team discussions [...] (OT03).

These reports show that, in addition to listening, observation is a mechanism for identifying maternal demands used by both occupational therapists and health professionals in the sector. The other professionals call the occupational therapists to care for the companions when they observe that these women have had health problems resulting from the hospitalization process. Impacts on self-care, difficulty adapting to the hospital context and emotional impairment (frequent crying, irritability and agitation) are some of the reasons for referral. Regarding emotional issues, it is observed that professionals have difficulty dealing with the companion, triggering occupational therapy.

any other situation in which the team has difficulty in dealing with the caring mothers. (OT08).

daily, when checking a very irritated mother [...] (OT07).

The literature presents several studies that exemplify the difficulty of companions in adapting to the hospital routine (Gomes et al., 2014; Pyló et al., 2015; Almeida et al., 2016; Joaquim et al., 2017a; Mendonça, 2018; Bazzan et al., 2020). In view of hospital norms and routines, it is important that occupational therapists and other health professionals are aware of the behaviors and complaints of accompanying mothers that may indicate such difficulty, seeking to provide the necessary assistance.

It is noteworthy that the experience of hospitalization by accompanying mothers can be permeated by negative feelings (Medrado & Whitaker, 2012; Almeida et al., 2016; Cardoso et al., 2019). In view of the occupational therapists' reports, it is important to emphasize that crying, sadness and other behaviors expressed by the mothers are expected emotional responses, as the child's hospitalization constitutes a phase of health impairment and life risk.

Still regarding the maternal feelings expressed during the child's hospitalization, it is problematized that the companion's role is also that of a legal guardian, with the decision to authorize health procedures being delegated to this mother, which may pose risks to the child's health. However, it is emphasized that such procedures are essential for the maintenance of life.

Occupational therapists are also called upon for demands related to the child, but which permeate maternal care, such as: guidance on stimulation of neuropsychomotor development and the prescription or guidance of assistive technology equipment. It is up to the occupational therapist, interconsultant in hospital contexts, to guide the family regarding patient care (Frizzo & Corrêa, 2018). In this direction, the participants reported:

guidance regarding the offer of stimuli in the face of acquisitions of neuropsychomotor development (OT05).

prescription and guidance regarding the use of assistive technology resources and guidance on neuropsychomotor development (OT04).

As for the evaluation with standardized protocols and instruments, the participants' reports showed that these are not commonly used in assisting accompanying mothers.

In the Occupational Therapy Service where I work, there is no specific assessment for mothers [...] (OT08).

A decade after the publication of Chaves et al. (2010), the use of specific occupational therapy instruments remains limited. Other studies show the lack of knowledge or non-use of such assessment tools by Brazilian occupational therapists (Borges et al., 2012; Matos, 2020). Despite this, the use of occupational therapy instruments “encourages the clinical and scientific recognition of the profession, in addition to enabling the production of specific knowledge in the area and the reliability of interventions” (Chaves et al., 2010, p. 245).

Regarding the objectives of interventions with accompanying mothers, occupational therapists list aspects related to the hospitalization process, such as the creation of strategies for coping with hospitalization, dialogue between companions and health professionals in the pediatric ward sector, minimization of impacts on the family's daily life due to hospitalization, social participation in the hospital, planning for the future, acceptance through listening and the re-signification of daily life in the hospital. The objectives mentioned by the participants of the present study corroborate the literature (Giardinetto et al., 2009; Lima & Almohalha, 2011; Joaquim et al., 2014; Almeida et al., 2016; Silva et al., 2020).

Based on the premise that the objectives of the interventions were achieved, occupational therapists observe contributions, some of them related to personal organization and adaptation: rescuing or maintaining the different roles that the accompanying mother plays or played, the organization of the hospital routine, the reduction of impacts caused by hospitalization, promotion of quality of life and social participation in the hospital environment. Other contributions were cited: strengthening the companion-health team relationship and the companion-occupational therapist bond. Finally, emotional improvements, such as reduced anxiety and working through feelings. Such listed contributions corroborate other studies (Giardinetto et al., 2009; Lima & Almohalha, 2011; Mendonça, 2018).

some demonstrate through subjective and/or verbal signs that after the occupational therapy sessions they feel calmer and less anxious [...] (OT02).

The objectives of the interventions also encompass aspects related to the dyad, such as strengthening the mother-child relationship, guidance and training to stimulate neuropsychomotor development, instrumentation for patient care, in addition to empowerment regarding the child's health factors, in relation to the milestones of child development and the treatment of the child. In this direction, the guidelines to stimulate the child and promote the bond between the child and the mother fit into the practices of occupational therapists who work in the context of child hospitalization (Lima & Almohalha, 2011; Berrios et al., 2019).

Contributions related to the listed objectives are also pointed out, for example, adapting to new forms of care, adherence and active participation in the child's treatment, strengthening the dyad and the elaboration of mourning for those who experience the terminality of the child. Thus, support during illness and grief, as well as incorporating the family into the treatment, corroborate the findings of other studies (Lima & Almohalha, 2011; Kudo et al., 2018). The reports indicate that the interventions contribute (in)directly with the accompanying mothers.

other mothers usually use the moment of the intervention with the baby/child to perform some activities, which could be: Activities of Daily Living (bathing, brushing teeth, self-care in general), Rest and Sleep or Leisure (getting in touch with some family member or even meeting another mother to share experiences). (OT02).

acceptance of the child’s current situation [...] (OT11).

It is emphasized that the report presented by one of the participants about the mother using the moment of the occupational therapist's care with the child to carry out self-care activities, such as bathing, brushing teeth, and also for other purposes, such as leisure and rest, show the influence of the hospital on the mother's daily life, especially those who do not have a support network capable of providing the rotation in the care of the hospitalized child.

As for the models and theoretical references that support the interventions, the Human Occupation Model and the Canadian Model of Occupational Performance were mentioned, similar to the results of other studies (Berrios et al., 2019; Perilla, 2019; Murray et al., 2020). They also list the Dynamic Occupational Therapy Method (Joaquim et al., 2017b; Perilla, 2019; Kurauchi et al., 2020) and the Client-Centered Practice approach. Other contents added to interventions are also pointed out, such as child development, aspects of pediatric hospitalization, palliative care and maternal and child health.

However, some occupational therapists do not base their interventions on occupational therapy models or approaches. This result is similar to what the study conducted by Joaquim et al. (2017b), which showed that the practice of occupational therapists in pediatric oncology did not have a model specified by some participants. Cruz (2018) assumes that Brazilian occupational therapists use terminologies derived from occupational therapy models in isolation.

I’m still thinking about what would be the best approach. (OT13).

I am not aware of specific occupational therapy framework for these approaches. (OT04).

Murray et al. (2020) pointed out some barriers encountered by occupational therapists for the use of occupation-based practice in the hospital context, among them: the predominant biomedical model, the scarcity of resources and physical environments that promote occupational engagement and the turnover of hospitalized patients. It is assumed that the implementation of practices based on occupational therapy models in the hospital environment is a challenge.

Occupational therapists address the techniques used, which permeate general aspects of humanization of care, such as welcoming and qualified listening, to aspects of promoting the companions' well-being, such as the use of massage and relaxation techniques. The review conducted by Aniceto & Bombarda (2020), about the occupational therapist's hospital practices and humanized care, demonstrated that listening and welcoming are part of the professional's actions with patients and their families; in addition, most publications are in the maternal and child area.

Handling demonstrations are techniques used by the participants with the aim of equipping mothers with childcare. In this direction, the literature points out that equipping the caregiver to care for the child and stimulate their development are among the behaviors of the occupational therapist who works in the context of pediatric hospitalization (Lima & Almohalha, 2011; Kudo et al., 2018).

About the resources used, graphic or reading materials, hygiene products, making souvenir books, games, guidance booklet on child development, electronic equipment, expressive and manual activities, handicraft materials and materials for setting the bed and the Internet were described. Similar to those found in the literature that cite craft products, graphic materials, games, making toys for the child and the construction of texts about the hospitalization experience (Dittz et al., 2006; Joaquim et al., 2014, 2017b; Correia et al., 2019).

In this direction, it is possible to verify that occupational therapists have mostly used resources acquired for the care of pediatric patients. However, considering the importance of the accompanying mother as the main caregiver in child hospitalization, as well as the guarantee of comprehensive care, the acquisition of materials for intervention with this population in the hospital context is essential.

The care facilities provided by the hospital for interventions with accompanying mothers are the toy library, the hospital classroom, the companions' room and the institution's external area. The toy library has been referred to in other studies as a place of intervention by the occupational therapist in the pediatric context (Lima & Almohalha, 2011; Nunes et al., 2013; Joaquim et al., 2017b), along with the living spaces. These places provide ambience and make the hospital space more welcoming, helping to adapt to the institutional routine (Aniceto & Bombarda, 2020).

Final Considerations

The objectives of this study were achieved and the data produced show the intervention process of occupational therapists with accompanying mothers in the pediatric ward, illustrated from the first stage of care, the evaluation, to the final process, through the contributions perceived by professionals.

The actions described, which pervade the outlined objectives, models, techniques and resources used, can guide the reasoning of other occupational therapists in assisting companions. It is emphasized that, despite dealing with occupational therapy intervention, maternal care is not restricted to a single profession, since other health professions have also contributed and may, based on this study, reflect on the importance of interprofessional work.

It is highlighted among the results that the evaluation is not carried out through the use of specific standardized instruments for mothers. Such difficulty becomes a barrier to measuring the progress of interventions. It is assumed that the hospital logic of care influences care resources for accompanying mothers. Another limitation in the assistance offered to mothers occurs due to the fact that the attention in the pediatric ward is primarily focused on the hospitalized child, considering that the resources destined for the intervention with the companions are acquired by the institution for the hospitalized patients. However, the importance of care for accompanying mothers in the child care process is reinforced, both in the hospital environment and in the continuity of care after hospital discharge.

The limitations of this study are related to the number of participants, with emphasis on a greater participation of professionals from the Southeast region, requiring the development of new research that seeks to expand the population and manage to include, in a significant number, occupational therapists from other regions of Brazil. Another limitation is the use of the online questionnaire as a collection instrument, which is supposed to have interfered with the detailing of the responses.

Future researches are needed aiming at a deeper understanding of the hospital practices, mainly in order to overcome the barriers of the context; as well as investigations that focus on the use or development of specific assessment instruments for mothers that can be applied in this circumstance of monitoring the hospitalized child. There i salso a need to develop randomized clinical trials for occupational therapy with accompanying mothers to provide evidence-based practices.

• 1
  This material is part of the dissertation presented by the main author as a requirement for obtaining a master’s degree in Occupational Therapy from the Federal University of São Carlos.
• How to cite: Souza, L. R. S., & Joaquim, R. H. V. T. (2023). Intervention of occupational therapists with accompanying mothers in hospital pediatric wards. Cadernos Brasileiros de Terapia Ocupacional, 31, e3301. https://doi.org/10.1590/2526-8910.ctoAO25243302

• Funding Source

  This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001.

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Edited by

Section editor

Profa. Dra. Marta Carvalho de Almeida

Publication Dates

• Publication in this collection
  23 Jan 2023
• Date of issue
  2023

History

• Received
  10 Apr 2022
• Reviewed
  22 Sept 2022
• Accepted
  05 Oct 2022