Bond between nurses and mothers of children younger than two years : perception of nurses

To promote child health during nursing consultations, it is essential that nurses establish bonds with mothers to guide them in childcare. The present study attempted to identify a possible bond during nursing consultations between the nurses who work in the Family Health Strategy and the mothers of children who are younger than two years old. This qualitative study was conducted in seven Family Health Units in the city of João Pessoa, in the state of Paraíba (PB), Brazil, between May and November 2013, through semi-structured interviews with nurses. The thematic analysis allowed the identification of relevant themes, namely, (1) the elements that create bonds and (2) the difficulties in the establishment of a bond. The nurses realize that in primary care, relationships are based on intersubjectivity. By acting within the concept of individual care, the nurses provide individualized and humanized care and believe that bonds are essential for comprehensive care. However, the nurses have difficulties in establishing bonds, and they attribute these difficulties to the high demand for care and the difficulty in giving continuity to the mothers’ presence in the health care unit.


Introduction
The first months of life are some of the most important for child health because vital processes that relate to growth and development occur during this period.Therefore, a child's health will depend on careful monitoring to prevent or mitigate possible impairments to his or her health 1 .
The role of nurses in the monitoring of child health is critical, particularly in primary health care (PHC) services, to promote adequate monitoring of child development and consequently, to improve the quality of life of children.The actions that are performed at this level of childcare are essential as prevention and intervention strategies and may help in the early detection of potential injuries and reduce the risk of child morbidity and mortality 1 .
PHC provides the most favorable conditions to monitor child growth and development because it allows the discovery of new needs and problems, is focused on the individual, and helps to coordinate and integrate the care that is provided at other levels of health care 2 .
The Family Health Strategy (FHS), which is the model that has been adopted in Brazilian PHC, proposes to renew health care considering the principles of universality, comprehensiveness, equity, participation, and continuity in a context of decentralization and social control.This strategy attempts to prevent disease and promote health through humanized care; the FHS involves bonding, acceptance, and accountability and is focused on the specific needs of families from a specific region 3 .
To be an effective model for the provision of quality health care, the FHS must be committed to the establishment of bonds with populations that have different care needs and the promotion of the continuity of care and the outreach of its benefits 4 .The concept of bonding is polysemic and integrated with the concepts of humanization, accountability, and comprehensiveness 5 .The National Policy on Primary Care encourages the bonding between the PHC teams and the affected populations as a principle of this level of health care 6 .Therefore, bonding can be understood as an interpersonal relationship that is established over time between health care users and health professionals and is characterized by trust, responsibility, and a sharing of commitments.
In this respect, the population must feel confident and secure regarding health professionals' work because the opposite can cause suffering or even depression.Therefore, because of the unique closeness with families during the process of care, nurses play an important role in the acknowledgment of these feelings and the effective development of bonds 7 .
In a basic health care unit, especially in the Family Health Unit (FHU), nurses are responsible for several tasks, including consultations with children who are younger than two years old, which is also known as childcare, and these professionals guide mothers on various strategies that promote child health.These consultations allow nurses who work in the FHS to strengthen their bonds with families.The interaction that is established between a professional and a family is crucial to stimulate mutual trust to progressively strengthen this bond, which allows families and communities to gain more respect for these professionals.The establishment of these bonds originates from the interactions among nurses, families, and communities and is considered essential for nursing consultations to be successful and positively affect childcare in these communities 8 .
A previous study 9 that was performed in a municipality in the state of Paraíba reported the community's lack of bonds with and acceptance of nurses and the need to develop these qualities to promote child health.The rationale of daily nursing practice in consultations was much more focused on treating disease and addressing complaints.The same study indicated that some nurses met the high demand for childcare, whereas others did not, although several children under the age of two were enrolled in the FHU.This result indicates that families select professionals who develop strong bonds with them.
Therefore, understanding the existence of a bond between nurses and the mothers of children under the age of two and how this bond affects the search of mothers for child monitoring during nursing consultations is essential.
The present study attempted to identify the presence of bond in nursing consultations between the nurses who work in the FHS and the mothers of children under the age of two in a specific district in the city of João Pessoa in the state of Paraíba (PB), Brazil.

Methods
This qualitative descriptive study was developed between May and November of 2013 in seven FHUs that belong to Sanitary District No. 3 in João Pessoa, PB, by using semi-structured interviews.These interviews were recorded and fully transcribed for further analysis.
Seven nurses who attended children under the age of two who were registered in these units participated in this study.The inclusion criteria were being a nurse, caring for children who were registered in the coverage area of the FHUs, and having worked in a FHU for a minimum of six months.The exclusion criterion was nurses who were on vacation or not licensed in the period of the field research.Data collection was completed according to the criteria of sufficiency, i.e., when the assessment of the empirical material allowed the establishment of a comprehensive evaluation of the study object.
The data were analyzed by content analysis in the transversal thematic modality, as described by Bardin 10 .This approach involved the use of a set of communication analysis techniques to obtain, through systematic and objective procedures for the description of message contents, indicators that allowed the inference of knowledge regarding the conditions of production and the reception of these messages.
For data analysis, the discussions were shortened, and the frequency of the themes was extracted from the interviews for the identification of the main units of meaning, whose presence gives meaning to the proposed goal 11 .Two thematic groups were identified, namely, (1) the elements that create bonds and (2) the difficulties in the establishment of bonds.
This study met the guidelines of Resolution No. 466/12 12 and was approved by the Research Ethics Committee under the Presentation Certificate for the Assessment of Ethics (Certificado de Apresentação para Apreciação Ética -CAAE).All participants signed an informed consent form.To ensure anonymity, the interviews were identified with the letters "N", in reference to the nurses, followed by the number according to the sequence of their documentation.

Results and discussion
The seven participating female nurses were between 35 and 57 years old.Only one nurse worked for 5 years at the FHS, whereas the other participants worked there for more than 10 years.The period of employment in the surveyed FHUs ranged between 8 months and 12 years.Becau-se the sample was composed of women, we will simply refer to them as nurses.
These nurses emphasized that bonding is critical to the performance of child consultations in PHC.Through trust and respect as elements of bonding, these professionals attempt to develop closer ties with the family through efficient and effective interactions.
A bond is a relationship that you have with mothers and involves trust and respect (N4).
In bonding, the respect from both sides is essential to develop a better relationship with mothers, and children are the most benefited (N4).
A bond is a relation of trust between the professional and the user (N6).
A bond involves not only the need for the professional to address the complaints of users but the creation of a relation of friendship, especially trust, which will be the basis of the entire relationship (N7).
A bond is strengthened by encouraging the relationship between the nurse and the family, and the family will gain confidence and respect if a professional is competent.The interviewees reported that a relationship that is based on sympathy and generosity is essential for nursing consultations to be successful and to positively affect the quality of care.

This relationship even involves confidentiality [...]. I feel the mothers trust me in caring for their children; they think I'm competent (N1).
The key point of the bond is trust, and the professional is able to provide care according to the needs of the users (N7).
Studies have shown that strengthening the bond between the nurse and the family promotes harmony, an exchange of affection, and interactions, which can help develop autonomy and improve the relationship between health care users and health professionals 5 .

Elements that Create Bonds
The establishment of bonds involves continuity, the uniqueness of care, the provision of care on an individual basis, reciprocity between the family and the professionals, and problem solving.
The period of interaction and care for the users of the FHS allows long-term monitoring that extends to different stages of life and favors the establishment of bonds.Bonding allows professionals to focus their actions on the actual needs of individuals, and these needs are acknowle-dged in everyday life and at work.For example, it was evident that the mothers who were monitored by nurses in the prenatal period had a greater affinity with them.
I think I have a good relationship with mothers because most who come to childcare have been monitored by me since the prenatal period (N1).
Most mothers have been assisted since the prenatal period, and monitoring is very effective after childbirth (N3).
This bond that we establish starts in prenatal care (N6).
The positive aspects of long-term monitoring are supported by the studies involving nurses of the FHS of Londrina in the state of Paraná.The authors emphasize that these professionals consider that child monitoring that begins in the prenatal period facilitates the establishment of bonds between nurses and mothers, provides open dialogue, which contributes to the adherence of mothers to the nursing guidelines, and ensures the continuity of care after childbirth 13 .
Similarly, a study conducted in Spain reported the opinion of primiparous mothers concerning prenatal care.The nursing profession is considered essential because nurses provide the solution to most of the problems and doubts that mothers experience, offer greater security and peace of mind to families, and help them to cope with their psychological and emotional needs through qualified and individualized listening 14 .
Nursing consultations promote the formation of bonds between nurses and children and the family through interactions with the family and community and through the actions and strategies that the professionals develop.A feeling of empathy should be cultivated from pregnancy, as well as at home during the first week of the child's life and during subsequent childcare visits 8 .One study 15 has shown that the development of a good relationship with families through successive consultations facilitates the continued support to promote child health and development.
One of the most important aspects of bond formation is to provide individualized and humanized care.
We nurses have this distinguished perspective, at least I try to have, by providing care to the mother and her children on an individual basis, respecting their condition and reality.And I suggest to her the best care in the context in which she lives.This is essential to maintain a good relationship with the mothers.The act of care depends on us and is a pure bond (N1).
Another study that was conducted in the UK assessed the relationship between midwives and mothers during prenatal care, labor, and birth, with a focus on the mother's care.This study emphasized the importance of professionals to develop bonds, respect, and the trust of mothers in the professionals and their childcare skills 16 .
For the formation of bonds, these authors emphasized the importance of valuing mothers as the primary caregivers of children and the bond between nurses and infants.The reciprocity between the health professional and health care users generates trust and mutual respect and is a significant factor in reducing health problems after birth.This factor is indicated by national and international studies.In the United States 17 , the incorporation of the opinion of mothers in the care that is provided to them has helped to determine the risks to their health.Here, the inclusion of mothers' opinions enables the early detection of women who are considered high risk but who would later have a natural childbirth (false positives) and, most importantly, reduces the number of women who are considered low-risk but who would later have an adverse outcome (false negatives).
Patient-centered care considers the biological, social, and emotional dimensions of care and promotes the solving of health problems.For the mothers who take their children to consultations, a good relationship with the nurse is associated with the perspective of health services that is based on the health care user's reality, in their human multidimensionality, and in the actual production of the expected and necessary results 4 .

I always try to value what the mothers say, always ask how the children are doing, what the mothers are thinking, and what the mothers think about the growth and development of their children (N2).
It is necessary to pay attention not only to the child but also to the mother because they are our connection with the children (N2).
The mother's opinion is essential for the nurse to obtain relevant information regarding child health because mothers know the reality of their children because they are the primary caregivers for their children in most cases.The literature emphasizes that the care that is provided to children will be limited if professionals do not consider the importance of parents for the maintenance and protection of child health 11 .Therefore, encouraging family participation during childcare, providing the family with information on health care, health problems, and with the necessary approaches and interventions, which is understood as the right of every citizen and is required for qualified and humanized care, is a health strategy that provides satisfactory answers in health care 18 .
The Ministry of Health 19 recommends the performance of seven routine visits in the first year of life (in the first week, as well as in the first, second, fourth, sixth, ninth, and twelfth months) combined with two consultations in the second year (in months 18 and 24).From the second year, annual consultations following the birthday month are recommended.These periods are chosen because they represent periods of immunization and the provision of guidelines on health promotion and disease prevention.In these stages, a close relationship with the family is crucial.
I think this bond is everything; it is very important because if [mothers] do not trust the nursing professional who will care for their child, they will not come for follow-up (N1).
The mother values nurses as professionals, and consultations are important for the child and mother (N2).
Because if [the mother] trusts the nurse, she understands the importance of bringing the children in to consultation (N7).
Therefore, we conclude that nursing consultations for children under the age of two are essential to monitor their growth and development and promote their quality of life.To discuss the consultation calendar with the parents, the family history and individual needs and vulnerabilities should always be considered 20 .
Therefore, from the perspective that caring for children involves creating bonds and forming support networks that promote health 21 , the bonds that are created in PHC ensures that mothers or other family members seek health units not only when the children are sick but also to monitor their general condition.

Mothers have confidence in the consultation because they do not come only when the child is ill but also for routine child monitoring (N2).
When you cannot create this bond, this trust, this exchange, the mother simply does not come or simply comes just for the record (N3).
If this bond is not created, of course the mother will seek the health unit only when the child is sick (N6).
In a program to monitor child health, the practices of the professional should be comprehensive.The focus of health services-health prevention, promotion, and care-requires the maintenance of bonds with the family and en-courages continuous and joint responsibility of the health service and the family in childcare 20 .
Another aspect that the nurses considered is the role that is played by all staff at the FHU, which indicates that good relationships among professionals are essential to enable the establisment of a positive relationship with mothers.The quality of care that is provided in PHC occurs because of a collective effort, where all professionals are vital players in the process.
So I think this bond also depends on the whole team.If you do not have a competent team, if someone breaks this relationship, there will be great challenges (N3).
The mothers should have a good relationship not only with me; because here we do team work, everyone needs to be involved and build this relationship with families (N5).
A multidisciplinary team is an essential prerequisite for the reorganization of the work process in the context of PHC.By using a comprehensive and problem-solving approach, this reorganization allows the exchange of information and the search for the best treatment plan and establishes cooperation to promote team work 20 .

Difficulties in the establishment of bonds
The nurses reported difficulties in establishing bonds with mothers during child consultations such as excessive workloads, a limited access to the family, and cultural difficulties of the families in understanding the guidelines.
A challenge that is experienced by the interviewees is the accumulation of a workload because in the FHS, the same professionals have responsibility for several health care users.Moreover, the work of nurses includes more than child consultations because the FHU has other activities that demand the work of these professionals.
The users come here and want to be cared for immediately because for them; their need is greater at that particular moment (N7).
I think the biggest difficulty is the demand for care because childcare is a service that has delays (N7).
The literature indicates that an excess demand for care creates a strong cognitive, physical, and psychological burden on a daily basis because health care services must respect certain specificities and must be effective 9 .
Childcare takes time because it requires an assessment of the problems that are mentioned by the family, a clinical examination and assis-tance to the child on an individual basis.When it is performed by using comprehensive and problem-solving approaches, childcare becomes a complex activity because it demands a set of attributes from professionals as well as diversified technological resources 9 .
Similarly, mothers require care on an individual basis because most of them report feeling insecure after childbirth.Many mothers complain that they have difficulties in contacting health professionals and receiving the care that they need 22 .Therefore, it is essential that nurses be available for mothers and provide a relationship that is based on empathy and bonding because this attitude will increase the attendance of mothers at consultations.Similar to the results of our study, the authors of another study 23 that was conducted in New Zealand with pregnant women emphasized the importance of a bond with health professionals and showed that the lack of a harmonious and trusting relationship leads mothers to feel vulnerable and anxious about childbirth 23 .
Another difficulty that was reported by the nurses relates to the absence of mothers in the health care unit, which is justified by their lack of time and need to work.
My challenge is to bring the mothers here, if only to make an appointment, and for this reason, I take the opportunity when they come for vaccination or for another service and ask about the child (N4).
There are more challenges with working mothers than with community mothers (N6).
For me, the most important reason is related to work because many mothers work outside the home and do not have time to come to the unit for child monitoring (N7).
A bond occurs more easily when health care users are active and systematic in the search and use of the health service and are interested in health monitoring; therefore, the unavailability of users to participate in the activities that are proposed by the health care service is a challenge to its effectiveness 4 .
A study 24 involving PHC nurses in the city of Imperatriz, in the state of Maranhão, reported the lack of adherence of mothers to appointments as one of the main problems that relates to childcare.One reason for missing appointments is that mothers disregard the importance of bringing a healthy child to a health care service.However, the nurses also reported difficulties in meeting the programmatic agenda that contains other work duties in the context of the FHS.
Accordingly, it is important to note that a study that was conducted in the northeast and south of Brazil indicated that childcare coverage, with nine or more consultations, reached only onequarter of the children who were registered in the health care units.The authors emphasize that mothers are non-compliant because they prefer specialized care for their children; the authors also claim that the FHS professionals must meet several demands from the population and therefore are less able to address the specific needs of a child.The study also reported a tendency for mothers to seek the FHU only when their child is sick, which reinforces the discussions of the professionals who were interviewed in the present study 25 .
In the bond that is established between nurses and the mothers of children under the age of two, an obstacle that the study participants routinely considered was the resistance of mothers to follow the guidelines that they receive during the consultations.The influence of the habits of family members and close relatives, cultural taboos, and even the media were identified as responsible for this situation.
My biggest challenge is to make [the mothers] listen to me and follow my guidelines because this will make them trust me.It is a cultural problem, and the opinions of the grandmother, aunts, the neighbors -all of this has an influence (N1).
When challenges arise, it comes down to the same old story about culture and taboos (N2).
The greatest challenge in the relationship with the mothers is that they usually do not follow the guidelines.And the habits peculiar to them, we cannot change; the family also interferes a lot, and the media itself also broadcasts certain things that influence the ingestion of food at a premature age [N2].
Among the contributions of childcare, the individual and collective actions of health education emerge as mediators in the health care process, which strengthen the participation of families in promoting the healthy development of children and in reducing the risks of illness.Health education allows the exchange of knowledge between nurses and health care users and is an opportunity to review the guidelines to meet the requirements and concerns that families bring to nurses 8,26 .
The literature emphasizes that the guidance of mothers and the formation of bonds with them allow the greater participation of mothers and relatives in childcare, increase their adherence to appointments, and enhance their interest in providing assistance to children 27 .The relationship between the mother/family and the nurses is essential to strengthen mother-child bonds because nurses offer care and incentives for parental participation in childcare and promote reciprocity, a sense of responsibility, and better maternal responses to the child.Therefore, the mothers who receive support from nurses are more likely to build a positive and healthy relationship with their children 28 .
Nurses should view mothers as co-responsible in childcare in a relationship that favors bonding, the exchange and establishment of consensus, and a respect for mothers' autonomy.In addition, this relationship should avoid viewpoints that consider mothers as passive and only capable of following professional guidelines.

Conclusion
The evaluation of bonds between nurses and mothers of children under the age of two in a nursing consultation is essential and has a direct impact on the comprehensive health care that is provided to children.Despite the challenges in the effective formation of bonds between nurses and mothers, it has been shown that nurses believe that they can develop an inter-subjective relationship in primary care.In addition, nurses have knowledge of the elements that are essential to the formation of this bond and consider bonding a fundamental process for comprehensive and quality childcare.A loving relationship and nurses' qualified listening of mothers influence them to search for health units to schedule nursing consultations for their children, even when their children are healthy.
Therefore, we emphasize the need to continuously provide spaces for the reflection of health workers so that the demands of the health team can be addressed.These actions will help health workers to strengthen the bonds with mothers to monitor child growth and development effectively.

Collaborations
APS Reichert was involved in all stages of the research and general procedures.PF Rodrigues was involved in all stages of the research and in the manuscript preparation as an advisee.TM Albuquerque was involved in the manuscript preparation and formatting according to the journal guidelines.N Collet and MCS Minayo were involved in the critical review and approval of the final version of the manuscript.