Nursing team, family and hospitalized child interaction: an integrative review

This study aims to present an integrative review of national and international scientific papers on nursing team, family, and hospitalized child interaction. Searches have been made to Bireme, Lilacs, Medline, IBECS, Psyc Info, Science Direct and Web of Science (2008-2013) databases, which allowed us to identify 31 papers represented by the following themes: Interpersonal relationship, Communication and Care. The establishment of interpersonal relationships in a technical and formal way causes difficulty in communication and in the actions aimed at providing care. Care has been the main theme in these researches. Companions demand increased attention to child and family needs from health professionals, and greater involvement of everyone in the process of care. Results suggest that health care teams need to recognize the dynamic experienced by the dyad (child/companion) in order to develop comprehensive care, encouraging family and child inclusion through humanization strategies.


Introduction
The moment of hospital admission is experienced with anxiety by children, companions and health care team, since they share the experience and value the interactions developed 1 . Stressful situations for the child and her family associate the illness with hospitalization and with the treatment performed by the health care team 2,3 . These situations cause emotional repercussions on everyone involved. Thus, it is necessary for the triad (child, family, health care team) to develop integrated actions.
In child hospitalization cases, hospital environment is perceived in a hostile manner, and the family experiences periods of uncertainty regarding child's clinical picture, due to the possibility of deterioration of the clinical condition with risk of death [4][5][6][7] . Pediatric Psychology emphasizes attention toward the hospitalized child and her family, in order to protect of healthy development conditions. Thus, the family is the care facilitation agent in relation to the child 8 .
Family must be welcome in a custom manner and be heard in order to identify their main complaints to humanize care 9 . According to the Política Nacional de Humanização (National Humanization Policy), humanizing means primarily to value the subjects involved (child, family, health care team), and emphasize careful listening, develop empathy capacity, offer support, identify complaints and establish bonds through welcoming 10 . These aspects are in accordance with the principles of the Política Nacional de Atenção Hospitalar (National Hospital Care Policy), which considers welcoming as the main resource to develop health promotion, protection and recovery actions 11 . This set of actions characterizes integrality, a principle of the Sistema Único de Saúde (Public National Health System), which emphasizes that health professionals must recognize every aspect involving the experience of the individual who seeks health care service, so they can determine educational, preventive, treatment and rehabilitation interventions when needed 12 . In Brazil, it is possible to verify that health policies have a set of articulated principles aiming to support the functioning of health services and the integration between health care teams, patients and family members.
The welcoming offered by health professionals to hospitalized children's family members, especially during the initial phase of hospitalization, is considered important to minimize parents' anxiety. Therefore, understanding the repercussions of hospitalization for the child and family, such as changes in family routine, absence of the mother at home, marital conflicts and tension regarding the sick child, is an ability to be developed by the health care team, so it is able to provide adequate care for each family's needs.
The importance of nursing team actions toward preparing the accompanying family member is discussed in the literature, so that they contribute with the relationship established between child/caregiver 13 . The cited authors consider it important to elaborate and implement structured programs to attend families from an interdisciplinary perspective, in which each professional can share experiences and build knowledge regarding child and family integral care. A major theme refers to the interactions between the nursing team and the hospitalized child's family, since in pediatric units the companion's presence is considered fundamental for childcare, and to some extent this relative establishes relations with the nursing team. Investigation on this theme allows us to identify the main aspects that have been analyzed in the literature, so that this knowledge is discussed among health professionals in order to promote interaction and communication between team and family members of children hospitalized in pediatric units. In the scientific field, access to bibliographic production on this theme allows us to delimit the scope and organize research summaries, so that it helps the researcher decide based on the aspects that have been investigated aiming at study improvement. This study aims to present an integrative review of national and international scientific production on nursing team, family and hospitalized child interaction.

Method
This is an integrative review study, which allows search and critical analysis of scientific production, in order to present a summary of evidence related to the investigated theme, to verify the possibility of developing interventions in the health field 14 . The analysis of research results contributes to discussions on the theme, in order to support the development of new studies. The establishment of criteria to be followed allows adequate systematization of the investigated theme review and analysis process.
The following inclusion criteria have been used in this integrative review: articles indexed in Bireme (Lilacs, Medline, IBECS), Psyc Info, Sci-ence Direct, and Web of Science databases in the last five years (2008-2013); using the keywords família e equipe de saúde, family and health team, família e criança hospitalizada, family and hospitalized child. We aimed to include papers published in Portuguese and English which referred to empirical research reports on the theme of interaction between nursing team and hospitalized child's family, regardless of the type of illness presented by the child (acute, chronic), or the environment in which she had been hospitalized (ward, intensive care unit). Dissertations, theses, books and papers that did not analyze the relations between health care team and hospitalized child's family have been excluded. The database construction helped in the task of selecting papers, and the criteria of inclusion/exclusion have been used in the process of reading titles and abstracts.
Thematic analysis 15 has been utilized to verify similarities in research themes and group papers through themes construction, which are unique and represent the set of results of the investigation object. Initially, papers were inserted in a table showing information on paper title, publication year, objectives, method, participants, and main results. We sought to identify keywords highlighted in titles and objectives. Through this procedure, the papers that presented content similarities have been grouped and later divided into theme groups. Research results represented the analysis focus of the papers that have been contextualized through interrelations between theme and participants (nursing team/ family/ hospitalized child). Qualitative research summaries related to the specific theme were developed, which allowed us to understand the results and reflect on the possibilities of interventions and research to be conducted.

Results
A number of 186 papers have been found in the databases. The repeated ones were excluded and the remainders' title and abstract were read, which resulted in 60 papers inserted to the database. In the following stage, it was found that 31 papers met the inclusion criteria, which allowed the analysis of the full text. Chart 1 provides an overview of the articles regarding the studied theme: 20 refer to national production, and 11 international. With regard to the research method, 27 papers have used qualitative research and 2 papers have used the quantitative method. Three themes have been defined: Interpersonal relationship, Communication and Care, which represent the summaries of research results.

Interpersonal relationship
Interpersonal relationships between hospitalized children's family members and health care teams differ, depending on specific situations and on health professionals 16 . Doctors and nurses are less likely to be involved when the child and her family are perceived as "difficult to establish contact." Involvement occurs when the child and her family are considered collaborative, which helps identify emotional and psychosocial issues. On the other hand, nurses consult a colleague when they need assistance related to patient/family's mental health issues, while the doctor refers it to a psychologist or psychiatrist. These results indicate that health professionals need to attend training to develop their management capacity regarding the relationships established with patients and family members. It is possible that the patient/family considered difficult to communicate is experiencing a period of anxiety or conflict arising from hospitalization. Understanding this aspect enables health professionals to utilize welcoming.
The relationships that nurses develop with the families of hospitalized children are focused on providing basic information regarding care procedures in the hospital environment 17 . In the first contact, the purpose is to collect data on the child's general state. Nurses recognize the importance of the presence of mothers and the anxiety they display, but there is no preparation of these professionals for specialized welcoming, or even family inclusion in the child care process. According to the authors, there is a lack of resources to minimize child and family suffering, and thus, nurse and family relationship is governed by hospital rules. A strictly technical family/nurse relationship makes it impossible to bond and share experiences.
Nurses value the companion's presence during child admission in hospital, because they consider caregivers support the child, which contributes to the actions taken by health professionals, such as identifying child and parents' needs 1 . As regards the impact of interpersonal relations between nurses and hospitalized children's family members, a survey pointed out that, according to nurses, information and experience sharing contributes to the care of the hospitalized child 18 .
As part of a proposal to build a theory regard-it continues Chart 1. Scientific production regarding the interaction between nursing team, family and hospitalized child. ing nurse and hospitalized child's mother interaction, it is necessary to structure joint actions that prioritize interpersonal relationship quality by assigning roles, for example, considering that nursing technical procedures are specifically performed by the health professional, while the companion plays the role of providing aid to the child 19 . The quality of relationships has been attributed to the manner in which the nurse establishes contact with the family member, so that integration between the nursing staff and the hospitalized child's companion improves communication. Nurses and doctors highlight the importance of language and of engaging companions in decision-making regarding child's treatment. However, it was stressed that there is not enough time to build interpersonal relationships 20 . On the other hand, accompanying family members of hospitalized children with chronic illnesses highlight the need to establish interactions with the nursing team, initially to understand information regarding the child's clinical condition, and in order to share hospitalization experience 21 .
In other contexts, such as intensive care units, there are changes in the relations established between the nursing team and hospitalized children companions. Relations between parents and nurses in a Neonatal Intensive Care Unit (NICU) are based on dialogue and continuous proximity, which allows trust building during the hospitalization process 22 . According to the authors, parents and nurses value the interactions developed in the hospital environment. The fact that companions were informed about the procedures carried out with the child was a positive aspect, however, the main challenge for both was related to the moment of hospital discharge, due to the bonds that had been built and the interest to keep in contact. Another study on the theme showed that nursing professionals and hospitalized children family members consider dialogue, empathy, and respect relevant for interpersonal relationships 23 .

Communication
Parents of children with special needs highlight problems related to the communication between nurses and other health care team mem-  24 . Another point highlighted by the authors was the importance of improving communication between parents and nurses, since these health professionals have the responsibility to inform about the procedures being carried out with the child. Positive results were observed in the communication between parents and nurses after an educational intervention with leaflets, which contained information regarding pediatric pain evaluation 25 . Parents' satisfaction with nurses' instructions regarding pain treatment was the main aspect identified, since they considered that the communication established helped them clarify their doubts and assist in the process of care provided to their children. In another study, nurses, doctors and psychologists participated in a training program to develop communication skills with hospitalized children companions 26 . Before being submitted to training, health professionals established contact with children's parents, who were then asked to answer a questionnaire about their level of satisfaction with the service. After health care team training, parents were asked to answer the questionnaire once again. Parents' responses in both moments were compared, and showed a significant increase in the average related to satisfaction with health professionals' communication skills after the team had attended training, because companions felt they were being understood and the information provided was sufficient.
Companions highlight the importance of communicating with the health care team, so they can share information regarding the child's pain management during the postoperative period 27 . For children's parents, the inclusion of a variety of pain-management techniques, such as distraction, is a positive strategy to be utilized in hospital.
The communication between nursing team and newborn/family in a neonatal health care unit was represented by a theoretical model, which assumes nursing professionals are interested in bonding with the newborn and his/her family 28 . Therefore, efforts are directed toward establishing communication, so that this initiative assists in childcare and nurse satisfaction, allowing the formation of safe bonds.
Communication experiences among parents, nurses and doctors have been compared, which highlighted that it is important for health professionals to implement an approach centered on the needs of each family, in order to contribute to the benefits of establishing interpersonal relationships, and to identify behaviors for interaction among the people involved, aiming at a positive communication 29 . Communication in the hospital environment facilitates the connection of the triad (patient, family and team), and when the principles of respect and appreciation for the other's discourse are utilized, it is possible to build relationships based on affection and trust.
The different forms of communication between health care team and hospitalized child's family in a neonatal intensive care unit impact the process of interaction of the people involved, which to some extent influences the professionals' technical procedures and family suffering levels 30 . Integration among these people is important to allow the sharing of information related to the demands presented, e.g., when the health care team clarifies to the family what the possibilities of treatment of the hospitalized child are.

Care
The nursing team believes it is important for the accompanying family member to stay with the hospitalized child, since it favors the establishment of a pleasant environment and contributes to the implementation of child care 31 . In this case, the family member is considered as an extension of nursing professionals, because they provide the care recommended by nurses, which facilitates child engagement in treatment. In some situations, e.g., performing painful procedures, family members' interference has been considered by professionals as detrimental to work development. Overall, family presence in the pediatric unit has been considered positive, since the collaboration developed between the team and family allows bonding and supports the child's recovery.
Companions believe the care provided by the nursing team is effective in terms of hospitalized children's pain management after surgical procedure 32 . Parents stress that the main resource utilized by the team is pharmacological therapy, however, they believe it is important to utilize non-pharmacological interventions, such as distraction and toys. These strategies are spontaneously utilized by parents, and if they were guided by a health professional, it would contribute to the inclusion of family members in the care for the hospitalized child.
The nursing team care for the family member/companion relates to providing educational guidelines, so that parents are able to identify the physical changes that occur with the child, e.g., increased temperature, and request the presence of a health professional 33 . To some extent, there are caring procedures aimed at the hospitalized child that are shared between nurses and family members, but the technical actions of these health professionals are child-centered. It is necessary to expand these practices through a comprehensive care that allows health professionals to know the different aspects inherent to child and family's experience.
Nursing team experiences in developing educational practices are aimed at family preparation to take care of children who rely on some type of technology, e.g., probes, catheters, tracheotomy, and who suffer from chronic diseases, such as children who require insulin application 34 . According to the authors, health education proposals remain focused on information transmission, however, they mention that it is important to understand families' social representations of health and illness. Educational practice focuses on teaching techniques regarding nutrition, hygiene, environment, child growth and development, childhood accident prevention, or any other topic nurses believe is of interest to families.
The care of the nursing team in a pediatric ward is mainly focused on technical procedures toward the child, such as, sample collection and cardiac monitoring, considering that isolated actions are aimed at the family 13,35 . Nurses highlight the importance of projects aimed at caring for hospitalized children's family members, in order to support assistance quality, which should occur by integrating other health professionals. Given the scarcity of systematic intervention programs for child/companion care in the hospital setting, it is important to promote training for health care teams, so that integrated actions that prioritize welcoming are developed.
In hospital practice, family care is discussed among health care teams, but there is no implementation of projects to be developed, making it difficult to understand the experiences and complaints of the families during the hospitalization period 36 . Health care teams realize that companions are working agents who assist nurses' tasks, thus, they should be considered subjects that require special attention and care.
Another kind of care is the use of alternative resources in the hospital ward, such as when nurses present toys to facilitate child engagement in technical procedures that need to be performed 37 . Children that are prepared for the probe passing procedure using a toy, for example, respond better when compared to those who do not receive the same kind of preparation.
The father's role in the care of his hospitalized child is little acknowledged by the nursing team, but they consider that in special situations his presence makes it possible to provide attention to the child 38 . The nursing team points out that the structure of the hospital environment, with shared wards, often with children's mothers, is the main challenge to host a male caregiver. Another point highlighted was that the father resists accepting instructions provided by the health care team regarding childcare, whereas the mother is considered receptive and able to provide a different care.
The health care team points out that the father's presence caring for the hospitalized child helps reduce emotional stress and contributes to increase child's sense of safety and cooperation during hospitalization 39 . The cited study shows the contributions of father permanence assisting the hospitalized child, however, the health care team points out that the father's presence during the performance of invasive procedures has negative repercussions, in terms of the child's lack of collaboration, which increases nurses' stress.
The nursing team understands that the care process is based on the hospital's standards and work routines 40 . Another study shows that nurses link their actions toward hospitalized child and her family to a professional practice that allows exercising health education, putting the knowledge acquired in professional training into practice and acquiring new knowledge 41 . The care provided to the child and accompanying family member becomes fragmented when only institutional principles of the hospital environment are considered. Thus, valuing child and family experiences is the main aspect to be utilized in health care.
Accompanying family members point out that the care provided by nursing professionals to hospitalized children is related to the execution of technical procedures, such as giving medication, and that positive evaluation of the provided care occurs when a procedure was performed effectively 42 . These companions are able to identify which professionals are responsible for complex care, i.e., doctors and nurses, and specific procedures of nursing technicians such as simple aid.
The care provided by the nursing team was considered of good quality by hospitalized children companions when health professionals were receptive to meet the needs of the child and family regarding sleep 43 . On the other hand, these companions are interested in receiving information about the child's treatment, in order to minimize the anxiety experienced in the hospital environment. Nurses report positive care experiences when they make use of dialogue and play in the hospital, in order to build ties, minimize suffering, and support the child's recovery process 44 . There is family members inclusion so that they become collaborators in child care, and assist nurses in the procedures to be performed.

Discussion
The studies on interaction of nursing team, family, and hospitalized child are focused on specific themes related to interpersonal relationships, communication and care. These works mainly depict the interaction among the nursing team, children and their families. It is important to point out that professionals from other knowledge areas who work in hospital settings geared toward children, do not publish studies on the researched topic. The results obtained in national and international literature reflect different socio-cultural contexts and health systems, which demands the analysis of specific aspects in order to verify similarities, differences and repercussions on the people involved. The health system in Brazil for instance, stresses comprehensive care, welcoming and humanization (Brazil, 2013) in its hospital care policy, but different strategies guide the functioning of health services internationally. Thus, it is important to consider the cultural particularities and health policies of each country to contextualize the results of the papers analyzed in this integrative review.
With regard to interpersonal relationships, there are times when nursing teams seek engagement with hospitalized children's family members, but some professionals point out that time is insufficient to make contact, while others find some time to convey information. The difficulties in establishing interpersonal relationships are due to hospital rules, which establish a hierarchy prioritizing nurses' technical tasks 45 . It is important for the nursing team and the hospitalized child's family member/companion to develop relationships based on empathy, to make sure the needs of the people involved are fully met 46 . Formal and objective relations centered on technical procedures make it impossible to interact and make interpersonal contact, thus, a useful resource is to consider that the subjects inserted in the hospital setting are protagonists in child care.
Communication is another aspect that needs to be contextualized, since family members point out the need for health professionals to communicate during child hospitalization process. It is important to note that there are positive results when intervention programs aimed at health professionals are implemented in order to develop skills in communicating with family members 25,26 . On the other hand, it was found that it is necessary for health professionals to develop communication skills, especially when communicating diagnosis that require invasive treatments. Information on the procedures performed by the nursing team assists in treatment engagement. In this case, when the family member understands the directions provided by professionals, the child engages in the necessary procedures. It is important to point out that parents should help their children cope with the hospitalization situation, since parents' anxiety is often a consequence of their children's emotional reactions 47 .
An integrative review on disabled children's experience as hospitalized patients sought to analyze qualitative studies involving children, parents and health professionals 48 . Communication was the main theme mentioned in those researches. Children emphasize positive experiences with nurses, while parents request that health professionals provide information on the children's clinical condition and the procedures performed and that children be involved in treatment decisions, so that they are aware of what is being done. Nurses consider communication as something complex, particularly with regard to child involvement in discussions and decisions regarding treatment.
In terms of care, companions mention that nursing team's technical care procedures are aimed at the hospitalized child, which confirms researches investigating this topic, since parental involvement is meant to assist child care 49 . Health professionals recognize the importance of caring for the hospitalized child's companion, and some actions are taken in this regard, however, there aren't any strategies that include companions in general care. In Brazil, the inclusion of the child's companion in hospital settings became mandatory under Law 8.069/90 of the Estatuto da Criança e do Adolescente -ECA 50 (Child and Adolescent Statute), which ensured the effective participation of the family member/caregiver in the hospitalized child's treatment.
Attention to the hospitalized child's family seems to be idealistic because even if there is full understanding by the health care team, hospitals do not have a work plan that includes the family member as an individual who needs care in the hospital 36 . The Política Nacional de Atenção Hospitalar (National Hospital Care Policy) emphasizes the importance of comprehensive care in health service, to promote quality assistance based on humanization, efficiency and networking 11 . The literature highlights the importance for health care teams to identify hospitalized children companions' emotional reactions, in order to minimize their suffering, so that the reflections on this practice support humanized care 41 .
In an integrative review on family in pediatric units, it was found that nurses have the interest to elaborate surveys on companions' needs; on the other hand, in professional practice families are not included in health care in the hospital setting 51 . It is necessary to broaden the notion of care, initially considering the dyad (child-companion) and the process of illness and hospitalization, so that the health care team analyzes possible interventions to be implemented.

Final Considerations
The integrative review on nursing team and hospitalized child's family has allowed us to highlight the themes related to interpersonal relationship, communication, and care. The results show that in a pediatric unit, interpersonal relationships have repercussions on communication establishment and on the actions aimed at providing care. It is necessary to understand that these themes are interrelated. It was found that it is important to improve the communication process and interactions made, considering the family as a group that also needs care in the hospital environment, both in terms of training to accompany, and the right to assistance as a user. The theme of care is predominant in the research on nursing team and hospitalized child's family. The main aspect to be considered is that the forms of care are primarily aimed at the child. It was found that it is important for the health care team to utilize hospital humanization strategies when attending to the hospitalized child's family, considering the dyad's demands, in order to improve its practices and ensure the satisfaction of those involved.
The overall analysis of the papers shows the possibility of developing hospital personnel management interventions to improve communication among health professionals-family members-patients in the pediatric unit, such as experiential workshops or social skills training courses. Interventions that seek to raise awareness among health professionals on the need to establish better contact with family members are strategies that can be performed through focus groups, clinical cases discussions, movie scene analyses, and role-playing. In summary, interventions aimed at health professionals in pediatric units allow the discussion of common topics experienced in their practices, such as communication and forms of care, since these initiatives contribute to hospital care quality, consistent with the health policy in Brazil.

Collaborations
AVS Azevêdo delimited the integrative review and the process of searching for articles in databases. AC Lançoni Júnior analyzed the articles identified in the databases and described in the results section. MA Crepald reviewed the general text and assisted in the process of categorizing the articles and synthesizing the results.