Perception of mothers when visiting their child in the neonatal unit for the first time

Objective: to identify feelings, experiences and expectations of the mothers during the first visit to the child hospitalized in a Neonatal Intermediate Care Unit of a teaching hospital in the interior of the state of Minas Gerais. Method: qualitative research conducted between November 2016 and April 2017, with 24 mothers during a first visit to their children in the intermediate care unit. Data were collected through semi-structured interviews, transcribed and submitted to Content Analysis. Results: from the analysis emerged three thematic categories: feelings that precede the first visit, the experience of the first visit, feelings experienced during the first visit. Conclusion and implications for practice: the participants demonstrated that the first visit to their children can bring positive feelings and negative experiences. Strategies to minimize fears and clarify doubts favor the realization of motherhood.


INTRODUCTION
The first visit of the mother to the Newborn (NB) hospitalized in a neonatal unit is considered a frustrating and shocking experience, regarding the expectation of taking care of a healthy child. The reality imposed by the neonate with health problems that requires hospitalization and care, makes the mother feel vulnerable, guilty, insecure and scared. 1 ,2 The maternal autonomy is challenged when the mother transfers the care of the newborn to the health team and has no control over the health condition of the newborn. Spending a lot of time in the hospital or on the way between the house and the hospital becomes a stressful routine. And those who have other children need to leave them under the care of family members, another source of concern. Impaired parental behaviors can affect the baby's growth and development. 3 The environment of the neonatal unit, while transmitting the possibility of healing of the newborn, is associated with the suffering and chances of death. The dense technology, the emission of equipment alarms sounds, and high illumination impact on the first visit. 4,5 In this coping process, informational support and encouragement in the participation of care are essential. 6 The availability of the health staff to be with and talk to mothers is important. They feel that by asking questions they may disrupt the care provision, becoming embarrassed, which increases fear and anxiety. Providing detailed and accessible language information about the clinical status and procedures that will be performed with their children, emotional support through groups, involvement in baby care are behaviors that make them feel welcomed and supported. 2 Being the nursing team responsible for the welcome at the first visit and providing guidance on treatment care, this team must improve new behaviors regarding the welcoming of parents, seeking to understand this particular moment. Therefore, it is necessary to reflect on attitudes that value the feelings expressed by the mothers, aiming at positive contributions to soften up the experience of this phase, minimizing the emotional and psychological sequels that usually characterize it. [7][8][9] In this sense, this study aimed to identify feelings, experiences and expectations of the mothers during their first visit to the children hospitalized in a Neonatal Intermediate Care Unit (NICU).

METHODS
This is an exploratory descriptive study through qualitative approach. This choice was based on the interpretative approach of observed reality, with the purpose of accessing the individual subjective world for the understanding of meanings that people construct based on what they experience. 10 The research location was a NICU of a teaching hospital in the interior of the state of Minas Gerais. The study participants were 24 mothers who were experiencing the first contact with the child after delivery according to the established inclusion criteria: those who had the delivery performed in the hospital under study; six to 12 hours after the childbirth and being over 18 years old. Those who were in the process of postpartum illness (eclampsia, Hellp syndrome, hemorrhagic syndromes and puerperal blues) and those who were not in a position to respond due to drug use, abuse or withdrawal were excluded.
The interviews were performed according to the availability of the participants in a room available in the referred service, with an average duration of 15 minutes. The data collection was performed from November 2016 to April 2017, through semi-structured interviews, which were recorded in audio and later transcribed in full and certified in two moments by two researchers to guarantee the reliability of the transcription and after stored in an electronic database for analysis. The interviews were divided into two parts: the first included socio-demographic data: age, marital status, type of delivery, number of children, schooling and prenatal care; the second, the following guiding question: How was your experience visiting your child for the first time at the NICU? Would you like to report anything else about this experience? The interviews had an average duration of 15 minutes.
The sociodemographic data were analyzed by means of simple frequency, and those of the guiding question were analyzed by the thematic analysis method, which consists of a grouping of techniques, divided into three parts: pre-analysis, which comprises the exhaustive reading of the material; exploitation of the data, where the exploitation of the material, the search for categories by means of classification, codification and categorization occur; followed by the treatment of the results, inference and interpretation of the data of the emerged categories, which is when the results are based on the theoretical references. 11 In order to preserve the identity of the study participants, it was decided to name them using the initial "E", referring to the interview, followed by an Arabic number, in correspondence to the inclusion sequence in the research (E1, E2… E24).

RESULTS
Twenty-four mothers, aged between 22 and 39 years old, were included in the study, 13 of whom were in the 28-35 age group. Of the participants, 20 were married, two had a stable relationship and two were divorced, ten performed a cesarean section and 14 performed a normal delivery, all of them had undergone prenatal care. As for schooling, 15 had secondary education completed or to be completed. The gestational age varied between 29.3 and 39 weeks and the number of pregnancies between one and four, being that four children were the first-born and 45% premature, representing the main cause of hospitalization of the NB.
From the identification of the registration units, the themes Mothers' perception when visiting their child Ued FV, Silva MPC, da Cunha ILR, Ruiz MT, Amaral JB, Contim D were grouped, which allowed the construction of three categories, as follows:

Feelings before the first visit
The need of hospitalization of a baby right after the birth, whether expected or not, is an unwelcome occurrence for the parents, they do not know what to expect or do. As mothers prepare to visit their child for the first time, they feel fear, anxiety, trembling, and despair. The support received by the nursing team is identified in the speeches. [

The experience of the first visit:
The interviews revealed that the experience of the first visit has a strong impact, leaving these mothers vulnerable regarding care. Even with all the suffering of seeing the child hospitalized for having the need of continuous care, they do not fail to offer love to the baby. This is demonstrated by the following speeches: The first encounter between a mother and her child in a regular birth is a great event; she will know its traits, receive the baby in her arms and perform the first touch. There is a break in this first encounter when something makes these actions impossible and the baby is taken to a neonatal care unit at birth. The first visit is of great expectation to mothers as she will finally meet and touch the baby, one of the mothers referred to it as the great moment. When the mothers arrive to visit the child they are confronted with a great technological apparatus, that until then was unknown, they feel frightened and they wonder if they will need that support forever. They question whether this is really their son, they become apprehensive and tearful. The support and information received by the nursing team that accompanies this first contact is important to guide and calm them down. One of them asks if the baby feels pain. In addition to the shock when seeing the child connected to equipment, to see them without clothing even though inside the incubator, makes them question whether it is being well cared for and not cold. The participants revealed that they felt bad when visiting the child, they had support of the nursing team, who through the care provision and communication, made it possible to reduce the anxiety, nervousness and fear of the first visit.

Maternal feelings experienced during the first visit
After discovering that they will have a child, the mothers expect them to come healthy so they can them home and perform the first care. However, the need for hospitalization in the neonatal unit causes a huge sense of sadness because it affects the family routine and the dream plans.
When seeing the child hospitalized and in an incubator, the mothers are sad because they cannot perform the role of mother as they imagined from the beginning. Including them in the care offered to the newborn as soon as possible minimizes separation and assists in the coping process.
[...] I cried a lot, because it is very, very painful for a mother [...] in pregnancy we are relating to the child, then it is born so small, the relationship comes from the pregnancy, you love, you are building real love [...]  Even with the sadness of knowing that the child needs hospitalization at birth, they do not fail to express their maternal feelings of love, affection and care. The concern about whether the baby is being cared for, whether it is breathing properly, whether it is being medicated and fed, shows that they are present in the NB recovery and feel emotional about their evolution.
[...] but the feeling is of fear because you never expect that your child will come to the nursery, you want your child to stay by your side, but love is inexplicable [

DISCUSSION
It is understood that the feelings and experiences of the mothers during the first visit to the hospitalized child is different from the expected reality in relation to the experienced reality, because they imagine during the gestation a healthy child, who after birth goes home. 2 When there is a need for hospitalization in a neonatal unit there is a restructuring of the plans and feelings Mothers' perception when visiting their child Ued FV, Silva MPC, da Cunha ILR, Ruiz MT, Amaral JB, Contim D of shock, denial, anger, frustration, guilt, depression, hopelessness, impotence, loss, isolation, confusion, anxiety, stress, fear and sadness that are manifested by mothers. 2,8 Thus, () the theory of the primary affective bond is privileged, establishing that the interaction between the mother and her child is a process that begins before birth, and consolidates at the end of the first year of life, being able to suffer influences and consequences of psychological and environmental variables. 12 Faced with the unexpected path to this experience, women often feel unable to care for or protect their babies, which interferes with the way they interact with their children. 13 In the speeches it is possible to perceive that the biological fragilities of the hospitalized children generate feelings of anxiety and stress. Results of a study showed that mothers with children admitted to a Neonatal Intensive Care Unit (NICU) had moderate to severe stress levels, reinforcing the need to develop coping strategies. 14 In addition, the birth of preterm infants can aggravate the emotional distress of these women, resulting in implications for the well-being and capacity of the maternal function. 14 () The neonatal intensive care environment is considered shocking because of the technology in it; mothers do not know how to behave and what they can or cannot do, many are afraid to touch their child because of the devices attached to it. This situation represents the feeling and sensation of impotence. 15 It is possible to see in the reports that the mothers, when they arrived at the NICU, received support from the nursing team. Although they were scared and anxious, the support offered helped them to cope with the situation. Providing emotional and informational support reduces distress and strengthens the bond of mothers with their children and staff. In other studies, there is a concern of the mothers regarding the preparation and informational support. 3,14 Although it is a traumatic moment to see the child with the whole technological apparatus, fragile and debilitated every detail becomes important. 16 The attitude and positioning were important memories reported by the mothers during a first visit. 17 When mothers arrive to see the baby, they believe they will be able to breastfeed them and pick them up, but this does not happen, generating feelings of frustration and expectancy. 14 Faced with the risk of death of the baby, mothers experience anxiety, concern and confusion, and sometimes feel guilty, 16 evidencing the feelings mentioned in this study, being the most frequently cited anxiety and fear of losing the child. The separation of the binomial is an important difficulty that the mothers will face, which was also shown in another study. 3 In the process of bond building, encouraging the touch represents the appropriation of the child and the fulfillment of a dream. The gradual and planned involvement of mothers in the care provision softens the feeling of impotence and assists in the construction of autonomy. 16 In this way, adequate support is necessary, as well as their participation in the care of the newborn, which may be useful to reduce anxiety, as suggested by the literature.

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE
The present study showed that the first visit of the mothers to their children in the NICU can bring positive feelings (development, care and love) and negative experiences (lack of information, fear, anxiety and stress). The positive ones could help them deal better with the critical situation. Therefore, it is important that the nursing team accompany them during the first visit to the NB, so that the impact and shock caused are minimized, fears diminished and their doubts clarified, favoring the realization of their motherhood.
The reduced number of participants is considered a limitation of the study, although it has been representative for this reality. Therefore, it is necessary to carry out new research on this subject in order to deepen the knowledge for the provision of evidence--based nursing care in humanized practice.