Evaluation of the Multidisciplinary Assistance provided in a Public Neonatal Care Unit from mothers ` perception

Objectives: this study aimed to investigate the evaluation of mothers about the care provided by the multidisciplinary team in a Public Neonatal Care Unit located in the Federal


Introduction
] Neonatal units are characterized as highly specialized places in the comprehensive care of newborns in severe conditions or potentially in severe conditions.These units are endowed with adequate assistance structures covering physical facilities, equipment and human resources and are divided into: Intensive Care Unit (NICU), which is intended for the care of newborns with severe or lifethreatening conditions, and Intermediary Neonatal Care Unit (INCU), which is intended for the care of infants considered to be of medium risk and requiring continuous and less complex assistance. 3he hospitalization of the newborn (NB) in a Neonatal Unit introduces both the baby and the mother into a different and impersonal environment, full of technological equipment and noise.This environment is often perceived by mothers as strange and aversive, which can generate feelings of impotence, fear and anguish in the face of the unfamiliarity about the behavior that they must adopt in that place. 2 A study carried out in Bahia found that although the NICU environment is familiar to health professionals working in it, it is seen as a frightening environment, a place of severity and suffering for the newborn. 4his hospitalization also causes separation between mother and child, which can weaken and impair this affective bond and the healthy development of the mother-baby dyad, especially since they are not prepared to deal with this separation. 5For parents, the experience of witnessing a child hospitalized in the NICU/INCU is considered unexpected and can cause stress, emotional turmoil and even depression. 6Research conducted in Chicago/USA demonstrated through the mothers' statements that many considered birth and hospitalization of the NB in the NICU an abrupt and undesired moment, different from what they had planned, leaving them overloaded and unprepared psychologically. 7imilarly, hospitalization in the neonatal unit can mean to the mother worsening of the newborn's health status, in addition to the risk of death, which may represent a threat to the emotional integrity of the mother causing suffering to her and to all family members.Research performed at a University Hospital of Rio de Janeiro showed that mothers see the NICU as a sign of impending death. 8umanization of care is understood as a quality care that aims at improving working conditions and recognizes the rights of users, as well as enhancing the reception and dialogue in order to improve and broaden the communication between professionals and patients, seeking in this way a new culture of care. 91] Other researches have also shown that the care centralized in the family promotes a better integration of parents with the newborn, which can reduce this abrupt distancing caused by hospitalization in the neonatal environment. 6,12] In this way, mothers need a more frequent and closer assistance before this new phase of their life: the experience of hospitalization of their baby in a Neonatal Unit.It is responsibility of all health staff to provide individualized care to them in order to provide them a safe, quiet and welcoming environment. 15his individualized assistance to mothers is crucial to improving the quality of care provided.One of the concerns about the quality of service is related to the degree of maternal satisfaction.The concept of satisfaction involves several factors and encompasses aspects related to health care, userprofessional relationship, access, infrastructure and organization.7][18] Thus, these mothers must be met in all their needs so that they can develop a good relationship with the health team, have confidence in the care provided to the NB, and feel supported in the role of mother. 19he assessment of the process of care provided in neonatal units from the point of view of mothers can provide useful and essential information regarding educational needs, problems and gaps in care provided, and even related to the success and failure of the health service, providing improvement of service and changes for improvement.
It is important for mothers to be heard, thus allowing a greater appreciation of the experience of these mothers in neonatal units in order to increase knowledge about the difficulties they face during the hospitalization of the NB.
Given this assistance model and considering the importance of the evaluation of the service in order to provide better care to mothers with children hospitalized in neonatal units, this study aimed to know the evaluation of mothers about the care provided by the multidisciplinary team in a neonatal unit of a high complexity public hospital of the Federal District.

Methods
This is a quantitative, descriptive and cross-sectional study performed in a high-complexity hospital linked to the National Health System (SUS), located in the Federal District.The hospital in which the research was carried out has a Neonatal Intensive Care Unit (NICU) with ten regulated beds and a Intermediary Neonatal Care Unit (INCU) with 6 unregulated beds, both of which have average occupancy rate above their capacity.Due to this high occupancy rate and also due to insufficient human resources, during data collection some beds were temporarily blocked and returned to operation as soon as institutional problems were solved, which harmed the data collection.
As an inclusion criterion, we established the minimum period of 7 days of hospitalization in the NICU and 2 days of hospitalization in the INCU, considering the need for a time of coexistence of mothers with the team to answer to the questionnaire, as well as inherent characteristics of each unit, as the NICU has lower turnover and longer hospitalization time.Exclusion criteria were: mothers with evident or self-reported cognitive or psychiatric disorder that compromised the ability to answer the questionnaire and women who had not answered more than 30% of the questions.
The study sample consisted of 57 mothers of infants who were admitted to the neonatal unit of the hospital in which the study was conducted.Data were collected between April and September 2015.The questionnaire was applied to the mothers in neonatal units by a properly trained research assistant.
The instrument used for data collection was a closed, pre-tested and already validated questionnaire used in a survey to evaluate the satisfaction of patients hospitalized in a university hospital specialized in women's health, in the city of Campinas-SP. 20The original questionnaires were developed to be applied in several wards, among them: gynecology, oncology, rooming-in, obstetric pathology and neonatology.However, only the questionnaire applied in neonatology was used in this research, which was adapted to the reality of the service through the addition and exclusion of some questions.The questions were answered using a 5-level Likert scale (excellent, good, fair, poor, terrible, and "I have not received") and were distributed in three main domains: accessibility and accommodation; communication and relationship with staff and assistance received.
Regarding the interpretation of the scores of the questionnaire, positive evaluation referred to the sum of the good and excellent scores and negative evaluation referred to the sum of the poor and terrible scores.In relation to the communication and the relationship with the team, the analysis was divided into two parts.The first one refers to information and guidance provided by the team to the mother, and the second one refers to the availability of physicians, nursing team and physiotherapists to clarify doubts.
At the end of the questionnaire, mothers were also asked whether they had received care from other professionals such as psychologist, speech therapist, social service and nutritionist at the neonatal unit.For these professionals, the questions on the evaluation of care were more general because these professionals were not daily present as the others, evaluated in a more specific way (physiotherapist, nursing team and physicians).
The data collected were computed into a data file in Excel 2013 software and then processed using the statistical software Software R, version 3.1.2.Descriptive statistics was used to identify the evaluation of care provided in the neonatal unit, using absolute and relative frequencies for the studied variables.
The Chi-Square test was also used to test independence between variables.The questions answered by mothers were compared two by two and information of the variables was crossed in a table called Contingency Table .When the assumptions of the test were obeyed, the hypothesis test was performed to test the association between variables.The p-value was used to obtain the results.This value is the probability of an observation occurring equal to or greater than the value obtained from the sample.When the p-value was lower than the level of significance, the null hypothesis was rejected.For the p-value analysis, a significance level of 0.05 was adopted.
In some cases in which all the assumptions were not met to perform the chi-square test, Monte Carlo computational method was used.This method consists of simulating the sample distribution of the Chi-Square test statistically several times in order to obtain a more cohesive result.All this treatment of the data was carried out by a statistician hired for this purpose.
This study was approved by the Ethics and Research Committee of the Foundation for Teaching and Research in Health Sciences, FEPECS, according to opinion no.979.357.The Informed Consent Form was signed by the mothers before they answered the questionnaires, after clarifying the research and ensuring the confidentiality of data collected only for scientific purposes.

Results
During the 6 months of data collection, 57 mothers of newborns hospitalized at the neonatal unit participated in the study.These were characterized by being mostly married (57.9%), young -in the age group up to 25 years -(52.7%),from the Federal Distric and the state of Goiás (59.6%), low income (50.9%),with complete secondary education (77.1%) and no paid activity (70.2%).Among the deliveries, only 28% had been normal, 14% of mothers of the newborns had suffered one or more abortions and 10.5% had had a child hospitalized in a neonatal unit previously.With regard to prenatal follow-up, the majority (59.6%) had attended 6 or more visits.
Regarding the accessibility and accommodation of the unit, most mothers (81%) evaluated positively and only 2.1% evaluated it negatively.The items with the highest number of fair evaluations in this domain were: ventilation/temperature (15.8%) and number of visits (17.5%).Only the quality of the bed received no negative evaluation among the mothers.(Table 1).
The results also showed that the majority of the mothers (79.8%) have positively evaluated the guidelines and information provided by the team.The best evaluations were related to guidelines on hand washing and changing clothes when entering the place where the baby was hospitalized (94.8%) and on how to touch and hold the baby (93%).The worst evaluations were on the information regarding the length of hospital stay, (10.5% evaluated it nega-tively and 38.6% rated it as fair), and on the names and roles of each team member (12.3% evaluated it negatively and 17.5% as fair).
Regarding the availability of professionals to clarify doubts, the results showed that the physicians received the best evaluations (91.2%); however, the difference was small compared to the nursing team, which was also well evaluated (86%).Regarding the evaluation of the mothers who had received assistance from the physiotherapist, their opinion was well balanced, since about 35% evaluated these professionals negatively and 15% as fair (Table 2).
Regarding the general assistance received, it was evaluated by the majority of the mothers (89.9%) in a positive way and only 5.2% of the mothers negatively evaluated this domain.The best items evaluated were availability of medication (91.2%) and availability of equipment (89.4%).On the other hand, the worst item evaluated was the number of professionals present per shift to take care of the baby (7% rated it as fair and 7.1% as poor and terrible).
Regarding the evaluation of the assistance received from each professional, the results showed that the nursing team was the best evaluated (88.9%), but the evaluation was also positive for the physicians (84.2%).For the nursing team, the items with best evaluations were about education and interest and the way they talked to mothers (91.2%) and for the physicians, it was about care when the newborn presented some discomfort (87.7%).It should be noted that mothers' opinions changed when analyzing physiotherapists, since an expressive number (28.7%) evaluated these professionals negatively.
It was found that 49 of the 57 mothers who participated in the research (86%) had received care from the psychologist, 34 from the speech therapist (59.6%) and 36 from the social worker (63.2%), but only 8 women (14.0 %) stated having received nutritionist's assistance.For those other professionals evaluated, the mothers' opinion was also positive (97.7%), and the best evaluated professional was the psychologist.
The results showed that the family per capita income showed an association with the mother's classification among those who had performed the best or worst evaluations of the neonatal unit (p= 0.004).The majority of women classified as having performed the worst evaluations had income of up to 1 minimum wage, whereas for the group that performed better evaluations of the unit, the amount was better distributed among the income ranges.
It is worth noting that the variable "lenght of Table 1 Accessibility and Accommodations of the Neonatal Intensive Care Unit.Table 2 Communication and relationship with the team-Availability to clarify doubts.hospitalization" also showed association (p-value = 0.024) with the evaluation made about the neonatal unit.The mothers who had performed the worst evaluations of the research questions were the ones that stayed with the child less time hospitalized, up to 10 days, while the number of mothers with better evaluated the unit remained with the child hospitalized for longer time, some reaching up to 20 days.The other variables (schooling, number of previous pregnancies, type of delivery, gestational age, baby's weight, age, marital status, number of prenatal consultations, planned and unwanted pregnancies) had a p-value greater than 0.05.Thus, the null hypothesis of independence was not rejected, that is, there is no evidence that these variables are associated with the general assessment of the mother in relation to the neonatal unit.

Physicians
It was also tested through the Chi-Square test whether there was a significant difference between the opinion of mothers in NICU and the opinion of mothers in INCU regarding the institutional conditions; communication and relationship with professionals; and assistance received.The results also showed that the p-value was greater than 0.05, so there is no significant evidence to affirm that NICU and INCU are different for mothers.

Discussion
The results of this study demonstrated that the majority of mothers evaluated positively the unit, being satisfied with the service provided.The concern with maternal satisfaction was also addressed in other studies that showed positive aspects regarding the reception, relationship and interaction with the staff and care received. 18,19,21n the other hand, some mothers may not feel welcomed and feel dissatisfied with the care provided in neonatal units, as demonstrated by research conducted in Marília-SP, which found that some negative feelings, such as fear, guilt, insecurity, sadness and pain experienced by mothers had not been perceived by the unit team.Another study carried out in Brasilia-DF also certified that mothers in general, despite being satisfied with care for the newborn, considered themselves as neglected and unattended by the hospital staff. 22,23n the present study, it was observed that although mothers are generally satisfied, it is evident that in the domain accessibility and accommodations, the number of visits by other family members and ventilation/temperature had the highest number of evaluations as fair.
The care of the NB in neonatal units is quite complex, as it involves not only the care of the baby, but also the care of the family, parents and relatives, who present a degree of vulnerability with peculiar needs that must also be met. 2 It is therefore essential to develop and prioritize humanized assistance.
Although neonatal units have undergone several changes over the years, there is still an overvaluation of technical aspects, which is observed in relation to visits to these units.When they are allowed, it is often prioritized the adequacy of visits to meet the technical needs of the unit, with limited periods, 13,14 factors that may justify the mothers' dissatisfaction with the item "visits of other relatives", observed in the present study.
It should be noted that during data collection, the neonatal unit had several institutional problems, such as air conditioning, which was damaged and had not been working for approximately two months.Thus, the greater number of evaluations as fair in the items temperature/ventilation may be related and restricted to that particular moment.
Still on the domain "accessibility and accommodations", the mothers did not show dissatisfaction with the noise present in the unit.The majority (84.2%) rated this item as good and excellent, contrary to the results of other surveys 6,24 which pointed out the noise of the NICU environment as a stress-enhancing component for mothers.
This study showed that the majority of mothers evaluated positively the orientations and information passed on by the team.These are extremely important because they can make mothers feel safer and more welcomed, as demonstrated by another study carried out at a NICU located in Maringá/PR. 10 Thus, effective communication between the multidisciplinary team and mothers is an essential part of the support provided to them and can contribute to reducing emotional stress, as observed in another research conducted in Sweden, in which communication was crucial for better coping of the parents with hospitalization of the NB in NICU. 11n the other hand, this communication can also be performed in an ineffective way, as demonstrated by the results of the present study, in which 49.1% of the mothers evaluated in a negative/fair way the item on the information provided by the team in relation to the length of hospitalization of the baby.Other studies 8,25 also showed that there may be flaws in the communication process between the neonatal team and the mothers.
It is interesting that about 65% of the mothers said they had not received assistance from the physiotherapist, despite the fact that most of babies had received daily care from this professional in the studied neonatal unit.This may raise a question as to whether mothers really know who the physiotherapists working in the unit are.On the names and functions of each member of the team, about 30% evaluated this item in a negative/fair way, corroborating the idea that this could be interconnected with a communication failure by the team about the functions that each one exercises in the neonatal unit.
Regarding the evaluation of the general assistance received, in this study it was observed that the best items evaluated were on the availability of medication and equipment, which is similar to another research carried out in a university hospital specialized in maternal and child health. 20egarding the worst evaluated item of the domain, which was the amount of professionals present per shift to take care of the baby, there is an explanation, which is the insufficiency of human resources in the unit in question.Even so, only 7.1% of the mothers evaluated this item in a negative way, which can demonstrate the commitment of the multidisciplinary team to care for the newborn in a way that does not jeopardize the care provided.
The present study also showed that the mothers were satisfied with the politeness, interest and the way the nursing team talked with them, besides being satisfied with the care offered to the NB by the physicians of the unit.This result corroborates with the recommendation that the multidisciplinary team should work as mediator of relations between mother/newborn, guided by the humanization of actions based on the reception, bonding, trust and listening. 15uring the hospitalization of the newborn in the neonatal unit, the parents suffer with the rupture of the bond that is still being made between them and the NB.Research conducted in Philadelphia/USA found that the parents of newborns considered the fact that they were separated from their children one of the most stressful factors in the experience of hospitalization of the child in neonatal unit. 6Thus, the insertion of the family, especially of the parents, in the care of the NB is essential, since they play a fundamental role in the recovery of the baby. 12The results of this study corroborate this idea, since they demonstrated that the majority of mothers evaluated in a positive way the item on the incentive of professionals for them to take care of their own children.
Regarding the evaluation of other professionals (psychologist, speech therapist, social worker and nutritionist) of the unit, it is noteworthy that the psychologist's service obtained the best evaluations, since all the mothers who said having received psychological care evaluated the professional as good and excellent.The role of the psychologist in the care and follow-up of the families in the NICU is important and of great relevance, since many mothers manifest suffering in face of the hospitalization of their child.Therefore, it is necessary to support the mother in this situation, so that they feel welcome. 26atient satisfaction with the care received may also be linked to sociodemographic issues, as demonstrated by the present study in which the mothers who provided the best evaluations of the unit had a higher income.On the other hand, there are other studies that go against these results, 27,28 which did not demonstrate this correlation between family income and user satisfaction level.
The variable "length of stay" also showed an association with the mother's evaluation of the neonatal unit, so that the longer the hospitalization time of the newborn, the better was the evaluation of the unit.An explanatory hypothesis for this result would be that mothers may have provided a better evaluation because of greater confidence in the multidisciplinary team over time, and/or because the initial emotional shock has been dispersed and they started to feel more receptive and confident in an environment previously unknown.The support and understanding of the team directed to the newborn's mother during hospitalization is extremely important so that they can face this situation with more stillness, confidence and security. 29t is interesting that even though the two units (NICU and INCU) are in different spaces and have different complexities and functions, the results did not show significant evidence of difference between them, since institutional conditions were similarly evaluated.Regarding the evaluation of communication and relationship with professionals and assistance received, the result found was already expected because it is the same multidisciplinary team that serves both units.
The study made it possible to identify the mothers' assessment on the multidisciplinary care received at the neonatal unit studied.The results indicated that mothers were satisfied in most of the three domains evaluated, which may be an indicator of the quality of provided services.The results of this study also demonstrated that the medical team and the nursing team were well evaluated, but it is worth noting the significant percentage of negative evaluations of the physiotherapists.This generates a reflection on whether the mothers really know who these professionals are, since the majority answered they had not received assistance from this professional, which is contrary with the reality of the service in which the majority of the babies receives physiotherapeutic care in a daily basis.
The knowledge of the evaluation of care through this research also revealed gaps in care such as the need to improve communication between the neonatal team and mothers, so that these women feel welcomed and better informed about the child's health status and also in relation to the functions that each professional exercises in the multidisciplinary team.This study also demonstrated that there is a need for a greater flexibility in the visiting policy in order to allow the presence of other relatives in the unit in a more frequent basis so that they become more involved, prioritizing in this way a more humanized and less technical assistance, instead of meeting only the needs of the sector.
The information obtained in this research may contribute to the improvement of the quality of the care provided by the NICUs and INCU teams, considering the importance of evaluation so that a better service is provided to the mothers, and also allowing a greater knowledge about the difficulties experienced by mothers during the hospitalization of the baby in neonatal units.However, it is known that a sample composed of only 57 mothers does not allow generalization of results.This sample could be composed of more mothers so that this population was better represented, which was not possible because during the data collection the unit was facing several institutional problems, such as insufficient human resources and the air conditioning that was damaged, which caused some beds to be temporarily blocked.
It should also be pointed out that, although the eva-luation of the professionals was positive, which may demonstrate the quality of the service provided, mothers may have been afraid to evaluate the professionals in a negative way, especially the physicians and the nursing team, since these professionals are constantly present in the unit, and a bad evaluation could imply in a worse care provided to the NB by the multidisciplinary team.
Further research related to this topic should be carried out with a greater number of participants to better represent the population studied.Also, studies should be conducted in other hospitals in order to compare the service of the units.

Ferraresi
MF et al.Evaluation of the Multidisciplinary Assistance in a Neonatal Care Unit