Technical nursing students interacting with family members of hospitalized children

Objective: To understand technical nursing students’ meaning of interacting with family members of hospitalized children. Method: Symbolic Interactionism was used as the theoretical framework and Qualitative Content Analysis was the methodological procedure. A total of eight graduates from an institution situated in the city of Osasco, Sao Paulo state, participated in this study. Data were collected through semi-structured interviews. Results: A total of five representative themes were revealed: Dealing with difficult situations with family members; Perceiving oneself to be unprepared to interact with family members; Family members being a helpful tool; Developing strategies to obtain a good interaction with family members; and Teachers being facilitators of the interaction with family members. Final considerations: To be acquainted with this experience has led to the understanding of the need to include the theme of family care in the curriculum of the Technical Nursing Course. Additionally, the present study contributed to reflections on the importance of such knowledge for this population and to the development of future studies, as this theme has been scarcely explored in the literature. Descriptors: Family; Child; Nursing; Nursing Education; Teaching. RESUMO Objetivo: Compreender o significado de interagir com os familiares da criança hospitalizada para o aluno do Curso Técnico em Enfermagem. Método: Utilizou-se o Interacionismo Simbólico como referencial teórico e a Análise Qualitativa de Conteúdo como procedimento metodológico. Participaram oito egressos de uma instituição localizada em Osasco/SP, sendo os dados coletados por entrevista semiestruturada. Resultados: Revelaram cinco temas representativos: interagindo com situações difíceis com os familiares; percebendo-se despreparado para interagir com os familiares; familiares sendo uma ferramenta de ajuda; desenvolvendo estratégias para obter boa interação com os familiares; professores sendo facilitadores da interação com a família. Considerações finais: Conhecer essa vivência levou à compreensão da necessidade de inclusão da temática relativa ao cuidado à família na matriz curricular do Curso Técnico em Enfermagem. Além disso, contribuiu para reflexões sobre a importância desse conhecimento para esse público e para futura realização de novos estudos, pois trata-se de assunto pouco explorado na literatura. Descritores: Família; Criança; Enfermagem; Educação em Enfermagem; Ensino. RESUMEN Objetivo: Comprender el significado de interactuar con los familiares del niño hospitalizado para el alumno del Curso Técnico en Enfermería. Método: Se utilizó Interaccionismo Simbólico como referencial teórico y Análisis Cualitativo de Contenido como procedimiento metodológico. Participaron ocho egresados de institución de Osasco/SP. Datos recolectados mediante entrevista semiestructurada. Resultados: Revelaron cinco temas representativos: interactuando con situaciones difíciles para los familiares; sintiéndose mal preparado para interactuar con familiares; familiares constituyendo herramienta de ayuda; desarrollando estrategias para obtener buena interacción con los familiares; profesores como facilitadores de la interacción con la familia. Consideraciones RESEARCH Technical nursing students interacting with family members of hospitalized children Alunos do curso técnico em enfermagem interagindo com familiares da criança hospitalizada Alumnos del curso técnico en enfermería interactuando con familiares del niño hospitalizado


INTRODUCTION
In Brazil, the basis of health care for hospitalized children has been changing, especially after the "Estatuto da Criança e do Adolescente" (ECA -Statute for Children and Adolescents) was issued.In Article 12, the ECA states that health care establishments must provide conditions for the full-time stay of one of the parents or legal guardians, in cases when children or adolescents are hospitalized (1) .
According to the Institute of Care Centered on Patients and Family, a family is not restricted to the physical body, but it also includes the emotional and social support which is essential for health care (2) .In this respect, the literature emphasizes that there is a trend in nursing care, seeking to understand what the best way is to receive and include families as a unit of care (3) .
However, in our experience with teaching, we observed that, during the practical activities of the Pediatric Nursing discipline of the Technical Nursing Course, students frequently felt discomfort when providing care to hospitalized children whose family was present.
This situation is aggravated when peripheral venous puncture is performed and intravenous drugs are administered, which are procedures that involve children crying and feeling pain.In these contexts, students had difficulties and felt insecure for not knowing how to gain the family's trust.
We are aware that pediatric hospitalization is usually a traumatic experience, one that involves fear and insecurity from both children and family members.Thus, health professionals must give clear information to those responsible, aiming to provide care for children in a safe and autonomous way (4) .
A study on this theme showed that, in the work routine in the hospital, the interaction between family members and nursing professionals has involved some conflicts that are mainly triggered by professionals' lack of preparation to deal with the pain and suffering of children and their family (5) .
It should be emphasized that nurses are the professionals who spend the most time with patients.Additionally, in Brazil, there is a significant number of nursing professionals with a technical level providing care to the population.According to data published by the Federal Nursing Council, 43.18% are technicians and 36.80% are nursing technicians, representing 79.98% of the total number of professionals (6) .Thus, they are determinants of quality of care and the recommendations for the inclusion of families as units of care should be extended to nursing technicians.
Reflecting on this reality, the following questions arose: How do Technical Nursing Students define the situation of interacting with family members of hospitalized children?What interactions do they maintain with family members while providing care to hospitalized children?What feelings are involved in this interaction during care provision?
Searching for responses to such questions and considering the specificity of pediatric care, we proposed the development of this study, aimed at understanding Technical Nursing students' meaning of their interactions with family members of hospitalized children.To achieve this, Symbolic Interactionism was used as the theoretical framework, as one must be focused on social interaction, human thinking, the definition of the present situation, and active nature of the human being, aiming to understand human action (7) .
Knowledge about this meaning is relevant, considering the fact that there are few studies on the inclusion of families as unit of care in nursing education (8)(9)(10)(11) .Additionally, we found no publications on education and professional practice aimed at families, especially those including nursing technicians.

Ethical aspects
The present research project was authorized by the teaching institution and approved by the Research Ethics Committee of the Federal University of São Paulo.An Informed Consent Form was signed by participants, agreeing to be included in this study, apart from being in accordance with the principles of Resolution 466/12 of the National Research Council, including human beings (12) .

Methodological-theoretical framework and study design
A descriptive study with a qualitative nature was performed, as this type of approach delves into the world of meanings (13) .The theoretical framework of Symbolic Interactionism was used, a perspective of analysis of human experiences, whose focus of study is on the nature of the interaction and dynamics of social activities that take place among individuals (7) .
Qualitative Content Analysis was the methodological framework, which has been used in the area of health as it enables knowledge about and understanding of a certain theme, when the literature is scarce.In its conventional type, as it was used here, categories originate from data obtained through interviews, bringing direct information from participants (14) .

Study setting
The present study was performed in a teaching institution located in the northern area of the city of Osasco, São Paulo state.At the time of this study, this institution offered professional technical courses in different areas, including Nursing.The Nursing course had two categories: Technical Secondary Education, which lasted three years, as students had the regular secondary education and Professionalizing Nursing Education; and Modular Technical Course, which lasted two years, as the curriculum was geared towards the professionalizing course.

Study participants
Participants in the study included eight former technical students who had concluded their professionalizing course between 2007 and 2011 at the previously mentioned educational institution.Regarding gender, one was male and the other seven were females.The following inclusion criteria were selected: to have studied during the time when one of the authors was a course teacher; to agree to participate in the study, regardless of the course taken (professionalizing secondary education or modular technical course); and to continue working in nursing or not.As the number of participants was not predefined, the criteria of data repetition to end data collection was taken into consideration (15) .

Data collection and organization
Data were collected between January 2013 and May 2014 and participants were selected from a list of graduates, obtained with the students' office of the institution under study.Next, a first contact was made, when they were invited and the research project was described.For those who agreed to participate, a day and time were set up for the interview, which occurred in a room granted by the educational institution.
For data collection, semi-structured interviews were used and performed individually, beginning with the following guiding question: How was it for you to interact with family members of hospitalized children during the pediatric nursing internship?This way, additional questions were made to further clarify and deepen the theme under study.To guarantee data reliability, interviews were recorded on audio and then fully transcribed for analysis.

Data analysis
Data analysis occurred during data collection, following the recommendations of conventional Qualitative Content Analysis.Thus, after the transcription, reading and rereading, data were submitted to Qualitative Content Analysis, being coded and subsequently grouped by similarity, seeking to construct representative thematic categories of the study phenomenon (14) .

RESULTS
Data analysis enabled us to understand the meaning given by Technical Nursing students when interacting with family members of hospitalized children, which was shown in the following thematic categories: Dealing with difficult situations with family members; Perceiving oneself to be unprepared to interact with family members; Family members being a helpful tool; Developing strategies to obtain a good interaction with family members; and Teachers being facilitators of the interaction with family members.These categories are described below, including the concepts that emerged, exemplified by statements extracted from participants' speech.
To guarantee participants' anonymity, narratives were identified by the letter "I", representing the interviewee, followed by the corresponding number of this participant, in addition to the letter "R", representing the researcher.

Dealing with difficult situations with family members
In this category, students revealed that their interaction with family members of hospitalized children during the internship was complicated, as they did not trust such students, due to the fact that they were still in school and children could be used as experiments: I think it's complicated during our internship.Families don't trust you because you're a student, because they don't know that before you got there, you had a lot of theory and practice in laboratory.To them, you're using their children as guinea pigs.(I1) Even when students sought to remain calm, they felt afraid, insecure and nervous, especially when it was the first time performing a procedure: [...]There are procedures that we'd never done in fact, that child would be the first one.(I4)

[...] I'd stay a bit nervous, as it was an internship and, sometimes, the first time I was doing this. [...] At times, I'd be shaking, but I'd do it anyway. (I3)
Additionally, the fact that the procedure was invasive or not had an influence on the interaction.For students, the interaction was always better during non-invasive procedures, as they were considered to be easier and family members were not unwilling to have them performed.Concerning invasive procedures, students revealed that they had difficulties to interact with family members, especially when these were performed.Thus, the interaction at the beginning of such procedures was regarded as appalling, as they felt nervous and shaky, incapable of enabling family members to feel safe: The interaction with the families was easier when procedures were non-invasive.There were no difficulties or restrictions from the family, not that I remember.(I3)

R: And how was the interaction with the family when you began the invasive procedures? I: Honestly, it was awful! […]
A venous puncture, for example, would make me so nervous that I could barely hold the catheter, apart from the gloves that really got on the way already.I'd start shaking when I had to begin the procedure.It was horrible!I tried to make the family feel safe and calm.But, oh my, it was almost impossible!I'd shake so much!(I2) Additionally, insecurity, fear and nervousness to perform invasive procedures, anxiety and parental lack of knowledge about how to allow their children to feel safe during painful Technical nursing students interacting with family members of hospitalized children Onishi JYT, Ribeiro CA, Silva MCFCR, Borba RIH.
was based on a simple personal introduction and explanation about what would be done with the child.Because of this and the fact that such interaction is considered to be difficult, he often avoided it, only performing the procedure and making sure it was correct: We'd usually walk into the room feeling unsure and afraid of the family, because we never had a real interaction.We just introduced ourselves and explained what we would do with the child […] There wasn't much interaction with family members.You'd do something, checked if it was right or not and leave the room.No interaction.(I6)

So, for me, it wasn't easy to interact with family members, because we didn't interact much. (I4)
As a result of the lack of preparation to deal with family members, this student even states that interacting with them is not a nursing practice:

I think the Technical Nursing Course doesn't instruct us on how to deal with patients' families, especially in pediatrics
[…] I didn't have the theory first, and then the practice.Because, to me, theoretically is not a nursing practice.(I4) Given their lack of preparation for interaction and family members' constant observation and scrutiny and requests for information, students felt freer when they were not present: I realized that the family watched our every step and usually asked what we were going to do […] we felt they were inspecting us to find out what we were going to do with the children, the techniques we were going to perform.I think I personally felt nervous, because we felt some pressure […] I felt freer when the family was not around […] The mother of a pediatric patient wants to know it all, even if you explain it before, she'll ask you.(I2)

Family members being a useful tool
Even when feeling freer without the family's presence and despite the innumerable mishaps to perform procedures in their presence, students considered families to be a source of safety and support for children.This is because they were the ones who explained what was going to be done, soothing children and helping to keep them under control during procedures:

Families help because, sometimes, you can't calm them down, especially if they're very small. The family brings safety for children. To have someone you trust is certainly much better. (I1)
Yes, some families helped, they understood what was better for the children, they helped to keep them under control and to explain what was going to happen to them.(I8) Thus, as students understood that children do not always grasp what is going on, they made efforts to explain procedures to parents, who are the communication mediators according to them, in the best way possible: procedures resulted in child restlessness, hindering the interaction.At times, parents were so frightened that they would request the ongoing procedure to be stopped: The mother let me do the procedure, but I could see she was nervous and anxious.I didn't know which of us was more nervous.[…] Honestly, I had many difficulties interacting with families, especially in these situations, because of, I don't know, fear, insecurity, nervousness.(I2)When we were almost accessing the vein, the mother or father told us to stop, because they were scared.In this sense, when they watch, sometimes it affects our work.(E1) [...] For me, there were some types of procedures when families even bothered us, they made the children feel more agitated.
[…] when the parents are together, instead of calming them down, they make children more restless as they're also nervous.(I7) To be a student and not to have the family's trust was a factor that turned out to be even more intense when students noticed they were being watched by family members: The same happened when parents asked students to provide a large amount of information about children that they did not know or could not inform, especially because they were still undergoing the learning process:

Perceiving oneself to be unprepared to interact with family members
A student reported that, during the Technical Nursing Course, he would frequently enter a room and feel unsure and afraid for not having received instructions on how to proceed to interact with children's family members.According to him, the interaction with family members during this time Additionally, students reported that they felt more at peace and safer with family members helping with child care, as they had the opportunity to explain the procedures and knew that these members were aware of what had been done:

Developing strategies to achieve good interaction with family members
Considering families to be a helpful tool for patients, students reflected that "dealing with" families was required, thus encouraging them to seek and establish a positive interaction: Families are a tool to help patients.As it's a tool to help patients, we need to deal with families.(I1) Thus, despite the difficult situations and the awareness of their lack of preparation to interact with family members, students were developing strategies to maintain a good interaction, through dialogue, to explain the procedure, to approach the child and family history, and to gain their trust and permission to provide care:

I'd ask many questions about the child, if the mother had more children, where they lived, things like this about the child's and mother's life. I tried to talk to make them feel safe and calm. (I2)
When there was resistance from the family, we changed this by talking […] No, we've done this before, we received training, we know the theory, nothing will go wrong, it's a simple procedure.We tried doing this and they'd ask us questions.(I4)

I think with a good conversation we could get their permission to provide care. (I3)
Due to their great need to speak, students end up defining interaction as the attempts of conversation with the children's mother: To interact was to try to talk to the mother.(I4) Another strategy developed by students was to show that they were available to explain the procedures and treatment process.They believed that, if they managed to adequately answer the family's questions about care, this would calm them down, especially in the case of invasive procedures, when the interaction was seen as a soothing element for the family: This was the way, we tried interacting like this, explaining things.(I8)

When I was performing any type of care, we always communicated and talked to parents, we explained what we were doing. (I7)
The interaction with the family was soothing, as we explained what we were doing, the medications, what they were for and how helpful they would be for child treatment.

When the parents are present, you can better explain what is going to happen […]
We explain about care and try to calm the child and mother.(I3) In the situations when family members requested a change in the way the medication was being administered, students explained that only doctors could change the procedure, so that these members would not think their request was not being met: We'd explain that this was a procedure prescribed by the doctor […] We only followed the medical prescription and this other procedure she wanted had to go through the doctor.(I8) Finally, when developing strategies to establish better interaction with family members, students reported that they tried to adapt to the situation to explain about the child's crying during the procedure, performing with confidence, always showing control of what they were doing and, consequently, allowing the family to feel safe: During the internship, you had to be adaptable, so that parents could understand the procedure his child was going to experience.And many parents didn't understand their child was crying because of the procedure.(I8)

Ah! During the interaction with the family, I tried to make them feel safe […]
The moment we felt safe to do the procedure, we also had conditions to make them feel that way.(I1)

Teachers being facilitators of the interaction with family members
Apart from developing strategies to obtain good interaction with family members, student recognized the importance of teachers acting as facilitators of this interaction, especially when there were difficulties in the internship.Thus, teachers enabled those accompanying the children to feel safe: The teachers facilitate a lot, we feel safer.(I5)

It was much easier with the teacher's help […] we often consulted the teachers. (I6)
When I had some difficulty, the teacher would come in with us and solve the problem […] in addition, the teacher was always present, so it helped to make families feel safer.(I7) Technical nursing students interacting with family members of hospitalized children Onishi JYT, Ribeiro CA, Silva MCFCR, Borba RIH.
Students reflected that, while this was required of them, asking questions about the procedures before they were performed, teachers knew how to speak with family members to calm them down, give support and guarantee that interns had already learned about these procedures: Teachers asked before the procedures: "Do you know what this is for?If the family asks this, do you know what this is?How are you going to do this?"A lot was demanded from us [...] Teachers really helped with this issue.(I1) The teacher always tried to calm the mother […] She'd say that we know what to do, that I'm an excellent professional and that nothing wrong will happen to their child.(I4) The teacher really knew how to speak with families.(I7) As a result, according to students, parents saw the teacher as a figure of authority, someone who had knowledge and who could calm them down as a result: [...] because there was the teacher, and he [the family member] saw her authority really well, because he could see she knew how to do things.(I4) Family members saw that we were being supervised, because there was always a supervisor [teacher] nearby.So they [families] calmed down and stayed cool.(I8)

DISCUSSION
The results of the present study enabled us to understand the meaning that Technical Nursing students attributed to the interaction with family members of hospitalized children and their needs.
It was possible to see that participants were ambivalent about the meaning of the presence of the family during the Pediatric Nursing internship.This is because, despite considering their participation to be important, they reported that there was resistance against the full presence of those accompanying children, especially during invasive procedures.It was often stated that family members affected the internship dynamics, whereas they calmed children down at other moments.Additionally, students perceived themselves to be unprepared to interact with family members.
Corroborating these data, a recent study on the difficult interaction between nursing technicians and the family of hospitalized adult patients emphasizes that professionals do not feel they are capable of interacting with this family, especially because they had not dealt with this theme during their qualification or professional life (16) .
Regarding professional safety, the literature emphasizes that it is important for nursing students to have a good theoretical and practical foundation during their qualification and constant training courses for professionals to be aware of their actions and perform them confidently (17) .
Additionally, a study on nursing concepts regarding family members in health care for hospitalized children identified the lack of preparation of professionals in the way children and those accompanying them are approached in the routine of hospitalizations, showing the need to discuss the family and nursing care dimension in child hospitalization.The present study revealed that the work of nursing professionals in pediatrics has been focused on procedures, whereas the interaction with children and those responsible for them is not the aim of the care process, including sporadic and superficial family support (18) .
Thus, the literature warns that the technical concern clearly appears in the perceptions of the instructions of nursing teachers during internships, with an excessive appreciation of technical performance and more concern about performing a procedure correctly rather than about family members (8) .This is a fact, despite the theoretical framework for family care already available in the literature on pediatric nursing (19)(20) , which could be associated with the low emphasis on learning about this preparation.
In the present study, although there were several difficulties to establish a positive interaction, it was evident that Technical Nursing students sought to develop strategies to achieve a good communication and interaction with the family of hospitalized children.This approach is in agreement with studies that emphasize the fact that dialogue between the nursing team and family members is essential, keeping them informed and participating, aiming to answer questions and reduce fears and insecurity found during hospitalization (21)(22) .
Additionally, a study showed that effective communication between nurses and patients, professionals' commitment to care, and careful listening contribute to parental satisfaction with child care in hospitals (23) .
In pediatric care, we are aware that the bond between child and family member is paramount.In this sense, the work with comprehensive health actions with children points to the need for holistic care, which takes the family and social environment into consideration, apart from the different needs of family members (9) .In our reality, in the last decade, there were some studies on the inclusion of this theme in undergraduate and graduate nursing courses (10)(11) , given the importance of including families in health care for hospitalized children (24).
In this context of changes, nursing education in Brazil has been changed in recent years, aiming to meet the new perspectives of an increasingly demanding and growing market, although there are Technical Nursing Courses still following the traditional educational model.In this respect, authors affirm that some of these schools focus on technical knowledge exclusively, neglecting the humanistic side of patient care (25) , whereas others emphasize the importance of the process of curriculum reorganization based on skills in Technical Nursing Education courses (26) .
Although the present study revealed that course students consider the interaction with family members to be complicated, teachers must encourage these students to interact with family members, so that they can perceive he importance and benefits of the presence and inclusion of families as a unit of care in the hospital institution.A study on nurses' perception of the presence of individuals accompanying patients emphasizes that the closeness between nursing professionals and families in hospitals primarily requires that such professionals promote the interaction between the health team and these individuals (27) .
Technical nursing students interacting with family members of hospitalized children Onishi JYT, Ribeiro CA, Silva MCFCR, Borba RIH.
Furthermore, during the practical part, nursing students from any level of qualification must be encouraged to go beyond being a simple provider of technical care.They must be concerned about supporting children and families that are dealing with a difficult situation, aiming to achieve their expectations.

Study limitations
The study sample only included Technical Nursing students from one teaching institution.Thus, the results obtained could have been influenced by the circumstances of organization of this institution.Due to these limitations, future studies should include participants from distinct teaching institutions, such as those that have this content as part of their technical nursing course curriculum, and other participants such as the teaching staff should be included in the study of this theme.
Contributions to the area of nursing, health or public policy As described in the Introduction of the present study, there were no publications associated with education and professional practice aimed at families, especially regarding nursing technicians.Concerning the international literature, there are few studies on nursing teaching contents developed during professional qualification that include families as a unit of care (28) .
Thus, the results can contribute to the understanding of the difficulties and needs for support of nursing students, on any level of qualification, so they can interact with the families of hospitalized children.Additionally, the importance of the introduction of the frameworks of this theme in technical nursing courses should be emphasized, thus promoting better qualification and aiming at a better qualified professional performance in the future.

FINAL CONSIDERATIONS
Reflecting on the results of the present study, we can understand that health professionals need to improve their actions towards Family-Centered Care, as this change will not take place while nursing does not value such practice and patient rights are not met.
To achieve this, the inclusion of this theme must be encouraged in health education institutions as a content that covers the entire curriculum, as families must be taken into consideration on all contexts of care.Even with the advances of public policies, it is evident that it is not only a matter of investing in laws and decrees, but also seeking teaching strategies that increase the bond and understanding of family members as clients.
Aiming to incorporate the family perspective into nursing teaching, we believe it is important for the teaching staff and students of both technical courses and undergraduate and graduate nursing courses in health care institutions to raise their awareness, as nurses will be the continuous educators of this theme.However, these professionals are not always qualified to care for and value families as a unit of care.
Finally, we hope that the findings from this study can contribute to reflections and positive changes in family care teaching.Moreover, we believe that this discussion can lead to new studies on the interaction of technical professionals and teaching staff with the families of hospitalized and non-hospitalized children.Thus, with some theoretical basis for this theme, it would be beneficial for students to interact and experience having conversations with families during their qualification, as this has not been well explored in the literature.
When the procedure was invasive, parents kept a close watch on you […] others were defensive.(I5) They kept watching you […] When the procedure was invasive, they kept a closer watch […] the mother really breathed down our neck.(I7) I thought they kept watching us […] if it was right, if it was wrong.(I6) When mothers helped, I'd feel calmer, because the family could see what I was doing […] I even felt safer when the family was around […] It was better when they were around, when you could explain the procedure, when they understood what you were doing and were aware of what had been done.(I7) Technical nursing students interacting with family members of hospitalized children Onishi JYT, Ribeiro CA, Silva MCFCR, Borba RIH.
Technical nursing students interacting with family members of hospitalized children Onishi JYT, Ribeiro CA, Silva MCFCR, Borba RIH.We explained, [...] we had to explain what we were doing, what the purpose of the procedure was […] You deal with the children, but they don't understand, so you really need to talk to the parents.(I7)