Patient safety : perception of family members of hospitalized children

Rev Bras Enferm. 2020;73(5): e20190525 http://dx.doi.org/10.1590/0034-7167-2019-0525 8 of ABSTRACT Objectives: to know the meaning attributed by family members to the health safety of pediatric patients, with attention to the possibilities of their collaboration. Methods: this qualitative study was conducted with eighteen family members of children hospitalized in a pediatric unit, from January to July 2018. Symbolic Interactionism was used as a theoretical framework, and Inductive Content Analysis as method. Results: child hospitalization poses risks to possible incidents and adverse events. Participants and professionals are responsible for patient safety. Thus, their actions focus on error prevention. Therefore, they seek information and observe in a vigil way professional care in classic aspects of safety. They conceive essential and favoring safety the approach centered on children and family members. Final Considerations: family members recognized the chances of errors and care damage, identified themselves as support in minimizing damage and were in partnership with the professional, increasing chances of effecting safety. Descriptors: Patient Safety; Pediatric Nursing; Child, Hospitalized; Family; Family Nursing.


INTRODUCTION
There is, in the Brazilian health and education spaces (1) , an increasing effort and commitment to Patient Safety (PS) (2)(3) , especially in view of the creation of the Brazilian National Patient Safety Program (Programa Nacional de Segurança do Paciente) (2) . Collaborative partnership with the family is among the challenges (2)(3)(4) , with a differentiated emphasis on child hospitalizations (4) .
Thinking about PS with pediatric patients implies not losing sight of the fact that children are in full process of development (5) , and family members are their primary context of life, the ones who know their particularities, reference people (6) . Thus, they are effective as important partners in ensuring safety (6) , since, during hospitalizations, they act seeking physical and emotional safety of hospitalized patients (7) . In pediatrics many adverse events (AE) could be minimized in the face of effective partnership and communication with the family (6,8) . With emphasis on nurses, who have an essential role within the multidisciplinary team for process standardization, thus reducing incidents and AE, considering that to carry out safe care is important senior management support (9) .
A global analysis noted that 3 to 16% of hospitalized patients suffer AE (10) . A study conducted in three hospitals in Brazil showed an index of 7.6% of AE, considering that of these, 66% were preventable (11) . Concerning Pediatric Intensive Care Unit, the mean rate is 2.9 adverse occurrences per child (12) . The proportion of AE among Brazilian hospitals was similar, but higher, when compared to international studies (11) .
The main factors that imply child safety are related to the identification, experience of professionals, performance of technical procedures, calculations of medication doses and communication among professionals, and also with the family, protagonist of care in the pediatric context (13) . Although the participation of the companion in building partnership in care is still a challenge of health institutions, the literature highlights that effective participation of family members in health care minimizes the occurrence of AE (4) . Based on this contextualization, the question related to research was: how do family members perceive safety of hospitalized pediatric patients and possibilities of contributing to it?

OBJECTIVES
To know the meaning attributed by family members to the health safety of pediatric patients, with attention to the possibilities of their collaboration.

Ethical aspects
All ethical recommendations for research with human beings were followed. The Research Ethics Committee of the Universidade Federal de São Carlos approved the study, under Opinion 2,414,418 and CAAE (Certificado de Apresentação para Apreciação Ética -Certificate of Presentation for Ethical Consideration) 78313517.8.0000.5504.

Theoretical-methodological framework
Symbolic Interactionism was used as a theoretical framework, and Inductive Content Analysis as method.

Type of study
This qualitative and descriptive study focused on understanding from integrating subjectivities, perceptions, symbolisms, and values (14) . Therefore, the theoretical framework selected was Symbolic Interactionism (IS), because it favors the understanding of social interactions and how meanings are established from them (15) .

Study setting
This study was conducted at a pediatric unit of a university hospital in the countryside of the city of São Paulo, between January and July 2018. There is in the institution a Patient Safety Center, with actions focused mainly on qualification and training of professionals. This unit has 12 beds distributed in single rooms. Hospitalizations in this sector account for 15%/year of the total institution. The main causes are respiratory system diseases, classified mostly as intermediate care and high dependence. Family companions are given a folder on admission entitled "Guidance to hospitalized patients and companions", there is information regarding identification and exchange of companion, time and number of visits, food, organization, recreation for children, and personal hygiene.

Data source
A total of 18 family members were part of the study, 17 mothers and 1 uncle, companions of children from 0 to 12 years old incomplete. With a view to anonymity, the excerpts were identified by letter (E), followed by the Arabic number in the order of entry of the participant in the study.

Data collection and organization
Participant selection was intentional, selected according to adequacy to the inclusion criteria and possibility of providing relevant data to the study. At random, the researcher checked the study criteria with the unit nurse, the person who intermediated the invitation to study. The invitation was made in the child's room, when accepted, a scheduled time was immediately agreed for the interview, a strategy used in the study. The selection criteria of participants were: a) to be a companion and family member of a child in hospitalization; b) to be accompanied by the child for a minimum of 48 hours of hospitalization. As an exclusion criterion, the companion was not able to generate understandable narratives.
The interviews were conducted in the child's own room, in the presence of the child, due to the absence of someone available to be with him/her. Before starting the interview, the Informed Consent Form was presented, read together, with openness to placement of doubts, which were promptly clarified. The semistructured interview was then developed, when the following guiding aspects were taken: perceptions about patient safety; meaning of remaining accompanying the child during hospitalization; previous experiences of hospitalizations of the child and follow-up. One hundred ninety-seven minutes and nine seconds of recordings were collected, with the aid of a digital recorder. The end of data collection occurred based on the criterion of theoretical saturation, that is, when interviews did not reveal new facts and/or evidenced repetition of reflections/notes (16) .

Data analysis
All interviews were recorded in audio, transcribed and analyzed in the light of Inductive Content Analysis. The inductive approach has the raw data as the starting point, and then develops deductive and inductive analysis processes. Reading and rereading supported by the theoretical framework direct the establishment of categories, from three phases: preparation, organization, and reporting of results. Preparation was the moment of data collection for content analysis, taking into account the data collection method, sampling strategy and selection of an appropriate analysis unit. Organization consisted of open coding, category creation and abstraction, in this phase the researcher was responsible for analysis, and the other researchers followed and complemented the process of analysis and categorization critically. In reporting, the results were described by the content of the categories that comprised the phenomenon (17) .

RESULTS
Data analysis allowed the understanding of three central categories: "Patient safety: continuous commitment", "Family presence: partnership for PS" and "Childcare: PS use" that together portray that companions conceive of themselves as co-responsible for PS, when they need to observe professionals in relation aspects that, in their view, integrate security.

Patient safety: continuous commitment
According to companions, PS is an institutional and professional obligation. This is an aspect that must be present longitudinally and is linked to the act of professionals to monitor the child in the hospital in an attentive and interested way. They highlight issues related to their illness, especially regarding medication administration and evolution of the condition. Therefore, as companions, they observe professionals in the direction of confirming whether they are behaving in this way. [ Among the aspects meaning as relevant to PS, there is the decrease in chances of transmitting pathogens/risks of infection. In this sense, they are highlighted: (1) hand hygiene by professionals, before, during and after procedures and care; (2) cleanliness of professionals; (3) cleaning of the environment and clothes used with the child; (4) use of gloves by the health team; (5) non-reuse of hospital materials.
[...] the first contact for our safety and patient safety is hygiene. We hear about the bacteria, but we don't see it, so we don't 'care' , but they're here and we have to be careful. If  Also, the controls appear as part of PS, whether access, compliance with the rules of visits in the pediatric unit/hospital space. The set of notes above is continuously observed and taken into reflection in terms of presence and its actual effectiveness in the establishment of opinions related to PS.

Family presence: partnership for PS
Companions understand themselves partners in PS, and this social role, the act of protecting the child is central. Paying attention and claiming the issues of PS are guaranteeing rights. To perform this role, they bet on the surveillance of child care either through observations of professional acts or dialogues with them. They need to understand what is being performed, the purpose and, thus, they launch themselves into a curious, questioning and reflective attitude of what they see and hear to articulate the various evidence, and understand the means and purposes of actions performed by the team.
Staying with the child is an essential condition for the exercise of this role, perceived as an obligation. The continuous presence guarantees the occurrence or the complaint of aspects related to PS, when they highlighted the team's prompt alert, of AE that may occur with the treatment, conference of the administered therapy and its relation with the child's situation, in addition to space for address risks it identifies. The presence continues with informational support provides the opportunity for the family member to take direct care of their child and to supply, in need, limitations of presence that professionals may have. This aspect is also perceived as a partnership in the direction of PS.

We also help because it's not always that they [professionals] can be here with patients, so we end up helping. (E10)
Experiencing AE places the companion in a redoubled position of attention in favor of PS.
[...] it was dangerous when I arrived, they put on the wrong bracelet, they put on that of another child [child with the same first name] who had a respiratory problem. I found out that the bracelet was wrong when they came and brought the medication to put in the inhalation, and I still asked: "but he has no inhalation, he has a urine infection", it was when she looked at the bracelet and saw that it was wrong. (E15)

Child welcoming: recourse to PS
PS permeates, in the perception of companions, the understanding of children as people who are impacted by hospitalization and its consequences. In this direction, they highlight that welcoming children by professionals and family members favors PS. Children's perception, when part of care feels safe and concomitantly, is a facilitator of PS, is still incipient in professional practices. Even when dealing with pediatric nursing, actions are still limited to identification policies, communication among professionals, medication administration, risk of falling and pressure ulcer, thus not recognizing the uniqueness of childhood.

DISCUSSION
This study composed and corresponded to the need for investigations on PS and companions of hospitalized children. It was possible to observe that, for family members, there is the possibility of reducing the chances of damage when professionals consider the impact of child hospitalization and when they are included in the care of their own. A study conducted with hospitalized children of school age reinforces the importance of care being performed with affection and respect, in addition to the step-by-step explanation of procedures by professionals, so that children understand the real need, feeling safer (18) . Hospitalization modifies the daily lives of children, implying their behavior in this period. Attitudes such as attention, respect, affection, patience, education, dedication, liking what you do are taken as an effective care under the gaze of pediatric companions (19) .
Previous notes refer to PS in the use of relational and communicational strategies aligned with the child's development. In this context, communication is a crucial tool for PS assurance, being a bidirectional process from the exchange of information between sender and recipient, both with the duty to ensure effective communication (8,22) . Being close is essential, but receiving guidance and information about the real situation is indispensable to reassure family members at this difficult time. Communication is essential according to SI, since without it social interaction does not happen. It is inserted in the concept of symbol, being actions or words with intentionality and meaning. The importance of clear and complete communication of the team and the attention given to children and their companions emerged, in the experience of the interviewees, as factors that favor safety. At the health service in question, companions were satisfied with the communication and interaction with the team.
In a study with companions of children hospitalized in pediatric hospitalization units in a university hospital in southern Brazil, communication was pointed out as a fragility in care, listed by the recurrent lack of information and non-consideration of observations of companions (5) . Although they considered communication important for safety, there were many flaws in the process (5) , a difficulty that was not identified in this study. From the perspective of SI, we highlight the importance of knowing how and why people act in certain ways, in order to achieve effective communication and symbolic interaction (23) .
Family means to be co-responsible in issues of PS (6) , when being with the child is a condition to pursue their role, as well as the informational support conveyed in the relations with professionals. This allows us to say that a care approach that recognizes and accomplishes it is fundamental in order to guarantee support for the role designed by it. Information on family structure and functioning is essential in this context. Family needs to be included in care, highlighting these interactions for the construction of bonding, respect, trust, and care, considering the particularities of each family member in understanding information about child safety and health (20) .
The adoption of an approach centered on children and family members contributes to interactions based on respect, affection, compassion and other values that promoter bond and collaborative relationships. The findings of this study endorse the relevance of professional-family-child collaboration for the achievement of partner care practices, including AE prevention in child hospitalization (6) .
There are chances of care errors in child hospitalization and companions are fundamental in minimizing and preventing them when they work with vigilant observation, requesting clarifications and/or performing care actions with children. The family acts according to the meanings of the facts and the moment they are living, and they are changing through a constant interpretative process of symbols, from social interactions established with health professionals (15) .
From the perspective of SI's central ideas, we act according to our definitions established in the present, depending on the social interactions experienced (15) . Protection is the social action envisioned by the family member who established, for the participants of this study, from the identification that there are efforts of professionals to reduce the chances of errors/damages, but that despite them, chances remain present with errors happening, exemplified here in terms of exchange of identification, medication, relationships that favor tensions with children. Thus, they understand that they need to take a role in this setting, but they find limits in terms of establishing an effectively collaborative relationship with professionals. Recommendations to professionals include getting closer to the companions, contributions of knowledge about the theme "PS" (5,24) and investments in their involvement (companions) in care (3,25) . An Austrian study pointed out the desire of companions and patients to be involved in PS issues, the presence of strategies to improve participation in health institutions, but still with gaps in terms of effective collaboration of health professionals in this direction (26) , an aspect also revealed in this study.
In treating PS as a continuous commitment of institution and professionals, there is a growing concern of health and teaching institutions with the patient safety policy, focusing on the adequacy of action plans for greater effectiveness of the institution and advancement of the services provided (1,27) . There is investment in bringing the companion closer to the care being provided, to make them partners for the prevention of failures and damages, with increased chances of a safe hospitalization (3)(4) . Efforts are to ensure rights and an active role in the health service (3)(4) .
When directing the aspects treated as PS, risk of falling, identification of the child, and delay or exchange of meals were mentioned on a recurring basis, with emphasis on hygiene and issues related to medication (28) , especially from an understanding of being avoidable errors. Hygiene was named as paramount to ensure safe hospitalization. Family companions recognized that the team practiced this care, and instructed them to do the same. Personal, environmental and furniture hygiene were observed and denoted a lower risk of infection.
Hand hygiene is a simple and effective measure in the prevention of infections related to health care, considered the measure with the greatest impact in this regard, since it prevents the crosstransmission of microorganisms. However, compliance with this practice by professionals is still a challenge in health services, patients and companions (29) . Despite being a simple measure of security, there is still low compliance with carrying it out. A study revealed that approximately 55% of professionals sanitized their hands before and/or after manipulating the child (6) . This fact is not highlighted in this study, since participants demonstrated satisfaction with hand hygiene performed by professionals.
Concerning medication, the family member, even without knowing the literature on the subject, has concern and remains attentive in some aspects that seem to him/her to be of paramount importance -that the medication is for his/her child, the right medication, as well as the right time -besides valuing the attention of the professional in its administration. Medication errors are any preventable events that can lead to improper use of the drug. To prevent these from happening, there is the recommendation to check the "right 9" for safe administration: right patient, right medicine, right time, right way, right dose, drug compatibility, patient guidance, right to refuse the drug, correct annotation (3,30) .
Participating in the time of medication is a right and being attentive to the team can significantly help the improvement of care and damage reduction (3,30) , a practice highlighted by the participants of this study. In addition to the participation of the family member, a research points out the benefits of using technology in this process, reducing up to 65% of medication errors when implementing electronic prescription (31) .
In contrast, physical safety of space, presence of access control to the hospital unit also composes the child's safety during hospitalization, the result of the symbolism of being barriers. A study conducted with companions in a pediatric clinic in the city of Goiás revealed that attention, respect, affection, and patience are directly related to the quality of care, in addition to the concern with the presence of strangers in the hospitalization space (6) , factors that these participants also highlight as promising safety in the hospitalization process.
The statements bring out observations related to the current hospitalization of the child, as well as to the previous experiences of family members in other health institutions -which may compromise patient safety -being related to several points, from physical space to professional preparation. These experiences support some attitudes that the companions took during the hospitalization process; that is, the want to participate more and watch to protect the child from AE. Another study obtained results that corroborate ours, in which the most reported themes in previous experiences dealt with medication errors, poor equipment and/or professional unpreparedness, inaccurate diagnosis and communication failure. For these reasons, companions and patients experienced a series of negative emotions, frustration, stress, unhappiness, mistrust and fear (32) .
The individual develops his actions through a process of symbolic interaction with himself and with others, allowing a distinct understanding of the experiences lived (33) . This interaction occurs by the interpretation of symbols -such as language, feelings and behaviors -and under the influence of the past and the present for decision-making. The meaning attributed to the experiences experienced by family companions directly influences their behavior in the face of stressful events, shaping their conduct and directing their actions towards the child's safety in this hospitalization process.
Advances in pediatric PS are necessary and the suggestion is to invest in the continuity of exploration related to PS and care approach, especially exploring the partnership with the child and with the family.
PS is a patient's right and has a direct relationship with the quality of health care and with the professional's commitment to his/her social role (34) , an aspect highlighted by the participants of this study and others (4,6,24) . To effectively involve the family member in child safety, it is still necessary for professionals to improve the instrumentalization of companions through education in this aspect and in the formalization of records in medical records, considered still incipient (35) . The involvement of family members in safety and damage issues strengthens the culture of PS (6) , as well as the involvement of the child himself/ herself within his/her developmental possibilities. Expanding the culture of PS implies instituting the culture of the approach centered on the person of the child and the family in pediatric units. Recognizing children and family members as individuals with rights that need and deserve to be included in care at the level of their understanding, with affection, compassion, and patience enables safe and inclusive care.

Study limitations
The study was conducted at a medium-complexity health service, in a short period of hospitalization, not extending to other realities. Furthermore, it explored in a limited way the notes related to the child-centered approach, since this was a finding of the final analytical phase. Thus, studies that take more pediatric clinics are suggested, as well as studies that explore PS and welcoming of children and PS, and communication with the family.

Contributions to nursing, health, and public policies
Concerning contributions, it was revealed that companions relate PS with the care approach used by professionals. It considers reducing the chances of damage when the professional considers the impact of child hospitalization and child care processes on interaction with it. In fact, interest and effort in knowing the child and their needs contribute to the establishment of a more solidary and collaborative relationship, minimizing the performance of procedures and actions under the pressure of time, as well as the use of restraints, constraints or other disrespectful ways to force their collaboration. In addition, there is the possibility of creating strategies that increasingly involve companions, so that they become active participants in health services and help reduce damage and minimize risks to patients.

FINAL CONSIDERATIONS
The study allowed us to know how family members accompanying hospitalized children understand PS and their role in this context. They demonstrated to define it from aspects that in fact integrate it, signify co-responsibility for it, with chances of being active in preventing errors and damages. Therefore, they point out the importance of establishing a collaborative and complementary relationship between them and the professional, in which effective communication throughout care and hospitalization is essential. Still, they point out the relationship between the professional and the child as a member of PS, when professionals need to recognize the impact of hospitalization and illness on children. The understanding is that the partnership between professionals and family members for children is relevant to safe care, and should be an assistance bet.

FUNDING/ACKNOWLEDGMENT
We would like to thank the Brazilian National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico) for funding this study.