Meta-synthesis about man as a father and caregiver for a hospitalized child

ABSTRACT Objective: to identify, analyze and synthesize the father’s experience in care for a hospitalized child from results of primary qualitative studies. Method: this is a qualitative meta-synthesis through which 12 articles were analyzed, selected in the Cumulative Index to Nursing and Allied Health Literature databases, Latin American and Caribbean Literature in Health Sciences, Public Medline, Scopus, PsycINFO and Web of Science, published between 1995 and 2015. The methodological steps proposed by Sandelowski and Barroso were used to systematize the review, as well as concepts from the anthropology of masculinities to analyze and discuss the synthesis. Results: the synthesis was presented by means of two themes: 1) paternal dilemmas - what man feels and faces during the hospitalization of the child, highlighting the emotional involvement and change in the family and work relationship, and 2) paternal identities - masculinities readjusted in view of the child’s illness, which reveals identity marks and repressed fatherhood in the hospital environment. Both themes illustrate the challenges and readjustment of parental identity. Final considerations: to get to know the experiences of the father during the hospitalization of the child and the way in which the challenges for the readjustment of roles related to masculinity could broaden the range of nursing and other health professionals, alerting to the importance of including the father as a protagonist or coadjuvant in the care for hospitalized children.


Introduction
Although the differences between the concepts of fatherhood and motherhood are interpreted in various ways, in some cultures, the identity of the child's caregiver, historically assumed by the woman, seems to be a universal consensus when analyzed from the hegemonic perspective of masculinity (1)(2) . Masculinities multiply in the cultural universe of men though, and certainly coexist among the established social power structures; thus, complicity, subordination, marginalization, among others, are also power relations present in the paternal identities.
As for the care provided during the child's illness, even when the primary caregiver is the woman, the family is reorganized the roles are redistributed among its members in view of the child's illness and hospitalization (3) . At this stage, a range of feelings integrate the identity of the father, such as love, responsibility, concern, fear, anxiety, stress, guilt, sadness, impotence, helplessness and uncertainty regarding the child's improvement (3)(4) .
The distribution of identity roles in the traditional family, in which man is acknowledged as the provider and the woman as the caregiver, has been modified over the years (5) . This change is mainly due to social and economic changes, with emphasis on women spending more time outside their home, and culminating in the redefinition of the father's participative roles in child care (5) .
At present, researchers have pointed out that, when the child is hospitalized, the father assumes the care for healthy children and domestic activities, while at the same time developing work activities to provide for the family, while the mother is responsible for accompanying the hospitalized child, giving up her daily activities (3) .
Even when health professionals value the presence of the father as a caregiver in the hospital context (6) , the mother still has the role of the child's primary caregiver (3) .
What the social aspect is concerned, the presence of the father as a caregiver in the hospital has been little observed, as has the incorporation of this identity by the fathers. Thus, in addition to the emotional factor, other impacts fall on the mother due to the child's hospitalization, such as overload and concern with the domestic routine, the family at home, the sick child and the context of the hospitalization (3) .
When the father assumes the role of caregiver, a positive contribution is observed for the whole family, mainly concerning the physical, emotional, intellectual and social development of the child (7) . The man shows difficulty in assuming this role though, and considers himself to be an adjunct to the woman in this role, believing that she performs it better (4) .
The male hegemonic identities men have assumed in history as fathers of traditional Western families help to understand why they advocate the reproduction of behavioral stereotypes that do not fit the caregiver role. In diverse cultures, taking care of the children is interpreted as the incorporation of a hypo-male or feminine identity that is not compatible with the power and dominion exercised by the patriarchal man (8) . Thus, men distance themselves from care and approach the valuation practices of their protective, procreative, heterosexual and virile identity (2) .
Knowledge about parental practices in care for the hospitalized child is still scarce when compared to studies focused on the mother's experience as a caregiver (9) . A search was conducted in the Cochrane Library to identify potential qualitative reviews about the father's care for the hospitalized child, or the analysis of this care from the father's own perspective.
No review was identified, however, that emphasized the results of qualitative research focused on the father's care for the hospitalized child, independently of the hospitalization sector, or the analysis of this care from the paternal perspective.
Different literature reviews have evaluated the experiences of the father of children with cancer (10) and type 1 diabetes (11) , of the father with newborns admitted to Neonatal Intensive Care Units (NICU) (12) , of the father during the first year of the child's life (13) , his contribution to managing the child's chronic condition (14) , his participation in the child's hospitalization (15) , and the different role perceptions between Eastern and Western parents in view of crisis situations related to the child's illness (16) . The lack of reviews on the experience of the caregiver father of a hospitalized child expresses the importance of synthesizing the current knowledge from qualitative studies based on the perspective of the father who experiences the hospitalization of the child with different clinical conditions. The interpretation and synthesis of these qualitative data are crucial aspects to identify the direction of future studies, to maximize the father's experience, besides appointing the father's needs in care for the hospitalized child.
The review question was "What has been the paternal experience in care for hospitalized children?".
The objective of this review was to identify, analyze and synthesize the father's experience in care for the hospitalized child from results of primary qualitative studies.

Methods
This is a qualitative meta-synthesis. The approach used to develop it involved the following steps, proposed by Sandelowski and Barroso (17) : a) elaboration of the research question and problem, b) systematic identification and selection of articles for analysis, c) quality appraisal of articles, d) extraction of the data and e) elaboration of the synthesis. Recommendations described in ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research) were used to report the qualitative synthesis (18) .
We started with a comprehensive literature search to identify all articles that used a qualitative method to describe the experience of the father in care for the   (19) to report on the inclusion process of the studies. In total, 136 references were obtained, of which 118 were identified in the databases and 18 in other sources, derived from the personal collection of the authors of this meta-synthesis (N = 2), from the references of the included articles (N = 1) and from relevant literature reviews on parental care (N = 15) (10)(11)(12)(13)(14)(15)(16) .
A total of 119 articles were reached after the removal of repeated references. Two reviewers read the titles and abstracts of these articles and judged, independently and later together, if the articles met the inclusion criteria.
As a result of this process, 28 articles met the eligibility criteria. To evaluate the interobserver agreement, the Kappa coefficient (20) was calculated, and the result Two reviewers independently assessed the studies, based on the criteria listed above, and discussed the differences between their assessments to achieve agreement. It was not considered relevant to exclude any of the 13 studies based on quality, since this meta-synthesis is focused on a problem in a knowledge are under development and, therefore, all were considered important, because they contribute to the understanding of the father's experience in care for the hospitalized child. Another reason was the lack of agreement on whether or not to include studies on the basis of structured approaches to the assessment of research quality (22) .
In the process of extracting and synthesizing the data, first, two reviewers carried out successive readings of the 13 complete articles, from which they extracted Rev. Latino-Am. Enfermagem 2017;25:e2922.
the data independently. According to the review question, the data were organized in a standardized form, developed by the reviewers for that purpose.
Information about the method, study participants, and results was extracted by thoroughly evaluating articles, line by line. Secondly, together, the reviewers reevaluated all the data extracted, reaching a consensus on divergences in the initial evaluation.
Simultaneously with the data extraction, coding was performed to elaborate the categories related to the experience of the father in care for the hospitalized child, in order to facilitate the synthesis of the data. The process of coding the results of the articles was guided by the thematic analysis, composed of 6 phases: i) get familiar with the data, ii) generate the initial codes, iii) search the themes, iv) review the themes obtained,  (23) . Coding was performed inductively, in that codes were continuously compared and related.
Subsequently, the reviewers independently organized the codes in descriptive themes and then together, aiming to solve some conflict, interpret them critically and develop the analytical themes. To complete the synthesis and maximize validity, a third reviewer integrated the team and carefully checked the fit of the codes in each category, as well as the concepts related to the categories listed.
The themes were carefully integrated and expanded to determine a general conceptualization of the data and, to this end, concepts from the anthropology of masculinities (1)(2)24) were used to explain the constructed themes. Thus, a new interpretation was possible for the results of the primary studies.
In five (25,27,29,31,34) studies, the theoretical framework that supported the development of the study was not presented. These articles were named in the present study as generic qualitative (38) , since they were not guided by an explicit or established set of philosophical presuppositions, in the form of a known qualitative method, such as the grounded theory for example (26,28) .
The quality of the qualitative studies was generally considered to be good, according to    6. Has the relationship between researcher and participants been adequately considered? 11 1 (30) 1 (33) 7. Have ethical issues been taken into consideration? 12 0 1 (26) 8. Was the data analysis sufficiently rigorous? In one of the studies (26) , there was no mention of ethical aspects. In another (30) , the information about the recruitment strategy used and the relationship between the researcher and the participants were not adequately reported. And, in a third study (33) , the information about the relationship between the researcher and the participants was not mentioned.

Themes Knowledge synthesis
Paternal dilemmaswhat the man feels and faces during the child's hospitalization

Emotional involvement
Conflicting feelings of sadness, fear, impotence, guilt, anger, pain, gratification, anguish, insecurity, concern, responsibility, suffering and anticipated mourning result from the child's illness and hospitalization (25)(26)(27)(28)(30)(31)(32) Change in family and work relationship Partner: experiences changes and divergences in the relationship with the partner (26,30,(34)(35)37) Children: modification of the relationship with the children, offering greater attention and care to strengthen the bond (26,28,30,34,(36)(37) Work: difficulty to conciliate work practices with new caregiver tasks, leading to stress, burden, feeling of guilt and unproductivity at work (26,30,(32)(33)(34) Paternal identitiesreadjusted masculinities in view of the child's illness Identity marks Caregiver: feels the need to put in practice the caregiver identity during the child's illness, being present and actively engaging in direct and indirect care for the child, despite being tiresome (28,31,33,(37)(38)(39) Family head: feeds the need to be strong and reluctant to demonstrate his feelings so as not to burden the partner, and to remain active in the relationship, without worrying about being the family's support when it is weakened, as he considers to be responsible for playing the role of the family head, with a view to keeping the family united when the child is hospitalized (25)(26)(27)(28)(29)(30)(31)(32)(33)39) Provider: feels responsible for being the family's financial provider, due to the costs during the child's illness (26)(27)31,35,37) Repressed fatherhood in the hospital environment  For parents, hospitalization is considered a moment of devastating crisis for the whole family (27)(28)30) . This phase is experienced with a variety of feelings, in which the bond and joy of becoming a father are threatened by the challenge of dealing with the child's vulnerability and possibility of death (26,33) . Among the conflicting feelings are guilt, anger, pain, sadness, insecurity, worry, responsibility and fear of the future (26)(27)(28)(31)(32)(33)(34) . All of them derive from the context of the child's illness and are capable of affecting the father's organism, who starts to present insomnia, anxiety, feeling of having a dry throat and lack of appetite (31) .
The hospitalization of the child also affects the relationships with the partner. Studies have shown the need to negotiate functions between the couple to meet the demand for care of the sick child and the family (27,36) .
In this process, divergences usually emerge when the mother directs her attention only to the hospitalized child, which affects the couple's relationship (31) . In addition, at the moment when she acts as an inspector, she directly and indirectly influences the father's involvement in the care for the hospitalized child, to the point of hindering his insertion in this function (35,37) . This maternal influence on parental care is also associated with the father's insecurity in dealing with the situation, which leads him to behave as a coadjuvant of the partner (27,32,36) , requesting her approval for any decision on the care for the sick child (27,36) .
Regarding the relationship with the children, the hospitalization made the fathers afraid of engaging in care out of fear of harming them (26,32,35,37) , and also because of the technologies and barriers of the hospital space, which hindered their involvement, especially in situations where twins were hospitalized in distant beds (35,37) . Parents identified positive changes in their relationships with their children after the illness (27)(28)31) though, acknowledging the importance of being present in the recovery process (29,35,37) . The situation of crisis made them more involved in parenting (37) , and when involvement in care culminated in the improvement of the children's clinical condition, feelings of happiness and love emerged (29,37) .
With the son's illness, new demands arise for the family; the father needs to support his wife emotionally, perform household chores, and care for other children, while at the same time financially providing the family with work, which creates high levels of stress (31,(34)(35) . The father, because he is considered the provider, needs to work and show productivity at work precisely at the moment when he would also like to be present in the hospitalization of the child (28)(29)(30) , or alongside other family members (27)(28)31) .
This impossibility of becoming more involved in the care for the child and the family, as well as the need to attend to the work activities, generates feelings of guilt that affect their productivity (28)(29)(30)32) . Studies have pointed out that men want flexible work hours to meet these demands; parents from higher economic classes are more successful in this negotiation though (31,37) . for positive meanings for the child's illness and support beliefs, maintenance of hope and resumption or adoption of spiritual practices (27)(28)(30)(31) . Studies show that, in the paternal perspective, the child's illness brings personal growth to the man (27)(28)34) and to those around him (30) .  (1)(2)24) have provided an appropriate approach to assign meanings to the paternal experience and the elaboration of the qualitative synthesis. When a cultural approach is given to male behaviors (1) , man is perceived as the product of his social environment, and the effects of his behaviors are justified by gender patterns and masculinities that fit each culture (24) .

Discussion
Thus, paternal behavior, during the illness of the child, is understood as influenced by the way in which the fathers experience the culture, masculinities and gender.
Studies have shown that seeing his child ill triggers a series of emotions in the father (26)(27)(28)(31)(32)(33)(34) because, as highlighted, when the child becomes ill, the whole family becomes ill together (27)(28)31) . The father's emotional involvement is characterized as a posture that leads him to try to escape from the male stereotypes that imply that he is strong, contains his emotions and does not care for others (12) . These masculine identity norms, acquired from the cultural midst, collide with the new needs of the family, since the father adopts new identities, like that of caregiver (31) .
He also assumes behaviors historically delegated to the feminine, like that of caregiver, and understands that they can be equally shared by man. There is, therefore, a redefinition of the hegemonic masculinity identity towards another, which is anchored in the concept of multiple masculinities, since men, as well as the culture that governs them, assume identity roles that vary according to their historical time, social class and experience they acquire throughout their lives (1,8) .
Regarding the paternal masculinities, evidenced in the literature analyzed (27,36) , specifically the identity of care approached the participants in the studies to in the hospital environment. Some showed that the presence of the man in the hospital generates discomfort for him, for other companions and for the team (28)(29)32,37) . He does not feel welcomed by health professionals and other companions of children in the pediatric unit, since it is a space predominantly attended by mothers and, therefore, it is their social function to accompany the child's hospitalization process. The fathers indicated that this environment is not prepared to welcome them (28)(29)37) .
In addition to not being accepted in the hospital context, the man feels judged by the other mothers because he does not have the same knowledge and the same abilities expected from the mother figure, which makes him feel sad and helpless (27,31) . Linked to this, he considers that health professionals can hamper the care he provides, limiting his access to information by using technical language (27,(29)(30)33) and making it difficult for him to take control of the situation (30,35,37) . He also feels a lack of support in the hospital environment and believes that the mother receives such support (30,32,37) .
With the son's illness, studies have pointed out that the father tries to assume his role of caregiver by being present and involved in caring for the child's needs, even if, in order to do so, he has to neglect his own needs (26,29,31,(36)(37) . In order to assert his masculinity, being head of the family, he is healthy and strong in front of the family (26)(27)(28)(30)(31)(36)(37) and is reluctant to show his feelings, so as not to burden the partner, since he considers her fragile (26)(27)(28)(30)(31)37) . There is a feeling of helplessness and sadness though because of the inability to protect the hospitalized child and his family (30)(31) .
The father also has a sense of lack of control as he is unable to protect the child from pain and suffering, as well as to maintain the stability of the family, because he cannot meet the entire demand deriving from the illness (26,(30)(31) . It is through work that man tries to recover his hegemonic masculinity, maintaining himself as provider of the family to mitigate the financial impact caused by the disease (26,(30)(31) . The father seeks, at all times, to make decisions that keep his family together, trying to reassume his role as protector (27)(28)31,(36)(37) . In this attempt, he also assumes the responsibility for guaranteeing the quality of care, defending the health needs of his son (27)(28)31,(36)(37) .
The fathers demonstrated overconfidence in their self-control to mediate the situation, but despite their reluctance to accept support, they made it clear that they needed help (28,31) . Other ways of seeking control were: escape from the situation with physical activity, search Rev. Latino-Am. Enfermagem 2017;25:e2922.
a subordinate masculinity, so that they reacted with concern towards the illness and responsibility for the care of the hospitalized child, culturally delegated to the female gender (1)(2) , which therefore fits them into a subordinate masculinity. The subordinate masculinity refers to the identity in which the man submits to a situation of being dominated by a hegemonic pattern (1) .
In this study, the fathers were subordinated to the women's domain, due to their insecurities to make decisions regarding child care without the prior approval of the mothers (27,36) .
The meta-synthesis showed that the child's illness interfered in the father's marital relationship, since there is the initial impact of the child's illness, uncertainties about the future, and the need to make new decisions about the child's treatment (27)(28)31) . Father and mother are frightened by the possibility of loss, generating an imbalance in the couple's relationship and the need for greater support (30)(31) . The negotiation of the roles occurs to attend to several other family activities, while at the same time it is necessary to provide the family with financial support through work (27,32,36) . The masculinity of complicity presents itself as one in which some precepts of patriarchy are shared, but there is no full adoption of hegemonic patterns, which places men in an identity of accomplice of various behaviors culturally associated with the feminine gender (1)(2) .
Throughout the child's illness, this meta-synthesis has shown that the woman reaffirms her role as a caregiver and may resist allowing the father to share this role (35,37) . When the father shows the ability to do so, the mother is receptive to his care, but when he shows insecurity, she resists allowing his involvement.  (27)(28)(29)(30)(31)(32)37) . These results agree with what has been pointed out in the literature (6) . It is perceived that the different masculinities are in constant disputes with each other, as well as the cultural identities that produce them (1) . Promoting the adoption of male behaviors, deviant from hegemonic patterns, contributes to the development of new identities, one of which is revealed by paternal care in the hospital space (39)(40) . Although this act calls for adaptations that restrain hegemonic patterns of masculinity, such as non-sensitivity and relations of dominance over women, parents feel insecure and have shown fear of harming the child in situations of fragility due to illness (26,32,35,37) .
The unfriendly hospital environment, with innumerable technological devices, and the impossibility of touching or holding the child (32,35,37) were other triggers of the fathers' insecurity.
Even with these barriers to care, the father were able to identify positive changes in the relationship with their children after the illness (27)(28)31) , as they became more involved in caring and became closer to the child.
The father acknowledges his importance in the recovery of his child (29,32,35,37) and wants to be a better father (37) .
Their presence has essential effects for the development of the child, who needs the support, security and values transmitted in this relation (14) .
Literature also points to the emergence of new masculinities for the father in the face of social changes as, besides continuing to serve as the family provider, he is expected to take care of the child, along with the partner, in a more flexible, affectionate and egalitarian way (41) . Therefore, being a man, father and caregiver of a hospitalized child corresponds to the adoption of an identity that is in constant process of redefinition of masculine roles. The field of pediatric health perceives the father as a potential caregiver and partner in child care, even if this role does not integrate the repertoire of concerns surrounding culturally established hegemonic masculinity, including in health services.

Limits and strengths
The results of this meta-synthesis should be

Final considerations
In this meta-synthesis, the father's perspective in child care during the hospitalization process was