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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.5 São Paulo Oct. 2011
The accompanying mothers' perception about humanization of assistance at a neonatal unit
La percepción del acompañante respecto de la humanización de la atención en una Unidad Neonatal
Eliete Genovez SpirI; Alda Valéria Neves SoaresII; Chang Yi WeiIII; Ilva Marico Mizumoto AragakiIV; Paulina KurcgantV
Head of the Neonatal Unit, University of São Paulo University Hospital.
São Paulo, SP, Brazil. email@example.com
IIRN. Ph.D. in Nursing. Director, Maternal-Infant Division, Nursing Department, University of São Paulo University Hospital. São Paulo, SP, Brazil. firstname.lastname@example.org
IIINurse Midwife. M.Sc. in Nursing. Head of the Obstetric Unit, Nursing Department, University of São Paulo University Hospital. São Paulo, SP, Brazil. email@example.com
IVNurse Midwife. Ph.D. in Nursing. Head of the Rooming-In Unit, Nursing Department, University of São Paulo University Hospital. São Paulo, SP, Brazil. firstname.lastname@example.org
VFull Professor, Professional Orientation Department, University of São Paulo School of Nursing. São Paulo, SP, Brazil. email@example.com
The objective of this study was to learn the perception of accompanying mothers at the neonatal unit as to humanizing actions. This is an exploratory descriptive study, with a qualitative focus, developed at the neonatal unit of the University of São Paulo Hospital with the accompanying mothers of hospitalized babies, from their fifth day of life until discharge. The study was performed from October 2007 to January 2008. A total 18 interviews were performed and analyzed according to Bardin's framework, which permitted to develop the following categories: assistance received, relationship with professionals and conditions of the institution. It was found that there was satisfaction regarding the received assistance and team support, and there is a need to make changes in the physical structure of the sector, to provide assistance that is more humanized.
DESCRIPTORS: Humanization of assistance; Intensive Care Units, Neonatal; Caregivers; Neonatal nursing.
Estudio que objetivó conocer la percepción de madres acompañantes en unidad neonatal, en relación a acciones humanitarias. Investigación exploratoria descriptiva, con enfoque cuantitativo, desarrollada en unidad Neonatal del Hospital Universitario de la Universidad de San Pablo con las acompañantes de bebés internados a partir del quinto día de vida hasta su alta hospitalaria. El período estudiado fueron los meses de octubre 2007 a enero 2008. Se realizaron 18 entrevistas, analizadas según el referencial de Bardin, lo que permitió la construcción de las categorías: atención recibida, relación con los profesionales y condiciones institucionales. Se constató satisfacción en cuanto a la atención recibida y apoyo del equipo; y fueron señaladas necesidades de cambio en la estructura física del sector, para proporcionar una atención más humanizada.
DESCRIPTORES: Humanización de la atención; Unidades de Terapia Intensiva Neonatal; Cuidadores; Enfermería neonatal.
As a result of establishing hospitals as places to give birth, and aiming to guarantee greater protection to mothers and their infants, institutional routines were created at the hospitals which regulate the actions professionals and patients have to follow from the moment of the pregnant woman's hospitalization until the delivery. At public hospital institutions, care humanization is an increasing topic of discussion. This term is associated with users and professionals' valuation of sociocultural and emotional aspects, with a view to enhancing care quality and adequate work conditions. The values that guide this process are the autonomy and prominent role of the subjects involved(1).
In that sense, the goal of the Brazilian National Hospital Care Humanization Program became a national policy launched in 2004 and called the National Care and Management Humanization Policy in the Unified Health System (Humaniza SUS). This policy aims for the formulation of a new institutional culture, including the establishment of new standards for ethical relations among users, technicians and managers with a view to improving care quality(2).
A consensus exists among experts in the area about using the term care humanization to denote any initiative that understands and values care quality excellence from a technical viewpoint, considering aspects that relate to users and professionals' (inter)subjectivity, cultural references and the right to health. One can also identify four discourse axes in the official documents guiding humanization. In the first, humanization is underlined as opposed to physical and/or psychological violence, expressed through mistreatment, or when users' expectations are not complied with. In the second discourse axis, the need to enhance the quality of service delivery is identified, that is, the ability to put in practice quality care, articulating technological advances with good relationships. The third axis presents the idea of humanization as improvement in the caregiver's work conditions, that is, to care of health professionals, resulting in healthy work teams. In the fourth discourse axis identified, humanization is seen as the expansion of the communication process, which is the central guideline of the humanization proposal(3).
In this context, the presence of the companion during the patient's hospitalization is one of the paramount actions to mitigate the hospitalization process.
The benefit of the companion's entry and stay at health institutions is also based on World Health Organization recommendations (Assistência ao Parto Normal: um guia prático - 1996), on Law No 10.241, which the São Paulo State government issues on 03/17/1999 and, in the national sphere, on the Child and Adolescent Statute(4), whose article 12 obliges health institutions to offer the conditions for the full-time stay of a companion during the child's hospitalization period.
In a qualitative research that describes women's experiences during antenatal monitoring and delivery care in the Unified Health System in Rio de Janeiro, the SUS' efforts to modify the dominant midwifery care model was evidenced(5). The results showed that users did not perceive the practice of ritualized routines, which science has condemned, as errors, but mentioned errors in the relationship with health professionals, expressed as a lack of communication with professionals, resulting in the fact that most of their user demands were not attended to.
From the health professionals' viewpoint, having the mother stay with her hospitalized child is important for the child, who feels safer and more supported, as well as for the mother, who is following and participating in her child's recovery process(6). Thus, besides the maintained relationship with her child, other factors, such as adequate accommodation and meals during this period, contribute to the wellbeing of mothers-companions in this process.
In the maternal-infant area of the University of São Paulo University Hospital, humanizing actions have been taking place for more than one decade, among which stimulating the accompanying mother's stay at the neonatal unit is highlighted. Thus, this change in the institutional routine is in line with national delivery and birth humanization guidelines. In this context of change, the need for research is evidenced, with a view to more thoroughly exploring the perception of mothers who accompany their children hospitalized at a neonatal unit.
In view of these inquiries, this study was accomplished to: get to know/understand the perception of mothers who accompanied their children during hospitalization at the Neonatal Unit with regard to care humanization.
This is an exploratory and descriptive qualitative research, which offers the researcher the possibility to capture the way individuals think about and react to the questions focused on, as well as to get to know the dynamics and structure of the situation under analysis from the perspective of who experiences it(7).
Qualitative research is interested in human experience, particularly its processes and the meanings people attribute to the experienced phenomena, so as to clarify the way they proceed with regard to these events(8).
This study was accomplished at the Neonatal Unit of the University of São Paulo University Hospital (HU-USP), which offers 24 beds for care delivery to infants who need hospitalization, with a mean hospitalization time of about five days.
Study participants were companions to infants born at the institution who remained hospitalized since birth until hospital discharge between October 2007 and January 2008.
The following study inclusion criteria were considered: companions who stayed with the infant as from the fifth day of life, during which the mother had already been discharged, until the infant's discharge from hospital.
The ethical aspects defined in Resolution 196/96 regarding research involving human beings were respected. The project was forwarded and received approval from the Institutional Review Board (IRB) at HU-USP, under No 743/07, on 07/06//07. The participants received detailed information on the goal and study objectives and signed the Informed Consent Term.
The researchers, who work at the maternal-infant area as nurses, collected the data through recorded semistructured interviews, based on a pre-elaborated script, after obtaining the participant's authorization and after having guaranteed secrecy and anonymity. The interview contents were analyzed simultaneously, seeking significant events extracted from the participants' narratives. The researchers themselves held the interviews, at a private room in the Neonatal Unit, who complied with the inclusion criteria and accepted to participate in the research.
For the sake of data analysis, content analysis(9) was used, which consists in discovering the cores of meaning that make up communication and whose frequency of appearance can mean something for the analytic purpose chosen. Thus, Units of Meaning (UM) were identified which, grouped according to similarity of meaning, permitted the construction of categories.
Through content analysis of the interviews, the interviewees' perceptions on humanized care could be grouped (UM), constituting the study categories: Care Received; Relationship with Professionals and Institutional Conditions.
In the category CARE RECEIVED, the accompanying mothers reported that the care the multiprofessional team offered was positive, both during their infant's and their own hospitalization, indicating satisfaction with the care received.
E1 = ... about the care I have nothing to say, according to me all employees here are...equal to take care of her, the feeling, for me, for her. The employees take very good care of her...
E10 = Very well, when I came here they treated me very well, and I am grateful to them because I came here with tremendous pain, and I can't say anything, they treated me very well... And here at the Nursery, now that I'm here with my daughter, even better, thanks God, I have nothing to complain about regarding this place. Very good, I am being treated very well, for everything.
The fact that they were already familiar with the care delivered at the institution due to previous experiences was also mentioned, demonstrating confidence about the care received.
E3 = I have nothing to complain of, the treatment is really good. So, since my first daughter who was born here, the three were born here, I've never had anything to complain about, on the opposite, I love it here, if I have another child, who knows, it will be here...
The category RELATIONSHIP WITH PROFESSIONALS reveals the way the multiprofessional team interacts with the mother-companion, as one of the most significant themes that emerged from the statements.
E2 = I particularly like the people who work here, some are considerate, take good care and so ...
E15 = Look, I thought..., I liked it a lot, I found the people were very respectful, very... I don't know, very present, I liked it.
The positive aspects regarding the relationship with the nursing team were frequently mentioned in the women's testimonies.
E5 = It's good, I'm enjoying. The way you treat us here. Ah! With respect, no stupidity. It's... with attention, all the time you're concerned with whether we're fine or not, the baby too. And that's good treatment, right? I think...
E16 = ...I liked it a lot, you're kind, considerate, right?, except for some who are more kind and others who are less, right?, but everyone took good care... it was good.
Negative aspects were also mentioned:
E3 = I was mistreated by one employee, you see, by... I forgot the name. I understood why, because I was having some difficulty to come here and stay with my daughter, and she ended up acting in a kind of annoying way... I understand her side, and I think she has to understand mine, because not everyone is able to come every day. As I have two others at home, I got back to work, you see? And she has to understand my side like I understood hers, to the extent that I was going to complain and then I said, no, never mind, I won't... I don't have anything else to complain about, it's very good here.
E11 = I saw some, you know, with a tight look, you asked things and it seemed that she didn't want to answer, then I got kind of embarrassed to ask questions.....
The nursing and medical team professionals' lack of identification was also mentioned.
E16 = It's a bit difficult at first, because there are so many people in a white coat. Ah, how I distinguish... to give an example, I pay a lot of attention to everything that happens. Then I pay attention for example the residents, they go and ask the physicians, what it's like, then they'll explain, they always hold a meeting, right, the residents with the physicians, they explain how it is being done.
E18 = I manage. I think it has been so long that I'm here that I already know. ... the physicians are always wearing white, the nurses blue and the assistants a T-shirt. The technicians...
The fact that the mothers consider the care delivered to their children important seems significant though.
E1 = Not for me, they are all nurses. They presented themselves the first time. I don't mind that they don't say their name, present themselves, what's important is that they are nice and take good care of my daughter. They know my name, I don't because there are many, I only know one. I don't have anything to complain about them, I ask and they answer, explain.
In the category INSTITUCIONAL CONDITIONS, the support the institution granted was one of the themes highlighted, such as accommodations to stay with the infant.
E3 = I sit in an armchair, sometimes I ask to sit on a chair because I think it's more comfortable for her, Nicole, because she gets more upright, not for me, when I ask they bring me the chair, I think that's it really...
E16 = Ah it's comfortable. Ah, I think because your spine is straight, you don't bend your spine, you can support your arm, I liked it.
The lack of a place closer to the neonatal unit to accomplish their personal hygiene was mentioned as a difficulty.
E9 = So..., I use the one at Pediatrics, the bathroom there is good, I take a shower, my hygiene I do it there at Pediatrics. OK, but it would be better if there were a bathroom closer, right? At night, I wake up to use the bathroom, and going far, it's complicated. ...
E11 = It's annoying that you have to walk to pediatrics, but what can you do? That's the solution. When my son came up her, they had me use the bathroom on the second floor, for God's sake, take the elevator, walk to the second floor, use the bathroom and then come up again.
The possibility to get meals was mentioned as a positive factor, while the long interval between lunch and dinner was considered a negative factor.
E9 = If there were no meals it would be very bad... I think it's very good!
E12 = ...the food is very good, for who's breastfeeding, excellent.
E5 = The meal is good, I just don't eat soup, I don't like soup that much... In the afternoon, there's no snack, I don't eat anything, I think that's why I get a headache...
Some mothers mentioned the economic factor of not needing to pay transportation.
E2 = It's good, that you don't have to go home, right? As I live far off, I don't have to go home to have lunch nor dinner. Very good. I used to live here in São Remo and now I moved to Taboão.
E13 = It's nice, it's very interesting. I don't have mony for transportation to go and come back twice.
The possibility to stay at the hospital contributed to learn about care for the infant, for unexperienced mothers as well as for mother who had already had other children.
E9 = Ah! I learned to take care of him, yes, I'm a first-time mother! They taught me, oh dear!, I learned a lot, they taught me, how to take care of him, care, I didn't know anything, I learned, it was very good.
E11 = I learned, to wash him, how to feed because I didn't know yet,...
E18 = I think I learned to take better care of him. I don't know, about everything, when I was more... I learned to take better care, with my daughter I didn't really know about care... About washing, changing, cleaning correctly, because I had never cleaned a boy in my life...
In this study, it is verified that the attention the multiprofessional team delivers, mainly the nursing team, which remains at the child and, consequently, the accompanying relative's side, in this case the mother, uninterruptedly for 24 hours, is perceived as care, that is, as CARE RECEIVED, in line with other studies involving companions(6,10-11).
When mentioning the care received by her hospitalized child, the mother also describes satisfaction with the care she received during her hospitalization. The fact that she already knows the institution and had a positive previous experience reinforces her confidence in the team.
Receiving care at the right time, medication at the prescribed time and by attentive and technically competent professionals takes the form of satisfaction with the care received.
The professionals' attention is part of the category RELATIONSHIP WITH PROFESSIONALS and evidences that the treatment the team provides, with education and respect, is interpreted as humanized care. On the other hand, if the professional does not respond to the patient's expectations, demonstrating lack of attention or negligence, this is interpreted as non-humanized care. Thus, it is concluded that professionals' attitude and behavior give form to the assessment of humanized care.
In a study accomplished at a pediatric unit of a teaching hospital in Maringá, the hospitalized children's companions pictured humanization in terms of quality of the therapeutic relation and the relationship of partnership established between team and family. Thus, treating with kidness and attention, demonstrating skills and interest in communication are essential characteristics of humanized care(11).
Also with regard to the study mentioned, the interviewees associated the idea of humanized care with professionals' who attendance aims to understand the patient's side. In this study, when the mother mentioned the team's concern with providing explanations so that she would understand how her child was doing, she interpreted this as humanized care.
Other studies on this theme identified nurses as the professionals who provide emotional psychic support and a relationship of help, making the hospitalization a more easily tolerable experience for the mothers in view of little things(10-11).
These little things derived from the way of relating with patients and family members, treating them in an individualized way, calling the children by their names, demonstrating love and respect, using touch, mild pitch and looks. Attitudes that do not depend on technology and make a difference for the mothers and hospitalized children(12).
The professionals' presentation and identification is the first item health professionals should take into account in the relationship with patients and family members.
For the accompanying mothers in this study, the professional's lack of acknowledgement did not show significance, while the care and attention received were considered more important.
The mothers suffered because of their children's hospitalization, mainly those with premature infants who needed to be hospitalized for a longer period, causing a sudden change in the family structure.
In a study involving mothers of premature and low-weight infants, the authors appoint the mothers' difficulties due to the child's hospitalization and the emotional aspect involved because, at first, they had dreamt about the birth of a healthy child(10).
Some mothers mentioned concern with other children at home, in addition to the need and importance for the woman to stay with the infant who needs her presence. At that moment, family and health professionals' support is fundamental to allow the mother to face her child's hospitalization period. Understanding is needed for the woman's situation, as one of the interviewees mentioned, and a joint strategy needs to be planned to combine the child's need with the possibility of the mother's presence.
With regard to the category INSTITUTIONAL CONDITIONS, although the accompanying mother had given birth not long ago and was in the postpartum period recovering from the delivery, the accommodation was appointed as satisfactory because it allowed her to stay with her child.
The mothers consider that this opportunity enhanced learning about care for the child, as well as the establishment and maintenance of breastfeeding. Once again, the importance of team support showed to be fundamental, as appointed in a recent study at the same Unit(13).
The possibility to get meals and spend the night was mentioned as a facilitator to stay with the children. The economic factor was also reported, as many mothers face financial difficulties. This result was also found in another study accomplished at the same institution, but at the Pediatrics Unit(6).
One negative aspect appointed was the lack of a bathroom and shower near the Neonatal Unit. The hospital administration has been concerned with permitting humanized care delivery to its clients and reforms have been made in this respect. A reform is being planned to address this need the companions reported.
The companions commented on the long interval between lunch and dinner. It should be highlighted that companions from all over the hospitals take their meals at the canteen, which functions during preset times for breakfast, lunch, dinner and supper, but an afternoon snack is not offered to the companions. In view of the need the mothers in this study appointed, the nutrition and diet service was contacted, which started to offer the afternoon snack. A place was arranged at the Neonatal Unit itself for the companions to receive the wrapped snack, containing a chocolate drink and cookies. The researchers believe this first measure shows to be an important step in response to the accompanying mothers' request.
Most companions reported satisfaction with the care received at the Neonatal Unit, but the lack of activities was mentioned as a suggestion:
Yes... some things can get better... The way the people here are treated is very good. But, it's... for example. Having a place here where we could stay to watch television, to relax a bit while we stay, because there is no relaxation whatsoever here, not for the mothers, you see? The child is very well treated, but for the mothers there is not... we stay there sitting the whole time, next to him, don't do anything, so... E9.
A study carried out in Recife(14) showed that recreation activities for the mothers-companions mitigate the stressful effects of their children's hospitalization and contribute to the comprehensive and humanized care process, focusing on the family, as part of the view of hospitals as a broader space for health intervention.
The existence of a leisure area for the accompanying mothers is also being planned as part of the Neonatal Unit reform.
The identified results appoint the four guiding axes of care humanization(3).
Thus, the first axis, when the accompanying mother reported she was mistreated by the employee who did not understand her difficulty to stay with her child every day, as part of the category RELATIONSHIP WITH PROFESSIONALS. This category is also linked with the second axis, which underlines the importance of articulating technological advances with a good interpersonal relationship.
As for the third axis, which addresses humanization aimed at professionals, a research is ongoing which looked at the nurses' opinions on the meaning of humanization, with a view to responding to their expectations regarding work improvements and which will enhance the achievement of the fourth axis, as the central guideline of the humanization proposal, which is the expansion of the communication process.
One of the principles that permeates delivery and birth care humanization is comprehensiveness, which should address care actions with a view to relationships of welcoming, dignity, bonding and respect among the different actors involved (professionals, users and institutions)(15).
As for the users, the accompanying mothers in this study reported satisfaction with the care their children received at the Neonatal Unit, evidencing the importance of an effective relationship as a valued aspect. Treating with education and respect was interpreted as a care humanization measures, reinforcing and reaffirming the results other authors found regarding the importance of raising professionals' awareness on different practices and knowledge, as well as the relevance of a consensus on these differences. These premises guarantee that team work goes beyond knowledge and that knowledge is put at the service of work(15).
Regarding the institutions, physical area planning at the Neonatal Unit, including adequate accommodations and offering of infrastructure to receive the companion, is another fundamental issue that has been discussed and put in practice at the HU-USP. In March 2009, the institution received the award for the second best maternity in São Paulo State according to Unified Health System (SUS) users' assessment, with a mean score of 8.843.
The award was granted after an unedited research by the State Health Secretariat, which involved 60.2 thousand patients who participated in hospitalizations and tests in about 500 health institutions affiliated with the public health network. A research form was adopted, delivered by mail and freely answered through the Internet, a response letter or telephone, in which the following were assessed: satisfaction level with the care patients received; the level of the service and the professionals who delivered care; the quality of accommodations and waiting time for the hospitalization, besides specific issues on delivery humanization(16).
The support the team and institution offered was also appointed as a humanized practice. In this sense, meetings with the team will be proposed, endorsing the study data and reinforcing the importance of treating children and their families with kindness and cordiality. These are simple attitudes the multiprofessional team should value and adopt in practice.
Raising professionals' awareness on the importance of the family's presence when the child is hospitalized represents a first step towards the family's better acceptance inside the Neonatal Unit, not as a legal obligation, but as a need felt based on the review of concepts, values and attitudes(17).
In conclusion, the team should consider the companion's presence as an essential part of comprehensive family care. Therefore, further research is needed to get to know the professionals' perceptions and opinion on companions' stay, enriching reflections on the importance of humanizing actions in care. This aspect entails the opportunity to inform, teach and support actions that are fundamental to put in practice holistic and humanized care.
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Eliete Genovez Spir
Departamento de Enfermagem do Hospital Universitário da USP
Av. Prof. Lineu Prestes, 2565 - 3º andar - Cidade Universitária
CEP 05508-000 - São Paulo, SP, Brazil