FAMILY PARTICIPATION IN PATIENT SAFETY IN NEONATAL UNITS FROM THE NURSING PERSPECTIVE

ABSTRACT

Objective:

to understand the influence of family involvement in patient safety in neonatal units from the perspective of nurses.

Method:

a descriptive qualitative study, conducted in the intermediate care unit and in the neonatal intensive care unit of a public maternity hospital in Belo Horizonte-MG (Brazil), with fourteen nurses as research participants. Data were collected through semi-structured scripts and submitted to thematic content analysis.

Results:

nurses recognize the family's participation in neonatal patient safety, however they have shown little understanding and unpreparedness in dealing with family in their daily work. Better reception/user embracement and orientation of family members were identified as significant strategies for safe care.

Conclusion:

it is believed that combining family as critical and active partners in professional health practices aimed at implementing safe practices is an important and promising strategy to promote health and patient safety.

DESCRIPTORS:
Patient safety; Intensive care units, neonatal; Family; Patient participation; Neonatal nursing

RESUMO

Objetivo:

compreender a influência da participação da família na segurança do paciente em unidades neonatais na perspectiva de enfermeiros.

Método:

estudo descritivo de abordagem qualitativa, realizado na unidade de cuidados intermediários e na unidade de cuidados intensivos Neonatais de uma maternidade pública de Belo Horizonte-MG, tendo 14 enfermeiros como participantes do estudo. Os dados foram coletados por meio de entrevistas com roteiros semiestruturados, os quais foram submetidos à análise de conteúdo temática.

Resultados:

os enfermeiros reconhecem a participação da família na segurança do paciente neonatal, porém demonstraram despreparo e pouca compreensão ao lidar com esse familiar no cotidiano de trabalho. Ainda apontaram o acolhimento e a orientação dos familiares como estratégias significativas para o cuidado seguro.

Conclusões:

acredita-se que inserir os familiares como parceiros críticos e ativos das práticas dos profissionais de saúde seja uma estratégia importante e promissora para a promoção de saúde e segurança do paciente.

DESCRITORES:
Segurança do paciente; Unidades de terapia intensiva neonatal; Família; Participação do paciente; Enfermagem neonatal

RESUMEN

Objetivo:

comprender la influencia de la participación familiar en la seguridad del paciente en las unidades neonatales en la perspectiva de las enfermeras.

Método:

estudio descriptivo de enfoque cualitativo, realizado en la unidad de cuidados intermedios y neonatal intensive en una maternidad pública en Belo Horizonte-MG (Brazil), con 14 enfermeras como sujetos de investigación. Los datos fueron recolectados a través de scripts semiestructuradas y sometidos a análisis de contenido temático.

Resultados:

las enfermeras reconocen la participación de la familia en la seguridad del paciente neonatal, pero mostraron poca comprensión y sin preparación para hacer frente a esta familia en el trabajo diario. Mejor recepción y orientación de miembros de la familia fueron identificados como estrategia para el seguro de cuidado.

Conclusiones:

se cree que la combinación de la familia como socios críticos y activos en las prácticas profesionales de la salud dirigidas a la implementación de las prácticas de seguridad, es una estrategia importante y prometedora para promover la salud y la seguridad de los pacientes.

DESCRIPTORES:
Seguridad del paciente; Unidades de cuidado intensivo, neonatal; Familia; Participación del paciente; Enfermería neonatal

INTRODUCTION

Patient safety is understood as a strategy to reduce the risk (to the bare minimum) of unnecessary damage related to health care. The discussion on initiatives to promote safety and quality in health care worldwide was put forward after the publication of the American report 'To err is human: building a safer health care system', in 2000, pointing out that millions of people worldwide suffer injuries and deaths from health practices.^1-3

Regarding patient safety in the Neonatal Intensive Care Units (NICUs) environment, newborns are more susceptible to incidents due to their particularities and vulnerabilities.⁴ Adverse events can be understood as an event or circumstance that could have resulted in or resulted in unnecessary harm to the patient.⁵ A study carried out in a NICU of a Brazilian hospital showed that 183 (84%) of the 218 infants admitted in a five-month period suffered adverse events, which corresponds to a rate of 2.6 adverse events for each patient during an average hospitalization period of 13.5 days.⁶

Given the current statistics in relation to the increase in the number of adverse events, another study pointed out that effective participation by patients and family members in care together with the health team has contributed to the patient safety process.⁷ In Brazil, the Child and Adolescent Statute (ECA) regulation guarantees permanence of a full-time companion during child hospitalization. Given this, it is imperative that the health team direct attention to the family needs, safely extending the object of nursing care to the newborn and family dyad. Thus, the Family-Centered Care (FCC) approach in the NICU recognizes the importance of the family as a care client, ensuring their participation in planning and implementing actions.⁸ This framework reveals a new way of caring, offering the opportunity for the family to participate in the care, as well as contribute to safe neonatal care.

In this context, nurses are a mediator between the nursing team and the family, having an important role in understanding the family' problems and their needs, as well as in developing an effective care plan for the newborn and their families. Moreover, they can act in preventing errors, since planning and appropriate intervention to maintain the safety of the neonatal patient are their responsibilities.

We emphasize that in this scenario, nurses need to pay close attention to the process of family insertion in the NICU environment, enabling them to participate in the care of the sick neonate, respecting their moments of stress, anxiety and anguish, providing a safe line of care that not only involves the newborn, but also the family members.⁹ On the other hand, studies have pointed out that the presence of the family close to the newborn can generate challenges for the nursing team, and that it can positively or negatively influence patient safety.¹⁰ Some studies also highlight the lack of preparation of nurses to deal with insertion of a family member in the care of newborns, resulting in insecure, deficient and distressing relationships.^9,11

Several authors address the concern for neonatal patient's safety;^3-4,6 however, studies that discuss participation of family members in the safety of neonates from the perspective of nurses are scarce. Thus, the following question arises: How do nurses perceive participation of the family in neonatal patient safety?

Due to the importance of seeking patient safety in the NICU, we consider that nurses understanding participation of the family in the work processes of this unit to be relevant, allowing them to incorporate and intensify comprehensive and humanized care into their practices, free of iatrogenesis. Thus, the research object of this study was to understand how participation of family influences patient safety in the NICU from the perspective of nurses. It is believed that these professionals are the ones with the closest contact to newborns and their family in search for care based on safety culture, with actions that minimize the risks to patients with the help of caregivers, thus ensuring safe and quality care.

From this study, reflections can be applied to nursing training and practice, seeking to change paradigms related to safer and more effective nursing care in relation to hospitalized newborns and their families.

METHOD

This is a descriptive qualitative study developed in two neonatal units; an Intermediate Care Unit and a Neonatal Intensive Care Unit of a public maternity hospital in Belo Horizonte, a reference in neonatology in the State of Minas Gerais (Brazil). It is worth noting that these units have Kangaroo/skin-to-skin and/or conventional beds, and grant full-time access to parents.

The study was carried out with 14 nurses who provided direct assistance to newborns and their families in the respective units, and who had been in the service for over a year. Professionals on leave or on vacation were excluded. Data collection was carried out through semi-structured interviews conducted by two study researchers from April to June 2014 in the work places, during the respective shifts of each participant. The subjects were randomly selected. The interview script consisted of three questions that referred to nursing care in relation to the newborn and his/her family, and to the family's participation in care of the newborn in the hospital, as follows: How do you perceive family members in the context of the hospitalized child's safety? What strategies do you use to promote insertion of family members into patient safety? What do you think about the way you have developed your work in caring for the newborn and their family?

Interviews were completed when the criteria for redundancy and repetition of responses were reached, with inclusion of new participants suspended after the 14^th interview.¹² We emphasize that there were no refusals from the professionals to participate in the study, nor did they request to interrupt participation.

The participants voluntarily agreed to be part of the study, and they were advised regarding the possibility of withdrawing their inclusion at any time, without any penalty to them or to the institution.

The interviews were recorded with prior authorization and were subsequently transcribed in full by the researchers and submitted to the interviewees for validating the respective testimonials. In order to maintain anonymity, the fragments of each interviewed nurse were coded by the letters NRS, followed by a number to represent the order of participation from 1 to 14; for example, NRS 1 (Nurse 1).

Data analysis was based on content analysis, consisting of three distinct phases: pre-analysis, material exploration and treatment of results.¹³ Pre-analysis refers to ordering the data after full transcription of the interviews, and organization of the material to determine the unit of analysis and the category form. The second step consists of exploring the material for the coding procedure, classifying and aggregating the findings.¹³ Finally, the third step is treatment of the results, according to the theoretical reference found on patient safety.

The ethical precepts described in Resolution N. 466/2012 of the National Health Council were respected, and therefore study participants previously signed the Free and Informed Consent Form. The research was approved by the Ethics and Research Committee of the Hospital Foundation of Minas Gerais (CEP / FHEMIG), under opinion number CAAE 27149414.9.0000.5119.

RESULTS

Fourteen (14) nursing assistants participated in the study, predominantly female and with an age range between 25 and 45 years. Regarding the length of professional performance, the interviewed participants had between two and six years of experience in NICUs.

By establishing family participation regarding patient safety as an investigative context from the nurses' perspective, it was possible to capture units of meaning that gave rise to the following categories: nurse's understanding and nursing challenges regarding family participation in patient safety, and strategies pointed out by nurses in favor of inserting family members in the safety of the patient.

Nurse's understanding and nursing challenges regarding family participation in patient safety

The study participants reported that neonatal care provided by family-centered nurses and family members can not only favor interaction between mother and baby, but results in a better prognosis for the patient, reducing stress and mitigating incidents in the NICU: I think that this care focused mainly on the family and on the patient, who is the newborn, I believe it reduces stress for the baby. [...] reduces their pain, and I think it really influences the child's prognosis (NRS 4).

The interviewees also considered that the presence of the family helps in detecting errors and prevents the occurrence of adverse events: because there are times when, due to work overload, some errors happen and, with those parents nearby these errors are noticed [...] (NRS 7).

In contrast, the respondents reported not feeling able to deal with family members due to lack of training: [...] but here in the neo (NICU), I did not receive any specific guidance, such as training on how to deal with the family, this was something that at no point was discussed when I started here. I think we should have actual training sessions, similar to the ones about caring for the newborn, caring for the family. We do not have a very well-established training routine, and the few sessions we have are focused on technical issues (NRS 13).

The nurses also demonstrated different conceptions regarding permanence of family members by reporting that their presence may represent a stressful factor for the professional, which can disrupt dynamics in the Unit: I notice that when the mother is always there, questioning everything, the employees move away, they sometimes even ask us to change their shifts, because they do not want that type of demand/pressure, and our demand/responsibility is already so high. The stress we are experiencing is already huge, and then this stress on top of that? Some infants we cannot puncture when they are around, because of the pressure of the mother being right there, it has already happened (NRS 7).

The nurses' speeches pointed out that the family participates little in the care of the newborn and that this participation is often prevented by the professional themselves. Similarly, the participants of the study understand that family participation is represented by co-participation and simpler care actions, leaving actions that demand technical knowledge for the team. It is a characteristic of the health professional, you know, who wants to manage all the care by themselves, because they believe it involves technical knowledge. Sometimes the baby needs the family, too, the child especially needs the family involved, and we do not see that very often. So, what we try to do on our part is to involve them in simpler care actions, such as changing diapers [...]. During procedures that require more technical ability, they are more removed. And, the family participates more for those more basic actions that the professional sees as less important (NRS 2).

Strategies pointed out by nurses in favor of inserting parents in the safety of the patient

Participants in the study reported that they welcome parents at the moment of admission of the neonates, and explain about the patient's condition and the care offered, also explaining about the equipment that is being used with the newborn in the NICU: [...] parents' welcoming usually occurs while the newborn arrive. So we do our initial welcoming routine, explaining about the general care that the newborn will receive in the unit, explaining to them some general aspects regarding the care, about the equipment that is connected to the newborn (NRS 3).

The interviewees reinforced the importance of family orientations being carried out in a simple way, with accessible language for parents' understanding: [...] a lot of the people that come here don't have any knowledge, so they look at the child and they see all those devices, they have no idea what is happening. So, we use more appropriate language, like a conversation, because the doctors themselves cannot use that language with the parents, so we talk to them and we try to explain in a way that they can better understand (NRS 4).

Nurses emphasized the relationship of Kangaroo Care for infant safety, improving the newborn's adaptation to mechanical ventilation, providing tranquility and reducing the risks of incidents common to the neonate, such as pain: I notice that the interaction between the mother and the newborn greatly favors tranquility of the mother and the baby [...] and when the baby is more relaxed, they are more adapted to mechanical ventilation, and we can handle them more gently with less sensation of pain, especially if we can prolong the kangaroo period. It speeds up the child's de-hospitalization, I think it also decreases the length of hospital stay, for babies that interact better, who can have a longer kangaroo period, right, I think these are the ones that leave the ICU faster (NRS 3).

Incentive for inserting parents in care of the child in the NICU by the nurse, even if the neonate is in a severe clinical condition, was pointed out by the subjects as a safety strategy and to reduce hospitalization time: [...] there have been cases here of the mother being able to connect the diet, PUFF, she was totally integrated into the care, so much so that the child's de-hospitalization was a success (NRS 3); So the first thing we need to do is teach/encourage them to touch (the baby) and sometimes the mother is already used to touching the baby. From the moment she touches the baby we move on to another step, right? Do you want to hold the baby? Regardless if the baby is being monitored, if the baby is having oxygen therapy. If the baby is able to go onto her lap/be held at that moment, we encourage it, placing them in the skin-to-skin position, putting them on as a kangaroo to favor this moment as well (NRS 5).

The nurses also suggested the creation of a weekly meeting with parents and professionals as a strategy to insert them in the care of hospitalized newborns: [...] what I think would make it easier, and would be good not only for the team, but mainly for the family, would be weekly meetings where we could guide them about the operation of the unit or, sometimes to demystify something that they see happening [...] Then this previous information, or even recurrent, would facilitate their stay in the unit, so they are not alarmed by the buzzers/beeps, by the procedures and just to make them feel more welcome (NRS 1).

Another strategy pointed out by the participants was the importance of guiding the family regarding hand hygiene, questioning about current medications and the use of cell phones within the NICU: to reduce some problems that can happen, we advise on the use of cell phones, how to wash their hands, how to enter the unit, questions about medications in the ICU (NRS 5).

The interviewees also reported the relevance of continuing education for all professionals involved, suggesting that creating more training will enable the team in the family integration process within the NICU: [...] and I think training that encompasses the part of raising awareness of the whole team, which I think is not something to be done only with nurses, I think it has to include from the medical staff to the cleaning staff, they have to be aware that we have this mentality of integrating mother and children here inside the NICU, and in addition to raising awareness, you need to have actual training, technical training to demonstrate how to do this, right? I think these are strategies (NRS 3).

DISCUSSION

The findings revealed that nurses recognize the benefits of including family in neonatal care, however they have demonstrated an unpreparedness to deal with family members, as well as little understanding regarding how this family member can aid in patient safety.

The involvement of family members as critical and active partners throughout the care process brings important contributions to safety and prevention of adverse events.¹⁴ Literature suggests that there are several moments of neonatal hospitalization in which the family could assist in the early detection of incidents, such as in observing medications administered, signaling possible allergies and supervising professionals hand hygiene practice, becoming agents of infection control.^14-15

Placing the patient in care consists of one of the items assessed by the Joint Commission International,¹⁶ which assesses whether the patient and their family are being listened to, if their rights are being respected, and whether a partnership was created with them in the care process. In addition, it also checks whether professionals inform patients and family members in an easy-to-understand way about care planning and treatment, and how they can participate in decisions about their rights, among other items.¹⁶

Participants in the study reported that they welcome parents at the moment the newborns are admitted, a strategy to insert them into care, explaining about the care and equipment that the newborn is using during their stay in the NICU. In this perspective, studies reinforce that the instruction and support of parents by professionals is extremely important at the moment of admission and during the entire hospitalization, sharing realistic information about the baby so that they understand the clinical situation of the newborn.¹⁷

An effective welcoming/embracement brings numerous benefits to the family and to newborns, favoring family interaction with the environment and consolidating the nurse-patient relationship, which results in a more humanized and safer care for newborns and their families. The study participants also reinforced the importance of the embracement/welcoming (moment), contemplating orientations with accessible language and in a simple way for the family members' understanding. The absence of these guidelines is a contributing factor for the occurrence of incidents.¹⁸

Through interviewees' speeches, it was also possible to recognize Kangaroo/skin-to-skin care as a strategy of parental empowerment towards the care and optimization of the bond with the child. An American study corroborates this finding and states that perinatal care aimed at improving the quality of care brings numerous benefits to the neonate, such as reducing the risk of infection related to health care, reduction of mortality, stress and pain in newborns, in addition to reducing the infant's length of hospitalization and favoring breastfeeding.¹⁹ This study emphasizes that the method also works as a complement to newborn care, combining available technology to the humanization of care and participation of parents and family members in care of the child, respecting them in their characteristics and individualities. In addition, this enables greater competence and confidence to parents in providing care for their child, even after hospital discharge, reducing the number of readmissions and contributing to optimizing neonatal beds.¹⁹ Thus, we can infer that Kangaroo Care assists in patient safety, reducing the risks of incidents common to newborns, and in the humanization of care through a closer approximation of the family, child and health team.

On the other hand, incongruence between the expectations of patients and nurses on patient's participation in care is apparent.¹⁸ Studies emphasize that family members and patients themselves participate less than they would like in the care, and that they could be better inserted and instructed by the team regarding hygiene care, medications and clinical decisions.^18,20

Moreover, the interviewees reported not being able to deal with family members due to lack of training, demonstrating that insufficient training of health professionals leads to an occurrence of adverse events. Seeking knowledge can reveal to professionals how to produce nursing care with quality and safety, avoiding the occurrence of iatrogenies.¹⁰

Thus, carrying out more training is a strategy suggested by the nurses in order to assist the team in relations with family members. This attitude of identifying the need for improvement and updating knowledge can be considered a tool to establish safety culture in the institution.²¹

Through the presented speeches, it was also possible to perceive that nurses understand the family as an agent of supervision in the care provided, and not as co-participants in the care of newborns. The idea of having to divide space with the family generates fear and anxiety in the team, because the team knows that it is necessary to reorganize the dynamics of the work process and to increase the care focus.²² A lack of understanding and consensus by the nurses about parents' participation in care becomes a major obstacle in neonatal care.

The narratives of the professionals also show that when parents are not well-oriented or feel insecure in the hospital environment, they can reduce the benefits of family presence beside newborns. A study carried out in the State of Paraná (Brazil) showed that parents believe that when they are emotionally unbalanced, they can transmit fear and insecurity to the newborn, negatively interfering in the recovery of the child. However, if the family can transcend these problems, its presence is beneficial and favors treatment.²²

An Australian study highlights the importance of nurses sharing the responsibility for patient care with the family, empowering them to increase their participation.⁷ Nevertheless, studies suggests that it is still difficult for nurses to relinquish power over care, so that they still maintain paternalistic attitudes in the care practice and establish a vertical relationship, based on resistance to insertion of the family.^10,15

Some limitations of the study can be pointed out due to the very qualitative nature of the research, since it is restricted to the space of experiences and the subjects involved. It is not possible to generalize its content to other hospital units, nor to other nursing teams. However, the study has contributed to identifying strategies for bringing nursing team and family members closer together in an attempt to provide safe and quality care. It is also worth noting that the addressed topic has contributed to knowledge of the relationship and influences of family-centered care and patient safety, especially considering the fact that studies on this subject are innovative and scarce in the country.

CONCLUSION

The present study allows us to understand the influence of family participation on patient safety in neonatal units from the perspective of nurses. The benefits of family insertion in safe neonatal care are recognized by some nurses, and it is possible to identify some strategies suggested by the interviewees for encouraging and supporting the family in this proposal of insertion in care. However, they demonstrate little understanding of how family members can assist in preventing adverse events, and point out professionals' unpreparedness to deal with the family as a co-responsible part of the hospitalized newborn's health/illness process. It was possible to perceive that the presence of the family is still seen by the team as an inspection agent to the care given to the newborn, or even as responsible for performing functions deemed less important.

It became evident that understanding the family as individuals who also needing care along with the newborns, and as an active agent in the prevention of adverse events is still limited among nurses.

The study suggests that joining family members as critical and active partners in practices with health professionals to ensure safe practice is an important and promising strategy for promoting patient health and safety.

Thus, further studies are needed to support the importance of the family in the safety of hospitalized neonates and to subsidize the knowledge and understanding of nurses involved in this care.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  01 Apr 2016
• Accepted
  25 Oct 2016