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FORCES INTERFERING IN THE MOTHERING PROCESS IN A NEONATAL INTENSIVE THERAPY UNIT

ABSTRACT

Objective:

to identify the driving and restrictive forces involved in the maternity process for newborns hospitalized in a neonatal intensive care unit.

Method:

descriptive and exploratory research, with a qualitative approach, which uses the Force Field Theory as a reference. Ten mothers participated. Data were collected from September to December 2014, through a semi-structured interview, and submitted to content analysis.

Results:

effective communication, inclusion of the family in care, teamwork, learning and adequate physical space served as forces that fostered mothering. Authoritative behaviors, stigmas related to the neonatal intensive care unit, lack of specialized care, failure to perform care for the newborn, physical fatigue, emotional stress and changes in the daily routine acted as forces that restricted the mothering process.

Conclusion:

identifying the field of forces made it possible to understand factors and situations that influence mothering and to diagnose the true biopsychosocial demands of mothers of hospitalized newborns.

DESCRIPTORS:
Children hospitalized; Maternal behavior; Mother-child relations; Professional-family relations; Neonatal intensive care unit

RESUMO

Objetivo:

identificar as forças impulsoras e restritivas envolvidas no processo de maternagem aos recém-nascidos hospitalizados em uma unidade de terapia intensiva neonatal.

Método:

pesquisa descritiva e exploratória, de abordagem qualitativa, que possui como referencial a Teoria de Campo de Forças. Participaram dez mães. Os dados foram coletados de setembro a dezembro de 2014, por meio de entrevista semiestruturada, e submetidos à análise de conteúdo.

Resultados:

comunicação efetiva, inclusão da família no cuidado, trabalho em equipe, aprendizagem e espaço físico adequado atuaram como forças que impulsionaram a maternagem. Condutas autoritárias, estigmas relacionados à unidade de terapia intensiva neonatal, falta de assistência especializada, não realizar cuidados ao recém-nascido, cansaço físico, estresse emocional e mudanças na rotina diária atuaram como forças que restringiram a maternagem.

Conclusão:

identificar o campo de forças possibilitou compreender fatores e situações que influenciam a maternagem e diagnosticar as verdadeiras demandas biopsicossociais das mães dos recém-nascidos hospitalizados.

DESCRITORES:
Criança hospitalizada; Comportamento materno; Relações mãe-filho; Relações profissional-família; Unidade de terapia intensiva neonatal

RESUMEN

Objetivo:

identificar las fuerzas impulsoras y restrictivas involucradas en el proceso de maternidad a los recién nacidos hospitalizados en una unidad de terapia intensiva neonatal.

Método:

investigación descriptiva y exploratoria, de abordaje cualitativo, como referencial la Teoría de Campo de Fuerzas. Participaron diez madres. Los datos fueron recolectados de septiembre a diciembre de 2014, por medio de entrevista semiestructurada, y sometidos al análisis de contenido.

Resultados:

comunicación efectiva, inclusión de la familia en el cuidado, trabajo en equipo, aprendizaje y espacio físico adecuado actuaron como fuerzas que impulsaron la maternidad. Las conductas autoritarias, estigmas relacionadas con la unidad de terapia intensiva neonatal, falta de asistencia especializada, no realizar cuidados al recién nacido, cansancio físico, estrés emocional y cambios en la rutina diaria actuaron como fuerzas que restringieron la maternidad.

Conclusión:

identificar el campo de fuerzas posibilitó comprender factores y situaciones que influencian la maternidad y diagnosticar las verdaderas demandas biopsicosociales de las madres de los recién nacidos hospitalizados.

DESCRIPTORES:
Niño hospitalizado; Conducta materna; Relaciones madre-hijo; Relaciones profesional-familia; Unidades de cuidado intensivo neonatal

INTRODUCTION

The birth of a child usually symbolizes a moment of great expectation for the woman and her family. However, some situations may occur whereby the newborn (NB) is required to rely on specialized care and the need to be hospitalized in a neonatal intensive care unit (NICU). When this happens, the people involved in this process begin to experience feelings such as anxiety and suffering, as well as emotional stress.11 Giménez EC, Sánchez-Luna M. Providing parents with individualised support in a neonatal intensive care unit reduced stress, anxiety and depression. Acta Pediatr. 2015 Jul; 104(7):300-5.

2 Finlayson K, Dixon A, Smith C, Dykes F, Flacking R. Mothers' perceptions of family centred care in neonatal intensive care units. Sex Reprod Healthc. 2014 Oct; 5(3):119-24.
-33 Santos LF, Oliveira LMAC, Barbosa MA, Siqueira KM, Peixoto MKAV. Reflexos da hospitalização da criança na vida do familiar acompanhante. Rev Bras Enferm [Internet]. 2013 Jul [cited 2016 May 19]; 66(4):473-8. Available from: http://www.scielo.br/pdf/reben/v66n4/v66n4a02.pdf
http://www.scielo.br/pdf/reben/v66n4/v66...

Most of the care given to the newborn in the NICU is performed by health professionals, who usually define who, how and when to care for the child. This situation can provoke tensions between professionals and the family due to the confrontation between models, practices, interests and opinions.44 Duarte ED, Sena RR, Dittz ES, Tavares TS, Lopes AFC, Silva PM. The role of the family in care delivery to hospitalized newborns: possibilities and challenges towards comprehensive care. Texto Contexto Enferm [Internet]. 2012 Oct [cited 2016 May 19]; 21(4):870-8. Available from: http://www.scielo.br/pdf/tce/v21n4/en_18.pdf
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The hospitalization of the newborn can compromise mothering/motherhood,55 Reis AT, Santos RS. Maternagem ao recém-nascido cirúrgico: bases para a assistência de Enfermagem. Rev Bras Enferm [Internet]. 2013 Jan [cited 2016 May 19]; 66(1):110-5. Available from: http://www.scielo.br/pdf/reben/v66n1/v66n1a17.pdf
http://www.scielo.br/pdf/reben/v66n1/v66...
-66 Esteves CM, Anton MC, Piccinini CA. Indicadores da preocupação materna primária na gestação de mães que tiveram parto pré-termo. Psic Clin [Internet]. 2011 Aug [cited 2016 May 19]; 23(2):75-99. Available from: http://www.scielo.br/pdf/pc/v23n2/06v23n2.pdf
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that is, the set of care performed by the mother to the baby in order to attend to their needs for "continence" which not consist of the physical act of holding the child in their arms and the care related to the handling of the body but also the physical and emotional support.77 Miranda MA, Martins MS. Maternagem: quando o bebê pede colo [Internet]. São Paulo (SP): Nove & Dez Criação e Arte; 2007. [cited 2016 May 19]. Available from: http://www.usp.br/neinb/wp-content/uploads/NEINB-USP-VOL-2.pdf
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-88 Winnicott DW. Os bebês e suas mães. São Paulo (SP): Martins Fontes; 2006.

The process of mothering involves the sensitivity of the mother (the person who performs the maternal function) in decoding and understanding the child's needs, establishing a routine that favors the child's growth, development and emotional stability, and offers protection against external dangers.77 Miranda MA, Martins MS. Maternagem: quando o bebê pede colo [Internet]. São Paulo (SP): Nove & Dez Criação e Arte; 2007. [cited 2016 May 19]. Available from: http://www.usp.br/neinb/wp-content/uploads/NEINB-USP-VOL-2.pdf
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-88 Winnicott DW. Os bebês e suas mães. São Paulo (SP): Martins Fontes; 2006. In this perspective, the importance of providing an environment conducive to the construction of a bond between mother and baby is highlighted, since the lack of adequate conditions to establish such interaction can affect mothering and also the psychoemotional development of the child.66 Esteves CM, Anton MC, Piccinini CA. Indicadores da preocupação materna primária na gestação de mães que tiveram parto pré-termo. Psic Clin [Internet]. 2011 Aug [cited 2016 May 19]; 23(2):75-99. Available from: http://www.scielo.br/pdf/pc/v23n2/06v23n2.pdf
http://www.scielo.br/pdf/pc/v23n2/06v23n...
,88 Winnicott DW. Os bebês e suas mães. São Paulo (SP): Martins Fontes; 2006.

Based on data previously presented, the following question guided the development of this research: what factors drive and restrict the interaction and care of the mother to the hospitalized NB in NICU? In order to understand these factors, the Forces Field Theory was used as a theoretical reference,99 Lewin K. Teoria de Campo em Ciência Social. São Paulo (SP): Pioneira; 1965. as through this theory, it is understood that the subject can only be understood within the context of its relations, from the most elementary relationships, with people in their close surroundings, to the most ample relationships, with society, history and the universe.1010 Baroncelli L. Adolescência: fenômeno singular e de campo. Rev Abordagem Gestalt [Internet]. 2012 Dec [cited 2016 May 19]; 18(2):188-96. Available from: http://pepsic.bvsalud.org/pdf/rag/v18n2/v18n2a09.pdf
http://pepsic.bvsalud.org/pdf/rag/v18n2/...

Throughout existence, each person synthesizes their experiences and experiences with the environment in which they are inserted in different ways. Thus, each human being has their own dynamic, interprets their experiences and perceives things, people and situations in a particular way. Thus, it is understood that the behavior of each subject is the result of a totality of facts and events coexisting in a given situation. In this process, the interrelation between the facts and events experienced by each person creates a force field that represents their psychological environment, the space that contains it and everything that surrounds it.99 Lewin K. Teoria de Campo em Ciência Social. São Paulo (SP): Pioneira; 1965.

This force field is represented by positive (impulsive) and negative (restrictive) behaviors, i.e., forces that help and also hinder work processes and personal interaction. These forces are distributed in the "I"dimension - which encompasses factors that relate to the person as an individual: motivation, talents, shyness; "Other" - includes factors relating to the relationship with other people, such as leadership, competence, conflicts, sympathy; and the "Environment" dimension - which consists of elements related to space and physical structure, material resources and organizational dynamics.1111 Moscovici F. Desenvolvimento interpessoal: treinamento em grupo. Rio de Janeiro (RJ): José Olympio; 2008.

Thus, the objective was to identify the driving and restrictive forces involved in the mothering process with hospitalized newborns in a neonatal intensive care unit. This is considered an innovative research that presents a new possibility, Force Field Theory, used to identify and understand situations related to the mother, the health team and the environment, which help and also make it difficult for the family to experience the reality of having a hospitalized NB, and to develop the mothering process in the NICU. It is believed that, by knowing the forces that act to favor or hinder the process of maternal care for the newborn, the health team can implement strategies that qualify and humanize the assistance to this population group, through interventions that can effectively meet their demands.

METHOD

A descriptive and exploratory research, with a qualitative approach, which used the Force Field Theory as a theoretical reference.99 Lewin K. Teoria de Campo em Ciência Social. São Paulo (SP): Pioneira; 1965. Participants included ten mothers of hospitalized RNs in the (NICU) of a public maternity hospital, located in the city of Palmas-TO, Brazil.

This unit is certified by the Ministry of Health as a State Referenced Center for the Kangaroo Method. It has 20 beds intended for the care of serious and high risk newborns who, due to their characteristics, remain hospitalized for a period of time that can vary from weeks to months, which commonly results in 100% bed occupancy.

Inclusion criteria in this study were: mothers of hospitalized RNs in the NICU for a minimum of seven days and a maximum of 27 days; experiencing the hospitalization of a child in a NICU for the first time; mothers of hospitalized RNs in the NICU due to prematurity. The exclusion criterion were: mothers under the age of 18.

Data collection occurred from September to December 2014 using a semi-structured individual interview which was conducted in a room located in the premises of the NICU, on a day and at a time previously agreed with those responsible for the health unit and with the mothers of the hospitalized RNs. The decision regarding the number of mothers interviewed occurred during the data collection and was guided by the criterion of data saturation, i.e. when it was possible to identify symbolic patterns, behaviors, classificatory systems, categories of reality analysis and worldviews of the investigated universe. Data collection was completed upon reaching the "saturation point".1212 Duarte R. Pesquisa qualitativa: reflexões sobre o trabalho de campo. Cad Pesqui [Internet]. 2002 Mar [cited 2016 May 19]; (115):139-54. Available from: http://unisc.br/portal/upload/com_arquivo/pesquisa_qualitativa_reflexoes_sobre_o_trabalho_de_campo.pdf
http://unisc.br/portal/upload/com_arquiv...

The interviews were recorded using digital media and guided by the following questions: "tell me about the experience of having and living with a hospitalized NB in NICU" and "tell me about situations that help and hinder your care of the NB". The interviews were later transcribed and submitted to content analysis.1313 Bardin L. Análise de conteúdo. Lisboa (PT): Edições 70; 2010. For this process, theoretical categories were used that were constructed from the theoretical framework adopted in this research,99 Lewin K. Teoria de Campo em Ciência Social. São Paulo (SP): Pioneira; 1965. namely: "Forces that drive the mothering process of hospitalized RNs in the NICU "and" Forces that restrict the mothering process to the hospitalized NB in a NICU". These categories represent the force fields constituted from the vectors" I "(mother of the NB)," Other "Environment "(NICU) that influences the mothering process in the NICU.

For the presentation of the results and in order to preserve the identity of the participants, the interviewees were represented by the letter "E" and an alphanumeric system (E1, E2, etc.). This research was authorized by the NICU Nursing Board and approved by the Ethics Committee in Human Research of the Federal University of Tocantins, protocol 036/2014.

RESULTS

Ten mothers aged between 19 and 35 of age participated in this research. Seven resided in the Municipality of Palmas-TO, and all had completed elementary education. Two were single and five reported formal employment. Family income ranged from one to four minimum wages.

The mapping of the force field in the NICU allowed the identification of factors that cause motivation and discomfort to the mothers, interfering in the mothering process of the NB. Although different feelings and situations may help the experience, in a less traumatic way, the process of hospitalization of the child, many experiences significantly compromise maternal/family well-being and even impair family/child interaction according to the following categories.

Forces that drive the mothering process of the hospitalized newborn in neonatal intensive care unit

In the mothers' testimonies, it was possible to confirm that many factors can boost maternal care and are positive during the period of the child's hospitalization . Some characteristics of the "Environment" (NICU) vector contributed to the physical and psychosocial demands of the mothers being attended to, thus favoring maternal well-being and the mothering process: [...] in the other hospitals I went to, there wasn't any room to stay in, there wasn't any food and here they have everything. [...] I'm with mothers who are going through the same situation as I am, we exchange experiences (E4); [...] there is space where the mothers can stay and I have made some friendships (E6).

Among the forces that drive the mothering process of the hospitalized NB in the NICU, the vector "Other" health team operated as a source of support to the mother and proved to be important to make the hospitalization process of the child less painful, as the following statements reveal [...] I had a lot of support from them, from the doctors, the nurses and everyone here (E5); they are very attentive, when I need something, if something happens, we call them and they are there (E8); [...] she [health professional] comes, talks, plays with us, helps a lot. She comes, and she does something nice: it makes us happy (E9).

The work of the multi-professional team also had a positive impact in the force field, which contributed greatly to the care that the mothers provided to the RNs: I have to thank the team of nursing technicians, psychologists, social workers and doctors. I really admire them, especially the nursing technicians. [...] and you realize that they all work together to care for you and anything that may involve your baby (E3); the helped me a lot to take care of her. The psychologist, the social worker and the nurses, as the days went by, it got better, because they always talked to us, explained the things to us, they taught me and gave me words of comfort (E10).

The statements show that, when mothers are included in the care process of the newborns, health professionals contribute a lot to their positive and pleasurable experiences, helping them to truly feel like mothers to their children: [...] experience of caring for a baby like that, so premature, the nurse takes great care to be with the mother and say 'that's the way you do it, that's the way' (E2); [...] the nurses always help. This is what helps me take care of him there [NICU] (E7); The nurses helped me a lot, they taught me what to do. I know a few things, but I'm afraid to hurt him because he's too small, premature, you know? Then they taught me things right and I learn from them (E9); [...] because the nurses have always helped. 'Mummy, do you want to get your baby?' Or 'Do you want to help bathe her?' So that helped me a lot to take care of her in there [NICU] (E10).

Effective communication also worked positively in the force field, as it was highlighted by mothers that it contributed to reducing their anxiety and suffering, especially by allowing families to understand the real situation of the newborns: the team is wonderful, always explained right. Ask if we have any questions to ask, do not miss anything. Then they are very realistic, they hide nothing from me (E1); They [doctors] are present, any questions you have, they answer. The nurses are very good, anything you need, if you are worried about the baby, all you have to do is just look for them and they will tell you who (E2); [...] the bulletin is so accurate that sometimes you do not even have to ask them anything. They tell me everything about how my daughter's situation is (E6).

In addition to the work of the health team, the "I" the mother" vector of the NB presented as itself as a force that drives the mothering process to the hospitalized NB in the NICU, in which the availability of learning and the desire to overcome the difficulties collaborated so that mothers could experience the hospitalization of the child in a less stressful way: another thing that makes it easier, is my willpower to overcome these difficulties and my fears and to fight (E3); And what helps is learning to be calmer and learning from what the nurses are explaining (E6); [...] and that my experience will be an example of overcoming difficulties (E10).

The resilience experienced by the mothers of the newborns has a positive effect on the force field and contributes to the woman identifying herself as a mother and exercising her mothering instincts.

Forces that restrict the mothering process to hospitalized newborns in a neonatal intensive care unit

In the statements of the mothers, it was identified that situations prior to the hospitalization of the newborn also cause stress to the family and may contribute to their emotional vulnerability. It was noted that the family's itinerary, up to the hospitalization of the newborn, is permeated by problems of access to health services, coverage and / or quality of care received, showing weaknesses in relation to child health care in the country: I was living in a city that had no resources for my son (E2); [...] why didn't they send me to a place that had the treatment? This all frustrates me and my family. [...] ever since my girl was born I have been fighting. [...] running behind the Ombudsman's Office, state and federal prosecutors, hospital and medical directors (E3).

It was possible to identify that the forces related to the "Environment" (NICU) vector can affect the NICU mothering process. The stigma associated with intensive care units exposes mothers to fear and uncertainties and causes them to suffer because of the very possible death of the child: [...] the name 'ICU' is the scary thing. Because looking at that all that equipment, it scares you, you knlw? (E7); I had already entered the adult ICU, but I thought the child ICU room very difficult,it's very scarey. And because of the name also, ICU, it reminds me of bad things, death, and when I say that my baby is in the ICU, people are already scared for me (E10).

It is understood from the statements of the participants that the clinical condition of the newborn, dependence on the NICU's equipment and other technological resources may limit the interaction between mother and newborn, and even prevent them from establishing physical contact with the child. Such situations have an effect on the force fields and have negative impacts on the mothering process: I think it's bad, because until today I haven't held my baby, because he has been intubated for three months (E3); so, I think it's bad, because I can't hold him, because he has so many tubes and wires, he'll be taken off this week, but he's still wearing his helmet, but either way, I can't pick him up him because he's on oxygen. E4); But it is not 100% the same when it is in our house, there are more difficulties because you can't hold him all the time, you have the right days for it (E5).

Although the mothers demonstrate the importance of the frequent interventions and painful procedures performed on the NB in order to keep them alive, the hospitalization of the child in the NICU is complex experience that generates great emotional stress and suffering: in the first days , I would go there, I would be so sad and I would think: 'Wow, my son is inside that incubator, you know?' But I knew it was for his own good [cries] (E2); There are days when they have to put needles in the child, there are days when we cry, I think it is bad to see that. [...] one day I arrived, they had put a lot of equipment on him, I was sad, I cried (E4); [...] I feel so bad, my daughter has to stay there with all those things attached to her, but, as I told you, it's for her good, we always let them do what is needed (E6).

In addition to the environment, the "Other" (health team) vector also compromised the mothering process in the NICU, because at times it acted in a way that made it difficult to interact between mother and baby: [...] a nurse told I gave her the excuse that I was disturbing her, I was kind of like that (E5); When I go to do it my way, to take care of it, soon someone arrives and says that it is wrong. Then I get nervous and it ends up kind of giving up on my caring, and it only works if it's the way they [health professional] want it. And they do not even wait to see how I look after them. This disturbs me a lot (E9).

In this research, the influence of the vector "I" (mother of the NB) in the force field that acts in the process of mothering was expressive. Mothers suffer because they do not have the necessary skills to perform the care required by the NB in the NICU: we have to learn a lot, even changing diapers is difficult (E2); As mine was born very small, weighing only one kilo and a hundred and fifty grams, if it were only with my care I would not be able to do it because, I become insecure just picking the child up (E6).

It was possible to perceive that these women feel insecure, and the fact that they are not always able to carry out activities that usually represent mothering, and thud contributes to the emergence of anxiety, frustration and emotional stress: I am afraid that when I pick him up I will pull the catheter or the needle in his head and it will hurt him (E7); [...] but I'm afraid of hurting him because she's too small, premature. (E9); So I thought, 'Oh my God, what am I doing?' I do not do anything to my daughter, she has been suffering since she was born and I can't do anything. (E10)

Many mothers still reveal that physical fatigue and emotional stress are factors that compromise their well-being and make it difficult to perform care for the newborn, configuring themselves in forces that operate negatively in the process of maternity: it's not because I can't stay all the time in the hospital, it's not because the hospital does not let us, we can stay as long as we want, but we physically can't do it. [...] there was a mother here, I do not remember which mother, who fell asleep with the baby in her arms, and it was only because of the stress and tiredness (E3); when I get to the house I'm staying in, the tiredness and sadness hits because you are here but your thoughts are in the hospital with your baby (E10).

The mothers report that innumerable changes have occurred in their lives, due to the hospitalization of the newborn, ranging from simple changes in family dynamics to changes in behavior, as the following statements demonstrate: [...] I can't stay at home cleaning up my things and I cannot finish a course that I was doing because I have to stay here with her and even when she leaves she will need all my attention because she is premature (E6); Before, I did not have many worries, I was very playful, I ended up changing a little because of what happened, I ended up becoming more serious (E9).

The "I" vector (mother of the newborn) was present in a significant way in all the statements, showing that maternal characteristics and feelings, experienced with the hospitalization of the NB in the NICU, could compromise the mothering process: [...] You look at her [NB], you don't even know how to hold her, your mothering side is very far away, do you understand? (E3); I think what's got in the way is that my mothering side was kind of hidden, I can not take her home (E6); [...] that moment of being a mother was repressed (E10).

The experiences and relationships established in the NICU integrate the force field and can compromise the mothering process, further intensifying the mother's suffering who experiences the hospitalization of her child.

DISCUSSION

Despite significant advances in recent years, child care still presents weaknesses and remains a challenge for several countries, such as Brazil.1414 Wang H, Liddell CA, Coates MM, Mooney MD, Levitz CE, Schumacher AE et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet [Internet]. 2014 Sep [cited 2016 May 19]; 384(9947):957-79. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4165626/pdf/emss-60026.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles...
In this scenario, it is worth pointing out that the itinerary covered by the mothers of ill newborns is permeated by difficulties due to access to health services, which corroborates families' suffering, apprehension and distress,1515 Oliveira K, Veronez M, Marques CDC, Higarashi IH, Marcon SS. Itinerário percorrido pelas famílias de crianças internadas em um hospital escola. Rev Bras Enferm [Internet]. 2014 Jan [cited 2016 May 19]; 67(1):36-42. Available from: http://www.scielo.br/pdf/reben/v67n1/0034-7167-reben-67-01-0036.pdf
http://www.scielo.br/pdf/reben/v67n1/003...
as evidenced in the statements of the participants of this study.

Thus, the need for social, economic, environmental, cultural and health public policies based on the principle of equity is identified so that they can effectively meet the different demands of the population, child care1616 Bühler HF, Ignotti E, Neves SMAS, Hacon SS. Análise espacial de indicadores integrados determinantes da mortalidade por diarreia aguda em crianças menores de 1 ano em regiões geográficas. Ciênc Saúde Coletiva [Internet]. 2014 Oct [cited 2016 May 19]; 19 (10):4131-40. Available from: http://www.scielo.br/pdf/csc/v19n10/1413-8123-csc-19-10-4131.pdf
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and also professionals capable of performing qualified care and health units with appropriate technological equipment to receive the seriously unwell NB.1717 Araújo JP, Silva RMM, Collet N, Neves ET, Tos BRGO, Viera CS. História da saúde da criança: conquistas, políticas e perspectivas. Rev Bras Enferm [Internet]. 2014 Nov [cited 2016 May 19]; 67(6):1000-7. Available from: http://www.scielo.br/pdf/reben/v67n6/0034-7167-reben-67-06-1000.pdf
http://www.scielo.br/pdf/reben/v67n6/003...

It must be noted that the NICU is characterized as a unit of high complexity, with technological and human resources that allow the survival of clinically severe NB. However, the hospitalization of the newborn in this place may expose the family to emotional vulnerability, especially since the NICU is associated with the possibility of the child's death.1818 Cartaxo LS, Torquato JA, Agra G, Fernandes MA, Platel ICS, Freire MEM. Vivência de mães na unidade de terapia intensiva neonatal. Rev Enferm UERJ [Internet]. 2014 Nov [cited 2016 May 19]; 22(4):551-7. Available from: http://www.facenf.uerj.br/v22n4/v22n4a19.pdf
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-1919 Santos LF, Oliveira LMAC, Munari DB, Peixoto MKAV, Silva CC, Ferreira ACM et al. Grupo de suporte como estratégia para assistência de enfermagem a família de recém-nascidos hospitalizados. Rev. Eletr. Enferm [Internet]. 2012 Jan [cited 2016 May 19]; 14(1): 42-9. Available from: https://www.fen.ufg.br/fen_revista/v14/n1/pdf/v14n1a05.pdf
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In this study, the fear of losing the newborn and the strangeness of the NICU environment had a negative impact on the force field.

It is also perceived that the separation of the mother from the baby, due to its hospitalization in the NICU, causes contradictory feelings in the mother. While she recognizes the need and the importance of the NICU for the maintenance of her child's life, she also experiences great sadness and anguish over the child's clinical situation, afraid that the child feels pain and dies, and uncertainties related to what the child still has to face.2020 Perlin DA, Oliveira SM, Gomes GC. A criança na unidade de terapia intensiva neonatal: impacto da primeira visita da mãe. Rev Gaúcha Enferm [Internet]. 2011 Sep [cited 2016 May 19]; 32(3):458-64. Available from: http://www.scielo.br/pdf/rgenf/v32n3/04.pdf
http://www.scielo.br/pdf/rgenf/v32n3/04....

For mothers, it is very difficult to see their child wrapped up in equipment and exposed to painful procedures. Thus, it is essential to understand that, in the NICU, although many mothers can interact with the child by skin-to-skin touch, some mothers due to their nervousness, estrangement from the environment, and severity of the child's clinical condition, can only observe the NB on the first visit.2020 Perlin DA, Oliveira SM, Gomes GC. A criança na unidade de terapia intensiva neonatal: impacto da primeira visita da mãe. Rev Gaúcha Enferm [Internet]. 2011 Sep [cited 2016 May 19]; 32(3):458-64. Available from: http://www.scielo.br/pdf/rgenf/v32n3/04.pdf
http://www.scielo.br/pdf/rgenf/v32n3/04....
Therefore, it is fundamental that the health professional refrains from making judgments or criticisms regarding the mother's behavior, and that they show sensitivity and empathy to the mothers and respects their limitations, and shows support.2121 Santos LF, Oliveira LMAC, Munari DB, Barbosa MA, Peixoto MKAV, Nogueira ALG. When the communication is harmful in the encounter between health professional and family of hospitalized child. Enferm Glob [Internet]. 2015 Jan [cited 2016 May19 ]; 14(37):216-26. Available from: http://scielo.isciii.es/pdf/eg/v14n37/en_docencia4.pdf
http://scielo.isciii.es/pdf/eg/v14n37/en...
As evidenced in this study, the health status of the NB, dependency on various equipment , and the impersonal environment of the NICU had a negative impact on the force field, compromising the mothering process.

The lack of structure and provision of minimal comfort to the family in the NICU and the noises and alarms coming from the technological apparatuses, mixed with the fatigue, the emotional stress and the lack of time to take care of themselves are all factors that can interfere with families who accompany hospitalized NB and which compromise their physical and mental health.33 Santos LF, Oliveira LMAC, Barbosa MA, Siqueira KM, Peixoto MKAV. Reflexos da hospitalização da criança na vida do familiar acompanhante. Rev Bras Enferm [Internet]. 2013 Jul [cited 2016 May 19]; 66(4):473-8. Available from: http://www.scielo.br/pdf/reben/v66n4/v66n4a02.pdf
http://www.scielo.br/pdf/reben/v66n4/v66...
Thus, health institutions should invest resources to create welcoming and harmonious environments that contribute to the improvement of care for hospitalized children and their families. In addition to providing well-being to this group, the use of the architecture can also facilitate the development of the work process of health professionals.2222 Ribeiro JP, Gomes GC, Thofehrn MB. Health facility environment as humanization strategy care in the pediatric unit: systematic review. Rev Esc Enferm USP [Internet]. 2014 Jun [cited 2016 May 19]; 48(3):530-9. Available from: http://www.scielo.br/pdf/reeusp/v48n3/0080-6234-reeusp-48-03-530.pdf
http://www.scielo.br/pdf/reeusp/v48n3/00...
In this research, the provision of food and a room for the mothers of the RNs had a positive effect on the mothering process, as it contributed to the mother's permanence in the NICU and, consequently, to the interaction and the construction of a bond between mother and baby.

In health care, strategies that minimize the suffering of mothers who accompany their children during treatment are imperative. Thus, it is up to health professionals to provide support in coping with these difficult days, through humanized care, which is founded on the bonds and responsibilities which go beyond the biological assistance of the body.11 Giménez EC, Sánchez-Luna M. Providing parents with individualised support in a neonatal intensive care unit reduced stress, anxiety and depression. Acta Pediatr. 2015 Jul; 104(7):300-5.,1919 Santos LF, Oliveira LMAC, Munari DB, Peixoto MKAV, Silva CC, Ferreira ACM et al. Grupo de suporte como estratégia para assistência de enfermagem a família de recém-nascidos hospitalizados. Rev. Eletr. Enferm [Internet]. 2012 Jan [cited 2016 May 19]; 14(1): 42-9. Available from: https://www.fen.ufg.br/fen_revista/v14/n1/pdf/v14n1a05.pdf
https://www.fen.ufg.br/fen_revista/v14/n...

In this perspective, the offer of support and effective communication represent forces produced by the health team that contribute significantly to the mothering process. 2323 Abdeyazdan Z, Shahkolahi Z, Mehrabi T, Hajiheidari M. A family support intervention to reduce stress among parents of preterm infants in neonatal intensive care unit. Iran J Nurs Midwifery Res [Internet]. 2014 Jul [cited 2016 May 19]; (4):349-53. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4145487/?report=reader
http://www.ncbi.nlm.nih.gov/pmc/articles...
The quality of care depends on both technology and the human factor, and the health team needs to understand that both are important to their professional performance.1919 Santos LF, Oliveira LMAC, Munari DB, Peixoto MKAV, Silva CC, Ferreira ACM et al. Grupo de suporte como estratégia para assistência de enfermagem a família de recém-nascidos hospitalizados. Rev. Eletr. Enferm [Internet]. 2012 Jan [cited 2016 May 19]; 14(1): 42-9. Available from: https://www.fen.ufg.br/fen_revista/v14/n1/pdf/v14n1a05.pdf
https://www.fen.ufg.br/fen_revista/v14/n...
,2121 Santos LF, Oliveira LMAC, Munari DB, Barbosa MA, Peixoto MKAV, Nogueira ALG. When the communication is harmful in the encounter between health professional and family of hospitalized child. Enferm Glob [Internet]. 2015 Jan [cited 2016 May19 ]; 14(37):216-26. Available from: http://scielo.isciii.es/pdf/eg/v14n37/en_docencia4.pdf
http://scielo.isciii.es/pdf/eg/v14n37/en...

Therefore, health professionals should not act as mere managers of technical patient care, but should play the role of facilitators of the hospitalization experience for both the child and his/her family, where the assistance focuses on the actual biopsychosocial needs of these patients, 1818 Cartaxo LS, Torquato JA, Agra G, Fernandes MA, Platel ICS, Freire MEM. Vivência de mães na unidade de terapia intensiva neonatal. Rev Enferm UERJ [Internet]. 2014 Nov [cited 2016 May 19]; 22(4):551-7. Available from: http://www.facenf.uerj.br/v22n4/v22n4a19.pdf
http://www.facenf.uerj.br/v22n4/v22n4a19...
,2121 Santos LF, Oliveira LMAC, Munari DB, Barbosa MA, Peixoto MKAV, Nogueira ALG. When the communication is harmful in the encounter between health professional and family of hospitalized child. Enferm Glob [Internet]. 2015 Jan [cited 2016 May19 ]; 14(37):216-26. Available from: http://scielo.isciii.es/pdf/eg/v14n37/en_docencia4.pdf
http://scielo.isciii.es/pdf/eg/v14n37/en...
because in doing so, they will positively contribute to the mothering process in the NICU.

Attentive listening, conversation, and therapeutic communication are valuable tools for the protection and strengthening of frail people, such as newborns in UTINs. It is believed that employing these instruments is essential for effective care, and this occurs when the professional acquires knowledge and sensitivity to the other.2121 Santos LF, Oliveira LMAC, Munari DB, Barbosa MA, Peixoto MKAV, Nogueira ALG. When the communication is harmful in the encounter between health professional and family of hospitalized child. Enferm Glob [Internet]. 2015 Jan [cited 2016 May19 ]; 14(37):216-26. Available from: http://scielo.isciii.es/pdf/eg/v14n37/en_docencia4.pdf
http://scielo.isciii.es/pdf/eg/v14n37/en...

Therefore, it is necessary that the health team understands that the hospital environment, due to it being an unfamiliar place for the family, can make them feel insecure and less likely to expose their doubts and fears, as well as feel excluded from health professional's conversations in relation to their child, as they quite often use language which is difficult for the family to understand.33 Santos LF, Oliveira LMAC, Barbosa MA, Siqueira KM, Peixoto MKAV. Reflexos da hospitalização da criança na vida do familiar acompanhante. Rev Bras Enferm [Internet]. 2013 Jul [cited 2016 May 19]; 66(4):473-8. Available from: http://www.scielo.br/pdf/reben/v66n4/v66n4a02.pdf
http://www.scielo.br/pdf/reben/v66n4/v66...

Recent research has shown that, in times of great emotional stress for the family, such as receiving news regarding the treatment and situation of the child's illness, communication using confusing and ambiguous information is ineffective.2424 Sanches MVP, Nascimento LC, Lima RAG. Crianças e adolescentes com câncer em cuidados paliativos: experiência de familiares. Rev Bras Enferm [Internet]. 2014 Jan [cited 2016 May 19]; 67(1):28-35. Available from: http://www.scielo.br/pdf/reben/v67n1/0034-7167-reben-67-01-0028.pdf
http://www.scielo.br/pdf/reben/v67n1/003...

Communication failures contribute to the highest incidences of anxiety in families.2121 Santos LF, Oliveira LMAC, Munari DB, Barbosa MA, Peixoto MKAV, Nogueira ALG. When the communication is harmful in the encounter between health professional and family of hospitalized child. Enferm Glob [Internet]. 2015 Jan [cited 2016 May19 ]; 14(37):216-26. Available from: http://scielo.isciii.es/pdf/eg/v14n37/en_docencia4.pdf
http://scielo.isciii.es/pdf/eg/v14n37/en...
,2525 Rusinova K, Kukal J, Simek J, Cerny V. Limited family members/staff communication in intensive care units in the Czech and Slovak Republics considerably increases anxiety in patients' relatives - the DEPRESS study. BMC Psychiatry. 2014 Jan; 14(21):2-7. On the other hand, effective communication allows professionals to establish authentic interpersonal relationships with their clients, helping them to recover and overcome traumatic situations,2121 Santos LF, Oliveira LMAC, Munari DB, Barbosa MA, Peixoto MKAV, Nogueira ALG. When the communication is harmful in the encounter between health professional and family of hospitalized child. Enferm Glob [Internet]. 2015 Jan [cited 2016 May19 ]; 14(37):216-26. Available from: http://scielo.isciii.es/pdf/eg/v14n37/en_docencia4.pdf
http://scielo.isciii.es/pdf/eg/v14n37/en...
and can contribute to keeping the bond between mother and newborn and boost the mothering process, as was observed in the statements of the participants of this study.

In addition, the inclusion of the family in the care process of the newborn and the multidisciplinary work also positively influenced the mothering process in the NICU. In this scenario, it is essential to carry out care practices based on dialogue, negotiation and participation of the mothers with the health team. During the development of norms and routines, professionals should envisage participatory management, which enables the family caregiver to participate in decision-making regarding the health and illness process of their children, which allows them to experience a learning and care environment in the hospital and recognizing themselves as being cared for and being caregiver as well.2626 Xavier DM, Gomes GC, Santos SSC, Lunardi VL, Pintanel AC, Erdmann AL. A família na unidade de pediatria: convivendo com normas e rotinas hospitalares. Rev Bras Enferm [Internet]. 2014 Mar [cited 2016 May 19]; 67(2):181-6. Available from: http://www.scielo.br/pdf/reben/v67n2/0034-7167-reben-67-02-0181.pdf
http://www.scielo.br/pdf/reben/v67n2/003...

However, this process can often be marked by conflicts, highlighting the need to incorporate dialogue as one of the care technologies for the newborn and its family.44 Duarte ED, Sena RR, Dittz ES, Tavares TS, Lopes AFC, Silva PM. The role of the family in care delivery to hospitalized newborns: possibilities and challenges towards comprehensive care. Texto Contexto Enferm [Internet]. 2012 Oct [cited 2016 May 19]; 21(4):870-8. Available from: http://www.scielo.br/pdf/tce/v21n4/en_18.pdf
http://www.scielo.br/pdf/tce/v21n4/en_18...
In this research, some mothers reported conflicting moments with the health team and these have negatively impacted in the force field, and compromising the mothering process in the NICU.

Therefore, it is emphasized that the integration of the family in the process of child care in the hospital admission unit through the flexibility of rules and routines needs to be encouraged by the health team. This is a strategy that presents itself as a possibility for more effective, singular care in which both families and professionals have the opportunity to feel valued and competent.2626 Xavier DM, Gomes GC, Santos SSC, Lunardi VL, Pintanel AC, Erdmann AL. A família na unidade de pediatria: convivendo com normas e rotinas hospitalares. Rev Bras Enferm [Internet]. 2014 Mar [cited 2016 May 19]; 67(2):181-6. Available from: http://www.scielo.br/pdf/reben/v67n2/0034-7167-reben-67-02-0181.pdf
http://www.scielo.br/pdf/reben/v67n2/003...
-2727 Lee S, O'Brien K. Parents as primary caregivers in the neonatal intensive care unit. CMAJ [Internet]. 2014 Aug [cited 2016 May 19]; 186(11):845-7. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119144/
http://www.ncbi.nlm.nih.gov/pmc/articles...
Such an attitude leads to the construction of a committed care with subjectivity, autonomy and empathy for the families of hospitalized children in the NICU.44 Duarte ED, Sena RR, Dittz ES, Tavares TS, Lopes AFC, Silva PM. The role of the family in care delivery to hospitalized newborns: possibilities and challenges towards comprehensive care. Texto Contexto Enferm [Internet]. 2012 Oct [cited 2016 May 19]; 21(4):870-8. Available from: http://www.scielo.br/pdf/tce/v21n4/en_18.pdf
http://www.scielo.br/pdf/tce/v21n4/en_18...

It is also crucial to understand that a woman is not primarily a mother. The maternal function is a process of construction.77 Miranda MA, Martins MS. Maternagem: quando o bebê pede colo [Internet]. São Paulo (SP): Nove & Dez Criação e Arte; 2007. [cited 2016 May 19]. Available from: http://www.usp.br/neinb/wp-content/uploads/NEINB-USP-VOL-2.pdf
http://www.usp.br/neinb/wp-content/uploa...
-88 Winnicott DW. Os bebês e suas mães. São Paulo (SP): Martins Fontes; 2006. Thus, when she shows herself ready or not to mother her child, the woman presents feelings that can be translated as clarification of doubts, frustrations and longings. In this sense, health professionals should initiate progressive approaches between mother and child, facilitating the development of motherhood/ mothering and create a healthy bond between the mother and her child.55 Reis AT, Santos RS. Maternagem ao recém-nascido cirúrgico: bases para a assistência de Enfermagem. Rev Bras Enferm [Internet]. 2013 Jan [cited 2016 May 19]; 66(1):110-5. Available from: http://www.scielo.br/pdf/reben/v66n1/v66n1a17.pdf
http://www.scielo.br/pdf/reben/v66n1/v66...

It is valid to point out that the factors that affect the affective bond between mother and newborn, fragmenting the formation of attachment, are closely related to the various emotions and suffering experienced by the mother due to the illness and hospitalization of the newborn.1818 Cartaxo LS, Torquato JA, Agra G, Fernandes MA, Platel ICS, Freire MEM. Vivência de mães na unidade de terapia intensiva neonatal. Rev Enferm UERJ [Internet]. 2014 Nov [cited 2016 May 19]; 22(4):551-7. Available from: http://www.facenf.uerj.br/v22n4/v22n4a19.pdf
http://www.facenf.uerj.br/v22n4/v22n4a19...
In this research, feelings of fear, anguish and insecurity, and lack of skills to care for the newborn in the force field that represents the mothering process. This situation demonstrates that it is essential for health professionals to implement strategies aimed at women, with the intention of collaborating with them so that they can effectively take care of their children and fully exercise their maternal side.

It is emphasized that mothering is exercised through the look, tender touch, voice and affective contact, and gives meaning to everything the baby is experiencing. The mother, when interacting with the NB, approaches her needs and can discern between what is pleasing to the child and what is necessary to relieve the child of any discomfort. It is evident that the lack of interaction between the mother and the baby can compromise the emotional development and the cognitive functions of the NB.77 Miranda MA, Martins MS. Maternagem: quando o bebê pede colo [Internet]. São Paulo (SP): Nove & Dez Criação e Arte; 2007. [cited 2016 May 19]. Available from: http://www.usp.br/neinb/wp-content/uploads/NEINB-USP-VOL-2.pdf
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-88 Winnicott DW. Os bebês e suas mães. São Paulo (SP): Martins Fontes; 2006. However, the harmful effects on the formation of the child's personality and the social consequences caused by the estrangement, such as rejection and can be minimized when health workers support good mothering.55 Reis AT, Santos RS. Maternagem ao recém-nascido cirúrgico: bases para a assistência de Enfermagem. Rev Bras Enferm [Internet]. 2013 Jan [cited 2016 May 19]; 66(1):110-5. Available from: http://www.scielo.br/pdf/reben/v66n1/v66n1a17.pdf
http://www.scielo.br/pdf/reben/v66n1/v66...

Thus, these women need the help of health professionals to improve and effectively assume the maternal role.1818 Cartaxo LS, Torquato JA, Agra G, Fernandes MA, Platel ICS, Freire MEM. Vivência de mães na unidade de terapia intensiva neonatal. Rev Enferm UERJ [Internet]. 2014 Nov [cited 2016 May 19]; 22(4):551-7. Available from: http://www.facenf.uerj.br/v22n4/v22n4a19.pdf
http://www.facenf.uerj.br/v22n4/v22n4a19...
,2828 Pereira LB, Abrão ACFV, Ohara CVS, Ribeiro CA. Vivências maternas frente às peculiaridades da prematuridade que dificultam a amamentação. Texto Contexto Enferm [Internet]. 2015 Jan [cited 2016 Nov 10]; 24(1):55-63. Available from: http://www.scielo.br/pdf/tce/v24n1/pt_0104-0707-tce-24-01-00055.pdf
http://www.scielo.br/pdf/tce/v24n1/pt_01...
However, despite the discussions that address the need to humanize care for families in situations of emotional vulnerability, systematized strategies of formal support for these people are incipient.22 Finlayson K, Dixon A, Smith C, Dykes F, Flacking R. Mothers' perceptions of family centred care in neonatal intensive care units. Sex Reprod Healthc. 2014 Oct; 5(3):119-24.,2929 Aliabadi F, Kamali M, Borimnejad L, Rassafiani M, Rasti M, Shafaroodi N, et al. Parental selfsupport: a study of parents' confront strategy when giving birth to premature infants. Med J Islam Repub Iran [Internet]. 2014 Jul [cited 2016 May 19]; 28(82):1-9. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4301256/
http://www.ncbi.nlm.nih.gov/pmc/articles...
-3030 Carmona EV, Coca KP, Vale IN, Abrão ACFV. Mother role conflicts in studies with mothers of hospitalized newborns: an integrative review. Rev Esc Enferm USP [Internet]. 2012 Apr [cited 2016 May 19]; 46(2):505-12. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342012000200032&lng=en&nrm=iso&tlng=en
http://www.scielo.br/scielo.php?script=s...

To enter the family life and look with the eyes of those who live the experience not only as a spectator can contribute to the professional's understanding of the true impact of the disease in the family dynamic and sensitize them to the valorization of the human experiences and to have compassion for the pain of others.2121 Santos LF, Oliveira LMAC, Munari DB, Barbosa MA, Peixoto MKAV, Nogueira ALG. When the communication is harmful in the encounter between health professional and family of hospitalized child. Enferm Glob [Internet]. 2015 Jan [cited 2016 May19 ]; 14(37):216-26. Available from: http://scielo.isciii.es/pdf/eg/v14n37/en_docencia4.pdf
http://scielo.isciii.es/pdf/eg/v14n37/en...

In this study, the mothers indicated that the work of the multi-professional team contributed to the mothering process in the NICU. The multi-professional team work to improve the quality of the service offered. Effective activity planning and communication among those involved are important tools in this process.3131 O'Malley AS, Gourevitch R, Draper K, Bond A, Tirodkar MA. Overcoming challenges to teamwork in patient-centered medical homes: a qualitative study. J Gen Intern Med [Internet]. 2015 Feb [cited 2016 May 19]; 30(2):183-92. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314489/
http://www.ncbi.nlm.nih.gov/pmc/articles...

When the multiprofessional team feels respected and motivated, it is able to establish more meaningful and healthy interpersonal relationships with the family of the patients.1818 Cartaxo LS, Torquato JA, Agra G, Fernandes MA, Platel ICS, Freire MEM. Vivência de mães na unidade de terapia intensiva neonatal. Rev Enferm UERJ [Internet]. 2014 Nov [cited 2016 May 19]; 22(4):551-7. Available from: http://www.facenf.uerj.br/v22n4/v22n4a19.pdf
http://www.facenf.uerj.br/v22n4/v22n4a19...
In turn, positive interactions between the health team and the family can help these people overcome difficulties and suffering which occur in the NICU.1919 Santos LF, Oliveira LMAC, Munari DB, Peixoto MKAV, Silva CC, Ferreira ACM et al. Grupo de suporte como estratégia para assistência de enfermagem a família de recém-nascidos hospitalizados. Rev. Eletr. Enferm [Internet]. 2012 Jan [cited 2016 May 19]; 14(1): 42-9. Available from: https://www.fen.ufg.br/fen_revista/v14/n1/pdf/v14n1a05.pdf
https://www.fen.ufg.br/fen_revista/v14/n...

Considering the adopted methodological framework, not measuring the intensity of each force that acts to boost or restrict the mothering process is presented as a limitation of this research. In order to better understand the impact of hospitalization and building and maintaining child-family bonding we also suggest new studies that consider parents, other relatives and health professionals.

CONCLUSION

Various forces are involved in the mothering process in the NICU. The "Other" (Health Team) vector, emotional support, effective communication, including the family in the care of the newborn and teamwork stand out as vectors which boost the mothering process, and learning and the desire to overcome difficulties, and in the "Environment" (NICU) vector, physical space for mothers stand out in the "I" (Mother of the NB) vector.

Regarding the factors that cause restriction in the mothering process in the NICU, the authoritative behaviors of health professionals were highlighted in the "Other" vector (Health Team); In the "Environment" (NICU) vector, the stigmas related to the NICU and the lack of specialized units for child health care, and in the "I" vector (mother of the newborn), distancing themselves away the child, physical fatigue and emotional stress, the clinical condition of the newborn, negative feelings (fear, anxiety, impotence) and changes in daily routine.

The results of this study can guide actions implemented by the health teams that work in UTINs, with a view to improve interventions that meet the real needs of the mother who experiences the situation of having a hospitalized NB. The approach to the theoretical framework of Force Field Theory and its application in the context of the NICU allowed us to glimpse forces that act to favor and hinder the process of mothering, as well as to understand how the environment, health professionals and the mothers of hospitalized RNs are related.

It is concluded that identifying the force fields that act in the NICU made it possible to understand factors and situations that influence the mothering process in this unit and was configured in a strategy that diagnoses the true biopsychosocial demands of mothers with a hospitalized NB. Thus, the force field is a tool that can be used by health professionals to qualify and humanize care provided to families and RNs in UTINs.

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Publication Dates

  • Publication in this collection
    2017

History

  • Received
    19 May 2016
  • Accepted
    20 Mar 2017
Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
E-mail: textoecontexto@contato.ufsc.br