Establishing action/interaction strategies for care delivery to hospitalized children with chronic conditions

Abstracts

The study aimed to understand the action/interaction strategies adopted by the nursing staff for care to hospitalized children with chronic conditions. Complex Thinking and Grounded Theory were used for theoretical and methodological reference, respectively. There were 18 participants who were organized in three sample groups: nurses, nursing technicians and their families. The semi-structured interview was used and the data analysis followed three stages of coding: open, axial and selective. In this article, the category Signaling attitudes and practices in inter-retro-actions of nursing care and its subcategories were discussed. The nursing team used dialogue, qualified listening, empathy, appreciation of family, teamwork, trust, professionalism, the playful, affection and spirituality as action/interaction strategies for care to hospitalized children with chronic conditions.

Pediatric Nursing; Nursing Care; Chronic Disease

O estudo objetivou compreender as estratégias de ação/interação adotadas pela equipe de enfermagem para o cuidado à criança com condição crônica hospitalizada. Foram utilizados como referenciais, teórico e metodológico, respectivamente, o Pensamento Complexo e a Grounded Theory. Os participantes do estudo totalizam 18 e estão organizados em três grupos amostrais: enfermeiros, técnicos de enfermagem e familiares. A entrevista semiestruturada foi utilizada e a análise dos dados seguiu as etapas de codificação: aberta, axial e seletiva. Neste artigo, abordou-se a categoria "Assinalando atitudes e práticas adotadas nas inter-retro-ações do cuidado de enfermagem". Compreendeu-se que o diálogo, a escuta qualificada, a empatia, a valorização do familiar, o trabalho em equipe, a confiança, o profissionalismo, o lúdico, a afetividade e a espiritualidade são empregados pela equipe de enfermagem como estratégias de ação/interação para o cuidado à criança com condição crônica hospitalizada.

Enfermagem Pediátrica; Cuidados de Enfermagem; Doença crônica

El estudio tuvo como objetivo comprender las estrategias de acción/interacción adoptadas por el equipo de enfermería para el cuidado de los niños hospitalizados con enfermedades crónicas. Fueron utilizados como referenciales teóricos y metodológicos, respectivamente, el Pensamiento Complejo y la Grounded Theory. Participaron del estudio 18 personas organizadas en tres grupos de muestra: enfermeras, técnicos de enfermería y la familia. Se utilizó la entrevista semiestructurada y el análisis siguió las tres etapas de codificación: abierta, axial y selectiva. Este artículo se dirigió a la categoría “Señalando las actitudes y prácticas utilizadas en las inter-retro-acciones del cuidado de enfermería”. Se ha comprendido que el diálogo, la escucha calificada, la empatía, el valor de la familia, el trabajo en equipo, la confianza, el profesionalismo, el lúdico, la afectividad y la espiritualidad son empleados por los profesionales de enfermería como estrategias de acción/interacción para el cuidado de los niños hospitalizados con enfermedades crónicas.

Enfermería Pediátrica; Cuidados de Enfermería; Enfermedad Crónica

INTRODUCTION

Care delivery to hospitalized children with chronic conditions demands that nurses articulate multiple sources of knowledge and practices to attend to the children and their families' needs. In that conjuncture, a web of events, actions, relations, interactions, retro-actions, coincidences¹ exists, which characterize the development of this practice as a complex phenomenon.

In this respect, considering this practice from the perspective of complexity implies acknowledging the children and their relatives as multidimensional beings and, as such, they should be valued in their individuality and diversity in the care relations. This circumstance calls upon the nurses to develop a wide range of interactions, considering that a one-way disease-centered approach is not sufficient to attend to the children and their family members in their complexity.

Concerning the interaction in the care relations, to take care, the nurses need relations that permit proximity among the subjects and culminate in mutual interactive processes, as they favor the establishment of bonding among professionals, children and families and avoid the affective distancing among them². Thus, the interaction is an initial condition for the nurses to take care of the hospitalized children with chronic conditions and their family members.

The National Humanization Policy³ highlights the challenge of overcoming the fragmentation of the work process, of the relations among the different professionals and between them and the users, and of improving the precarious interaction in the teams. These are situations that hamper the establishment of bonding, the construction of solidary and interactive networks, limiting health production in the sphere of the Unified Health System (Sistema Unico de Saúde/SUS).

In view of the above, it is fundamental to establish strategies aimed at advancing in the care relations, considering that the complexity attracts the strategy, which is understood as the art of integrating information and formulating action schemes aimed at joining as much certainty as possible to cope with uncertainties⁴. In that sense, the elaboration of action/interaction strategies by the nursing team for care delivery to hospitalized children with chronic conditions favors the continuity of this practice, which avoids the fragmentation of the care relations and enhances the construction of bonds and care networks in health production.

Thus, the question is raised: What action/interaction strategies does the nursing team adopt for care delivery to hospitalized children with chronic conditions? Hence, the goal was to understand the action/interaction strategies the nursing team adopts for care delivery to hospitalized children with chronic conditions in the light of complexity.

METHOD

Qualitative study based on Complex Thinking and Grounded Theory (GT) as the theoretical and methodological frameworks, respectively.

Grounded Theory is a research method that has been frequently used in Nursing due to its contribution to the understanding of hardly explored phenomena and to the production of explanatory models and theories, providing the researchers with a useful framework to study interpersonal relationships in the care context⁵. What Complex Thinking is concerned, this way of thinking the reality is opposed to the one-dimensional view, which is considered poor and insufficient to understand the multidimensionality of complex phenomena¹.

The data were collected at the Pediatric Hospitalization Unit (PHU) of a public hospital in the city of Rio de Janeiro, Brazil, between July and November 2012, using semistructured interviews as the data collection technique. At this hospital specialized in pediatrics, more than 50% of the hospitalized children have chronic or rare diseases, or are hospitalized without a defined clinical diagnosis⁶.

In view of the premises of the GT⁷, The study participants were organized in three sampling groups, based on theoretical sampling, which makes the researcher look for places, people or facts that enhance the possibility of discovering variations among the concepts constructed in terms of properties and dimensions.

In that context, considering that nurses are the professionals responsible for the organization, execution and assessment of nursing care services, initially, interviews were held with the professionals who complied with the following inclusion criteria: being a nurse with at least three years of experience in care for children with chronic conditions; working at the PHU; having worked at the institution for one year. Nurses on vacation, leave or absent from work were excluded. The interviews were guided by the following question: What action/interaction strategies do you establish to take care of hospitalized children with chronic conditions? The first sampling group consisted of eight nurses, seven of whom were women and one man, who had worked in care for children with chronic conditions between four and 32 years.

The analytic treatment of the interviews with the nurses revealed that, to take care of hospitalized children with chronic conditions, these professionals need to act and interact with the nursing technicians. This circumstance guided the research to the nursing technicians, with a view to understanding their engagement in the development of this practice. Therefore, these professionals should comply with the same inclusion and exclusion criteria defined to compose the first sampling group. The interviews with the nursing technicians were guided by the question: What action/interaction strategies do you establish with the nurses to take care of hospitalized children with chronic conditions? In this second sampling group, six nursing technicians participated, who possessed between 5 and 27 years of experience in care for children with chronic conditions.

When they revealed their engagement in nursing care for hospitalized children with chronic conditions, the nursing technicians mentioned the need to interact with the families, due to their importance and influence in the care relationships. This fact guided the research to the relatives of the hospitalized children with chronic conditions, with a view to discovering their perception about the nursing team’s interaction in care delivery. Therefore, being a relative of a child with a chronic condition hospitalized at the PHU was established as the inclusion criterion. The interviews with the family members were guided by the question: What is the interaction of the nursing team like in relations of care for the child? The third sampling group included four family members, all of whom were mothers of hospitalized children with chronic conditions.

It is highlighted that theoretical saturation determined the end of the data collection in each sampling group, when the new data collected were no longer altering the consistency and theoretical density of the concepts constructed⁷.

In GT, the data are collected and analyzed in parallel. The comparative analysis of the data followed the following coding phases: open, axial and selective. In open coding, the data were coded line by line, generating the preliminary codes that, in turn, after being grouped by similarities, originated the conceptual codes. The grouping of the conceptual codes by similarities originated the categories and subcategories. In the axial coding, the categories and subcategories were mutually related to determine their properties and dimensions. In this phase of the analysis, an analytic tool called paradigm was used. This permits the integration of the structure and process of the research phenomenon. Structure is considered as the causal, contextual and intervening conditions, and process as the action/interaction strategies and consequences. In selective coding, the central category in this study was determined. In combination with the coding process, memoranda and diagrams were elaborated that supported the theoretical analysis of the data⁷.

The category Signaling attitudes and practices adopted in the inter-retro-actions of nursing care emerged from the data analysis as action/interaction strategies of the phenomenon “Establishing relations and interactions for the management of nursing care for children with chronic conditions hospitalized at the Pediatric Hospitalization Unit”. Given its relevance to present the action/interaction strategies the nursing team established to take care of hospitalized children with chronic conditions, the researchers chose to present it separately in this article.

In compliance with the recommendations of National Health Council Resolution number 446/12, of the Brazilian Ministry of Health, the data collection only started after receiving approval from the Institutional Review Board at Anna Nery School of Nursing - EEAN/HESFA/UFRJ, under opinion 8921, and from the Institutional Review Board of the hospital where the study was developed, under opinion 07/12. The subjects were asked to sign the Free and Informed Consent Form. To guarantee their anonymity, the nurses’ statements were identified using the letter N, the nursing technicians the letter T and the family members using the letter F. All statements are followed by a number, according to the order of the interviews held in each sampling group (N1, T1, F1).

RESULTS AND DISCUSSION

The category “Signaling attitudes and practices adopted in the inter-retro-actions of nursing care” addresses the different action/interactions strategies the nursing team adopts to take care of hospitalized children with chronic conditions. It consists of the following subcategories: Interacting with the child’s relatives; Revealing interaction strategies in teamwork; Outlining mediating attitudes in the care relations for children with chronic conditions; and Manifesting being professional and human in the care relationships.

The subcategory “Interacting with the child’s relatives” reveals that the dialogue is an important interaction strategy in the relation between the nursing team and the family. Through dialogue, the nursing team interacts with the relatives, informing and explaining the care that is to be taken with the child.

We try to show the companion everything that will be done with the child (N5).

Everything we are going to do we first have to tell the mother, explain what will be done. (N7).

We try to talk, listen, explain to the companion. (N8).

Normally, everything I’m going to do I explain to the companion, we talk. (T3).

Next, the relative’s statement underlines the importance of dialogue in care relationships.

The dialogue sometimes calms down, we put lots of things into their head and people who understand more calm us down and we reflect that that’s it really (F4).

The dialogue enhances the approach among people and, through the dialogue, closer contact starts, a relationship of integration among cultures, an experience exchange⁸. Thus, it is a way for the professional to interact in the care relations. Nevertheless, it is highlighted that dialoging necessarily implies knowing how to listen, pay attention to what the other says, as listening permits knowing the care needs that will guide the management of this practice.

You have to listen to the person because, sometimes, people only need you to listen to them (N4).

Knowing how to listen to the other person’s complaints/needs is an attitude desired and cited in the National Humanization Policy as qualified listening, and is an important strategy to promote welcoming³. Qualified listening should not only be focused on the family and child’s complaints or biological needs, but also on their affective, social and spiritual needs.

Beyond the dialogue and listening, the following statements express empathy as an interaction strategy in the relation with the child’s relatives.

We need to know how to put ourselves in their place a bit [...] try to understand that the whole situation is difficult (N8).

I even try to put myself in that person’s place, if I were in that situation how would I be? (T1).

In line with that result, a study⁹ reveals that the nurses valued empathy as an interaction tool in its relations with clients in onco-hematology care and used it to mitigate their clients’ suffering. Empathy is related to individuals’ ability to understand, but without judging other people’s positive and negative experiences¹⁰, being an important interaction strategy in the care relations. In the complex relation of human intersubjectivity, other people’s feelings/suffering can be shared and experienced through empathy but, although they can be shared, feelings/suffering cannot be transferred⁴.

From another angle, a family member’s statement below presents observation as the first interaction strategy to interact with the nursing team. Next, he mentions a timid approach of the team professionals, followed by the establishment of a friendly relation.

First I look and I am quiet, I analyze, see if the person likes to play or not, I take it slowly, call his name, I make that always healthy joke, I say that my son is their son and the nurse says that the children are as if it were children and we make healthy jokes and interact (F3).

In this study, the nursing team’s valuation of the family was considered as an interaction strategy in the care relations. From that perspective, the statements below reveal the meanings the professionals attribute to the family member’s presence in the hospital context.

The companion is that person who is always there, we cannot detach the child from the family (N2).

I consider them heroes, heroines because I don’t know how I would feel in their place, you witness situations in which there is a lot of strength, they are very strong, very courageous (T2).

The parents’ presence is very important for the children (T4).

The meanings unveiled highlight the family’s importance in children’s hospitalizations, serving as mediators in the team-child relationship and as the children’s primary source of confidence, safety and kindness¹¹.

“Revealing interaction strategies in teamwork” is the subcategory that calls for reflections on the complementariness and on the relation of interdependence in nursing teamwork. The complexity of teamwork is highlighted and the need is appointed to value the uni-duality of beings in the care relations.

Teamwork is a work organization strategy that takes the form of quality in comprehensive care to the clients’ needs¹². In that sense, the nurses and nursing technicians valued teamwork as an interaction strategy for care delivery to hospitalized children with chronic conditions. Thus, they acknowledged the reciprocity in teamwork as an element that enhances the interprofessional relations.

There exists a reciprocity between the nurse and the group, so the thing flows, we produce (N8).

We are part of a team, we are a team (T2).

If you are in doubt or face difficulties the nurse is there to clarify them, and when everyone’s united the work flows well and we reach the objective (T4).

Working as a team is not an easy task though. It represents a challenge for the professionals due to the different opinions and behaviors in their relationships. These are circumstances that favor the appearance of conflicts, misunderstandings and disputes in the care relations. In view of relational problems in teamwork, the nurses remain impartial and open to dialogue and negotiation. They try to exercise good leadership and elaborate interaction strategies like those evidenced in the following statements:

I try to be impartial and make the appropriate combinations of pairs in work, who interacts well with whom, sometimes we do activities, like, birthdays, June celebrations, we do things to be able to facilitate interaction. We prepare a surprise for somebody, so these are things that strengthen this bond and break the ice (N3).

You need that flexibility, you talk and they do what has to be done, if you are very authoritarian you won’t get very far, I think you don’t get far with authoritarianism, I prefer to be accessible and negotiate (N7).

According to the nursing technicians, teamwork demands an attitude of respect for other people, trust, professionalism and dialogue as interaction strategies.

I think that, putting my responsibility, my professionalism first, trying to conquer the nurse’s trust in my work and respect as a human being as well, respecting everything, respecting both the professional and the human side of the staff (T1).

If I am not satisfied with something we’re gonna talk about it, my shift is always open to talk, the nurses in my shift are open to dialogue, you can come and say something you’re not satisfied with and that makes it easier for things to work out (T4).

In addition, a study² reveals that friendship, love, affection, credibility, privacy and understanding of differences are important tools in the interaction process.

In the subcategory “Outlining mediating attitude in the care relations for children with chronic conditions”, the nursing professionals talked about their ways of acting and interacting with the children. In addition, they expressed their action/interaction strategies to take care of these children.

To facilitate the children’s participation in care and favor a relaxed environment, the nurses adopt behaviors in accordance with the children’s reactions. Sometimes they are inflexible and firm in their care; at other times, they are flexible and available to play with them. The following statements present that circumstance:

Some children only accept the care when you’re firm, no, I need to do it and I’m gonna do it now and you need to cooperate and then you end up breaking the barrier and she starts to accept it, other children already start playing, the child says no and we say yes, you play and find a bypass (N1).

When the child interacts, we end up using the games typical of each child, each child has one, either a song or a game, a way of talking [...] when he smiles like that, opens up, we get close unless we really have to hold him, examine and move the child (N3).

Playing is the most important activity in children’s lives and contributes to their motor, emotional, mental and social development¹³. The nurses and their team should consider it as the most appropriate way to get close to the children, as it permits developing empathy and establishing bonds of friendship and love among the nurse, the child and the family¹⁴.

The games help the professionals to cope with the children’s difficult behaviors and serve as action/interaction strategies for care to hospitalized children with chronic conditions. They can be related to the use of toys, drawings, dancing and music, according to the following statements.

I have always used the song with them [...] wherever I go I have to sing the song. (N4).

You go, talk, take a toy, you draw, I sing, the worse the situation the more I sing, so who sing frighten their fears and things work out (N7).

In some circumstances, the nurses mentioned used play strategies to prepare the children for procedures they will be submitted to. This attitude aims to reduce the child’s tension, fear and anxiety. In some cases, this involves the family, as described in the following statement:

I bring a toy, it’s more that toy that she likes [...] sometimes when the child is starting the treatment and the venipuncture is very difficult, she’ll cry, I take a scalpel and break it, I puncture the doll’s vein, pretend to puncture the mother’s vein because I break the needle and put on the butterfly, I give a tourniquet, give gloves to allow her to go through that (N4).

The following excerpts from families’ discourse strengthen games as a playful interaction strategy the nurses adopt to take care of hospitalized children with chronic conditions.

They play, take the child and make her go for a walk when she’s calm, so they walk, play, sit her down (F3).

They interact well with her (child), they play (F2).

One professional also mentioned affection as an important interaction strategy in her relation with hospitalized children with chronic conditions.

I play with them a lot, I am very kind to them and I think you have to teach affection to the child, teach the child to be affective, to be kind (T4).

The use of affection in the care relations with the children is confirmed in the following family member’s statement:

They have a lot of love, a lot of kindness for our children in hematology (F1).

Affection in the care relations can serve as an important tool in the interaction process, enhancing the practice of sensitity². One study¹⁵ registers the need for nurses to be trained to develop sensitivity with a view to attending to the children and family members’ expectations and needs. Therefore, it represents an appeal to value rationality and is opposed to the rationalization¹ of care relations.

It is highlighted that everything that is human comprises affection and, therefore, that affection lies in intersubjectivity. It permits social communication in interpersonal relationships, sympathy, as well as projection/identification with the other, producing connivance⁴ in the care relations.

The subcategory “Manifesting the professional and human being in the care relations” is an invitation to envisage nurses as multidimensional beings and to acknowledge the dialogical relation reason/emotion, body/spirit, science/empiricism in the complexity of human existence. In the dialogical relation, principles and notions that should be mutually exclusive are united due to their inseparable nature⁴.

In this interval, the professional statements below reveal that, in nursing care for hospitalized children with chronic conditions, the nursing team gets emotionally involved in the child’s suffering and that, in some care situations, this attitude causes concerns, as it culminates in implications for their professional practice.

You suffer, she will soon die and I try not to give myself that much emotionally to that child [...] I see colleagues who suffer, cry, I think I suffer less when I don’t get that emotionally involved (N7).

I try not to absorb the suffering that much because I know that will hamper my care (T1).

I try to set a limit for self-preservation, I am really like that, kiss, hug, so I preserve myself a bit, sometimes you want to do that much, but I save myself a little [...] it’s a lie if you say that you don’t bond, you do, but I try to slow down when I see that I’m too involved even with the patient, I think it’s not good because then you no longer have the courage to do something that needs to be done (T2).

Sometimes it’s difficult because it hurts and people even say ah, that’s why I don’t like to get involved, but I think that, in pediatrics, it’s very complicated for you not to get involved (T5).

In line with this result, a study¹⁶ registers the dialogical relation of the “I - human being” with the “I - professional” of the nursing professionals in the care relations. In their testimonies, the study participants mentioned the possibility to separate the “I - human being” from the “I - professional” in the care relations and, at other times, manifested difficulties to make this distinction. Nevertheless, the testimonies express the uni-duality of the “human being” and “professional being” that mutually engages with the beings received care, but without distinguishing between giving care as a professional and as a human being, revealing the impossible nature of that division.

The complexity perspective shows the unity in human diversity and the diversity in human unity. Unity does not only rest in the biological traits of the homo sapiens. Similarly, diversity does not only rest in the psychological, cultural, social traits of the human being. The human unity also contains a biological diversity, and the same is true for the mental, psychic and affective unity⁴.

To cope with that situation, the professionals use spirituality as an action/coping strategy, as observed in the following statements:

I pray a lot, I ask God to take charge not only of me, to give me strength each day. I pray for myself and for the people who are here too, both the patients and the caregivers (T1).

It’s a lot of praying because I am very religious and I believe that God puts us where he wants, so I think that by praying I get all that even if it’s difficult, sometimes it’s very difficult to separate things, I am a professional, you are the patient’s mother and he is the patient (T5).

Based on the above statements, spirituality can be considered an action/coping strategy the nursing professionals adopt for self-care and to take care of the child. From this perspective, it is considered that the spirituality expresses the values according to which the person lives and believes in, the lifestyle she follows, how and what she lives for, related to everything that refers to the in-depth experience of human life¹⁷. It is therefore intrinsic in human beings, acknowledgeable when it emerges as a need, as an aspect inherent in nursing care¹⁸.

CONCLUSIONS

The category “Signaling attitudes and practices adopted in the inter-retro-actions of nursing care” and its respective subcategories permitted understanding that the nursing team’s elaboration of action/interaction strategies is a resource needed to develop nursing care for hospitalized children with chronic conditions.

This category evokes the complexity of the human and interprofessional relations, highlighting that taking care of the other implies paying attention to what that person says, feels and thinks. This category acknowledges the non-linearity of care relations, revealing how the nursing professionals act/deal with the situations that emerge from their network of relations that sustain nursing care.

Dialogue, qualified listening, empathy and the valuation of the family emerged in the results as action/interaction strategies the nursing team established in its relation with the child’s family. The nurses employ these strategies to achieve a pleasant relation with the family, acknowledging its importance in the child’s hospitalization process. Teamwork as an action/interaction and work organization strategy, in combination with respect, confidence, dialogue and professionalism showed to be conditions needed for a solid interaction in teamwork.

In the care relations with hospitalized children with chronic conditions, it was perceived that the nursing team uses the playful as an interaction strategy, involving toys, drawings, dancing and music to favor the children’s involvement and participation in care. In this case, affection was employed as an important interactions strategy.

Affection in the care relations favors the exercise of sensitivity, as mentioned in this research. This, in turn, has motivated the professionals to get emotionally involved in the child’s suffering. This study highlights the need for the professionals to set limits for their emotional involvement with the children in order to avoid future emotional, affective and psychological problems.

The study signals that the nursing professionals need emotional, psychological and spiritual support to cope with the subjective aspects of hospitalized children with chronic conditions. Nevertheless, one study limitation is the fact that only the action/interaction strategies the nursing team elaborated were investigated. Therefore, the theme under analysis should be further investigated through the development of new studies that explore the multiprofessional health team’s perspective in care for these clients.

Finally, the following aspects of the National Humanization Policy are signaled, which are employed in the care relations: shared care and management; valuation of dialogue for effective communication, as well as for welcoming; teamwork as a strategy to organize work and cooperation with a view to overcoming the fragmentation of the relations and the precarious interaction in the teams; and alterity in the care relations.

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Publication Dates

• Publication in this collection
  Apr-Jun 2015

History

• Received
  17 Feb 2014
• Accepted
  02 Sept 2014