Family culture versus institutional hospital culture: a relation between two worlds^*

Cultura familiar versus cultura institucional hospitalaria: relación entre los dos mundos

ABSTRACT

Objective:

To understand the relation between family culture and hospital institutional culture.

Method:

Qualitative study, carried out in 2017, with relatives of children admitted to a Hospital in southern Brazil. The study included non-participant observation, to gain familiarity with the investigated cultural context; participant observation, to know the respondents’ experiences; and interviews. The data were coded and theoretical formulations and recommendations were made.

Results:

Fifteen family members participated. Hospitalization is a time of encounter and interaction between family culture and institutional culture.

Conclusion:

Hospital culture is presented as an instrument of family care and adaptation and flexibility of norms and routines to humanize cultural care.

DESCRIPTORS
Child, Hospitalized; Family; Child Care; Culture; Pediatric Nursing; Transcultural Nursing

RESUMEN

Objetivo:

Comprender la relación entre la cultura familiar y la cultura institucional hospitalaria.

Método:

Se trata de un estudio cualitativo, realizado en 2017 con familiares de niños internados en un hospital del sur de Brasil. Se llevó a cabo mediante una observación no participante, con el objetivo de familiarizarse con el contexto cultural investigado, una observación participante para conocer las experiencias de los informantes, y entrevistas. Se codificaron los datos y se hicieron las formulaciones teóricas y las recomendaciones

Resultados:

Participaron 15 familiares. La internación hospitalaria es un momento de encuentro e interacción de las culturas familiar e institucional.

Conclusión:

La cultura hospitalaria se presenta como un instrumento de atención a la familia y de adaptación y flexibilidad de las normas y rutinas como una forma de humanizar el cuidado cultural.

DESCRITORES
Niño Hospitalizado; Familia; Cuidado del Niño; Cultura; Enfermería Pediátrica; Enfermería Transcultural

RESUMO

Objetivo:

Compreender a relação entre a cultura familiar e a cultura institucional hospitalar.

Método:

Estudo qualitativo, realizado em 2017, com familiares de crianças internadas em um hospital do Sul do Brasil. Realizaram-se observação não participante, visando familiaridade com o contexto cultural investigado, observação participante, para conhecer as vivências dos informantes, e entrevistas. Os dados foram codificados e realizadas as formulações teóricas e recomendações.

Resultados:

Participaram 15 familiares. A internação hospitalar é um momento de encontro e interação das culturas familiar e institucional.

Conclusão:

A cultura hospitalar apresenta-se como um instrumento de cuidado familiar e a adaptação e flexibilização das normas e rotinas como forma de humanizar o cuidado cultural.

DESCRITORES
Criança Hospitalizada; Família; Cuidado da Criança; Cultura; Enfermagem Pediátrica; Enfermagem Transcultural

INTRODUCTION

In family life, members develop affection for each other, which promotes security, maintenance, health care. The family is the main support group and is considered the first social unit where the individual is inserted and the first institution that collaborates for the development and socialization of individuals(¹).

The ethical and moral values culturally transmitted guide the relationships and support family life. In this context, it is necessary to enter and get involved in the family context in order to understand how families manifest their culture when providing care for hospitalized children and to apprehend the meaning of this care. When the cultural aspect of care is valued, human condition and lifestyle can be improved(²–³).

This understanding allows better interaction and quality of care for the child and their family, favoring the construction of an affective bond. Thus, when considering the client’s culture, the professional can improve the management of the primary care activities performed daily by the family with a child in the hospital(³).

The family is the main support for the hospitalized child. Therefore, care targeted at the family-child dyad must be respectful and sensitive to their needs and values. Their participation in the hospital care environment generates a continuous process of construction and deconstruction of norms, routines, values, and beliefs, which support collective actions aimed at promoting the child’s health(⁴–⁵).

A study about families’ experience with hospital rules and routines showed that the family presents itself as an entity with rights, who wants to exercise them in the struggle to maintain their autonomy during hospitalization, aiming to guarantee the care and recovery of the child’s health. However, for the child’s sake, in many situations, they to submit to the health team(⁶).

In this context, performing childcare in the hospital generates a relational process between family, child and nursing team. Each family, in its singularities, has different needs, which are included in the agenda during care at a pediatric unit. The joint construction of care incorporates new elements, expanding the possibilities of arrangements and generating a universal way of care, full of historicity(⁷).

A possible culture shock may occur when, based on their cultural beliefs and values, the family interferes and disagrees with the care provided to the child by the Nursing team. Nursing professionals have explored the perception that culture influences the forms of care, seeking comprehensive care in a holistic, culturally defined, standardized, and expressed manner. This sort of care is adapted to the lifestyle of the hospitalized person. In this context, the strengths, culture, traditions, and knowledge that each family brings to the hospital should be valued(²,⁸).

In this sense, the nursing professional who works in the hospital needs to consider the client’s culture when planning care, as the family can remain healthy according to their care practices, that are based on their beliefs, values, and the knowledge acquired both in the popular system and in the professional care system(²,⁹).

Thus, one of the strategies to provide care is trying to know the ways of life of the being who is receiving care, seeking to understand them in their multiple dimensions, including the cultural one. Therefore, human beings must receive care that is based on their culture and that takes into account their experience, environment, and care references(²). Nursing professionals needs to get closer and learn about the culture of families with whom they interact professionally, broadening their view of the world and its social role. In this context, the guiding question of this study was: how family culture and hospital institutional culture relate to one another? That said, the objective was to understand the relation between family culture and hospital institutional culture.

METHOD

Type of Study

Qualitative study using Madeleine Leininger’s Culture Care Theory of Diversity and Universality as the theoretical framework and ethnonursing as the methodological framework. Ethnonursing is used to extract, from the research data, facts, feelings and world views that help revealing the real world of the participants, allowing the understanding of their beliefs, values and ways of life(¹⁰).

Population

Fifteen family caregivers of children hospitalized in a pediatric unit of a University Hospital (HU) in the extreme South of Brazil participated in the study. The hospital included in the study is a reference in maternal and childcare. The Pediatrics Unit has 18 beds and serves children aged between zero and twelve years old. These are attended by the Unified Health System (SUS) and interns for clinical and surgical care.

The respondents met the inclusion criteria: being a family member of the child, being over 18 years old and providing direct care in the hospital environment during data collection. Family members who only visited the child were excluded. The days and times of the observations and the interview were arranged with the participants who agreed to participate in the study. The total number of participants was determined by information redundancy (saturation point), which occurs when the respondents’ data are repeated and do not add anything new, showing that they said and shared everything(¹⁰).

Data Collection

Data was collected from December 2016 to May 2017 and followed the methodological model of ethnonursing, composed of observation, participation and reflection, and semi-structured interviews(²,¹⁰). The researcher entered the field, presenting the project to the Nursing team and the participating family members.

Data collection was carried out in four phases of observation and interview. Each family member was observed in three morning shifts, three afternoon shifts, and three night shifts (from 7 pm to midnight), in order to register their manifestations of child care, at different times of the day, totaling 765 hours of observation. Their relation with feeding, hygiene, medical evaluations, exams and procedures performed by health professionals and their child care actions in this context and dynamics were observed.

The observations of the care provided by the family member to the child made during the investigation were recorded in a field diary. The observation script was based on the beliefs, values, and ways of caring of these families, trying to portray how they express their cultural values in the hospital environment and how family culture and hospital institutional culture are related.

During non-participant observation, that is, without establishing any sort of relationship with the family(¹⁰), the researcher tried to obtain a perspective of the cultural context of the place of study. In the second phase, the observation included some participation: informal conversations and interaction with key informants occurred, and the researcher observed and perceived their actions and responses. In this stage, the researcher spent more time with each participant, and was able to follow their activities in a closer and more detailed observation.

In the third phase of observation, after establishing an interaction, participation became more active. It was noticed that the context of the families is constituted of different ethnic origins, in which each participant expresses their way of living, basing their way of caring on their beliefs.

After these three phases of observation, an interview script with questions about the identification data and others that addressed specific situations related to childcare and present in the field diaries of each family informant was elaborated. The proposed semi-structured individual interview sought to capture the meaning attributed by the informants to their experience in the hospital(¹⁰). The family caregivers were asked about their way of caring and how the family culture and the institutional hospital culture are related. The interviews were conducted in the child’s own ward and recorded for transcription and analysis.

In the fourth phase of observation, reflective observations were made, rethinking the observed phenomenon and evaluating the information recorded in the field diaries. In this phase, the results could be discussed with the informants to give greater reliability to the results(¹¹). This stage was characterized by leaving the field and reflecting on the experiences with the informants.

Data Analysis and Statistical Treatment

The analysis of the data obtained in the interviews and in the observation was carried out in four phases, as recommended by Leininger, based on specific criteria(²,¹⁰). In the first stage, the researcher collected, described, recorded, and began the data analysis. In the second stage, the data were coded and classified, seeking to meet the guiding question of the study. The third stage was the contextual analysis, seeking saturation of ideas and recurring patterns of similar or different meaning. In this stage, recoding was carried out. In the fourth stage, the relevant research themes and findings were identified, and theoretical formulations and recommendations were carried out. Scientific rigor was guaranteed by the use of the criteria of credibility, confirmability, saturation and transferability proposed by the method(¹⁰).

Ethical Aspects

Resolution No. 466/12, of the National Health Council, was considered. The study received a favorable opinion from the Research Ethics Committee, protocol 1,911,254, of February 8, 2017. To guarantee their anonymity, participants were identified by the letter F, followed by the interview number. All participants signed the Informed Consent Form to participate in the study.

RESULTS

Fifteen family caregivers, 12 mothers and three grandmothers of hospitalized children participated in the study. Their ages ranged from 18 to 58 years. They had a family income between R$ 500.00 and R$ 5,000.00. Eight family members had incomplete elementary education. The children were between five months and nine years old, and eleven of them were male.

The data analysis showed that, in the hospital, there is: The apprehension of the hospital culture as an instrument of family care and Adaptation and flexibility of norms and routines as an instrument of humanization of cultural care.

The Apprehension of the Hospital Culture as an Instrument of Family Care

The family unit is composed of individuals who perceive themselves as family, who have affective, interest and/or consanguinity bonds. They relate dynamically to one another, possessing, creating, and transmitting beliefs, values, norms, and knowledge, under the influence of the environment in which they live. At the hospital, the family may be sensitive. During interaction between family members in this context, beliefs, values, norms, and knowledge are transmitted.

The mother makes her child sleep and, sitting next to the crib, cries silently. The child’s grandmother hugs her and talks about the child’s illness, trying to calm her daughter (OBS).

The team must try to understand the reality of the family at this time, trying to establish a relationship of affection and cooperation, sharing these worlds, and building a relationship between family and hospital institutional cultures.

Nursing girls come and talk. All my doubts, the staff comes and talks. I take care of my son according to what I believe and what I do at home. The difference is that here it is calmer to take care. At home it is busier because I work outside (F1).

At home I prefer to give medicine along with food, but here I was taught that it can be given at any time. They must know because they have studied and it is also part of the routine of this place (F8).

The nurse taught me how to give bath without getting the bandage and the plaster on the vein puncture wet (14).

Norms and routines are part of the organizational culture. Families recognize they need to favor the good functioning of the pediatric unit and seek to adapt, as they perceive themselves as important instruments in the work for the recovery of the child’s health. The health team often considers that the family demands and questions too much during the process of apprehension and appropriation of the hospital’s culture.

The nurse was called to the room by the child’s mother, who asked her about the tests that the child had to do. The mother was advised about fasting (OBS).

I know that everything has a schedule here at the hospital. The schedule is completely different than the ones we follow at home, but I know it’s important. Here everything is guided by the clock (F2).

What affects me the most is the change in the way we live. Here, everything is different, but we go with the flow. [laughs] In the morning we have a doctor’s visit and exams. In the afternoon there is physical therapy. At that time, I try to clear all my doubts with the nurse (5).

The hospital is a place where everything has to be and get done in a specific way. Nurses control everything. But I think that because we are too many, they must have this control (F10).

During hospitalization, I received a leaflet with guidelines on the hospital’s rules and routines. We have to follow these rules. I thought it was good because everything is well explained and it is clear to us. But I questioned the lunch and visiting hours. They are very bad for me (F13).

Adaptation and Flexibility of Norms and Routines as an Instrument of Humanization of Cultural Care

Although they consider the existence of rules imposed by the institution to be important, family caregivers would like these to be adapted, meeting the individual needs of each family. The flexibility of norms and routines for families is mostly designed to benefit professionals to the detriment of patients, making it even more difficult for them to adapt to the hospital. The implementation of changes aimed at favoring patients can be recognized as a strategy of humanization and respect for individualities.

Family members believe that, when health professionals adapt rules and routines to meet a special need of the child or family caregiver, they are favored and the normal functioning of the sector is not compromised, as the institution’s specificities are preserved while families are allowed to express their ways of living. The family cannot be seen only as an entity that follows the determinations of health professionals, since, when incorporating the hospital culture, they are only asking for the care of the child.

The adaptation and/or flexibility of the rules and routines enable the construction of an ethical, democratic, and humanized work process of the health team, since their relations with the child and their family caregiver are inseparable. In this context, a relationship between family culture and institutional hospital culture is established. This relationship between cultures happens through a process of (de)construction of norms, routines, values, and beliefs that support the process of childcare in the hospital.

Families question about who set the rules and routines that they must follow (OBS).

My husband is a fisherman. There is no way to follow these visiting hours. They need to allow him to come in to see us at night (F12).

Our case must be assessed. Each case is different and I think they can make it easier for everyone to meet their needs without disrupting the unit’s functioning (F15).

I can’t leave my child up here and I go down to eat in the cafeteria. My son does not stay with anyone. They can order my food up here too (F3).

On the day of the surgery, I asked the nurse to let my mother stay with me in the room (F11).

The health care model highlights the importance of the multiprofessional team working to improve care. Consolidating the work in child and family care in the pediatric unit is challenge that requires sharing beliefs, values and structural and organizational conditions, from both the families and the institutions, as they need to coexist and build a harmonious relationship of partnership.

I take care of everything I can, but the food she won’t eat. I asked the nurse to let me bring some food from home and she spoke to the nutritionist and they allowed (4).

I think the service is very good. Everything is well organized and the child even has time to play in the play room (6).

The nurse came here and arranged for me to leave for consultation. Before leaving, I will leave my son with them at the nursing station. The other mothers in the room pledged to help look after him as well. We are here for each other (7).

I help in whatever I can: I clean the room, I help holding my son during the procedures, I help the other mothers in the room. And in return, we are helped by the team (9).

The hospital structure is focused on the maintenance of life, based on the care provided by the health team, and filled with technical and scientific knowledge, aimed at diagnosing, planning and executing treatment. These represent the elements of the team and reveal the way of being of this team in the hospital world together with families and children.

DISCUSSION

The study revealed that hospital culture in seen as an instrument of family care and that norms and routines, when adapted and flexible, can humanize care and highlight its cultural aspect. This shows that culture is not rigid, nor static. On the contrary, it is dynamic and is the result of constant interactions, in which different actions occur, showing that culture, in this perspective, is the result of the interactions we experience(¹²).

The interaction between the family and the nursing team, both with their own values, beliefs and attitudes experienced in the hospital environment, enables an exchange, allowing the creation of a new culture within the hospital environment. Regarding the apprehension of the hospital culture as an instrument of family care, it was found that the family, when entering the world of the hospital, is sensitive. In this context, the team must try to understand the reality of the family and establish relationship of affection and cooperation, sharing this world and building a relationship between the family culture and the institutional hospital culture. In the hospital, the systems of values and norms constitute the organizational culture(¹³).

Norms and routines are part of the organizational culture and it is through them that the family gets to know the hospital culture. Families often recognize they need to favor the good functioning of the pediatric unit and seek to adapt, as they recognize themselves as important instruments for the effectiveness of the work for the recovery of the child’s health.

Organizations are characterized by social interactions that comprise cultural, symbolic, and imaginary systems, with values and norms that guide the behavior of its members. The fact that there are different groups with different cultures in the hospital shows the possibility of different human groups being able to share, even if temporarily, values and beliefs, conditioning their actions in the organizational environment(⁹,¹⁴).

The hospital is influenced by health team professionals, patients and family members who have their histories, values, contexts, and subjectivities. The cultures of each family taking care of hospitalized children generate infinite possibilities for health professionals to coordinate equalities and differences, using common cultural elements, which support the reflection of socio-cultural plurality, in their nursing practice(⁹,¹⁵).

When trying to adapt to the hospital and reproduce the care given at home to the child, the family encounters some difficulties. In the hospital, several rules and routines must be followed to organize the work process of the different sectors that are part of this environment(⁹,¹⁶).

Culture is an invisible presence in the relationships within family care for children. For families, it presents as a traditional heritage, historically constructed and specific, although heterogeneous. Family care practices are acquired in the family itself and are part of its traditions and culture. However, their experiences do not always meet the needs of care when the child is in the hospital. Interactions that occur in the hospital lead family members to incorporate references that enables them to provide care and acquire knowledge of the hospital culture in favor of childcare(⁹,¹⁶).

The nurse needs to apprehend the family care culture when interacting with each child and family, so that they can provide the family members with new care references to support specific childcare needs. At the hospital, both the child and their family caregiver need to receive care from the Nursing team(¹⁷).

As for the adaptation and flexibility of norms and routines as an instrument for the humanization of cultural care, it was found that families recognize the necessity of the rules. However, they consider it important to make them more flexible and do not accept their rigidity. They believe that the norms must be adapted, taking into account the specific needs of each child and family.

Authors who analyzed the apprehension of the hospital culture by mothers/companions and its implications for pediatric nursing practice verified that the family caregivers demand and oversee the compliance with the rules and the determination of the time schedule for carrying out the routines, because they understand these actions as important for the proper functioning of the unit(¹⁸). In the perception of families, norms and routines benefit professionals to the detriment of patients, making it difficult for them to adapt to the hospital. When in the hospital, the family must follow specific rules and routines and meet the institution’s requirements. This imposition can make the family feel depersonalized by the institutional duties that are different from their culture and family care. The need for hospitalization of the child may put the family in confrontation with institutional hegemony. The imposition of rules in the hospital reveals relationships of submission and shows that the family has difficulties in exercising their autonomy(¹⁹).

The management of the hospital requires the imposition of norms and routines that organize the team’s work process, characterizing rigid relationships. These formal rules need to be respected, but they should meet the reality of each family, considering their individualities. However, it appears that there is not always flexibility, causing normative impasses(⁶).

Family members believe that, when health professionals adapt the rules and routines to meet a special need of the child or family caregiver in the hospital, they are favored and the normal functioning of the sector is not compromised, as the institution’s specificities are preserved while families are allowed to express their ways of living. Hospital norms and routines can’t be sources of stress, subjection, and family disruption, but of qualification of care(²⁰). Consequently, they must elaborated in order to organize the participation of the family in child care in pediatric service, but guaranteeing the humanization of the care provided(⁶).

Family culture is used by the family to care for the child in the hospital and it changes according to the experiences, interpretations, and internalization of customs and institutional culture, enabling them to exercise their way of being and freedom(²¹). Norms and routines are administrative instruments that organize work in the pediatric unit and should not be used as an instrument of subjection and obedience of the family caregiver. The work process must be organized focusing on the interests of the health team/nursing team, while also addressing the needs of the child and their family caregiver. The use of norms and routines should provide to the family a space to practice their freedom and autonomy(⁶).

CONCLUSION

During the child’s hospitalization, the worlds of the family and of the hospital and their cultures interact. It is important for the family to apprehend the institutional culture and it is important that hospital rules and routines are adaptable and flexible to humanize cultural care. Families believe that they are favored when health professionals adapt the rules and routines to meet a special need of the child or of a family caregiver in the hospital and that this does not compromise the normal functioning of the sector, preserving the institution’s specificities.

Therefore, the culture of each family generates infinite possibilities for health professionals to coordinate equalities and differences, using common cultural elements, which support the reflection of socio-cultural plurality, in their nursing practice. Thus, it is essential that the team understands the relation between the family culture and the institutional hospital culture, enabling the implementation of a care that respects the culture of each family.

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Publication Dates

• Publication in this collection
  16 Aug 2021
• Date of issue
  2021

History

• Received
  24 June 2020
• Accepted
  16 Mar 2021