THE MEANINGS OF CARING FOR PRE-TERM CHILDREN IN THE VISION OF MALE PARENTS¹

LOS SIGNIFICADOS DEL CUIDAR DEL HIJO PREMATURO EN LA VISIÓN PATERNA

ABSTRACT

The purposes of the study was to analyze the meanings assigned by the father to the assistance of pre-term infants in a Neonatal Intensive Care Unit and to discuss how these meanings influence paternal care. It is a qualitative study with an ethnographic approach, carried out in a neonatal unit in Rio de Janeiro. Twenty-two fathers whose pre-term infants were hospitalized have been interviewed. Data were collected by means of a field logbook, participative observation and semi-structured interviews. Through thematic analysis, the inferred categories were a) father-child proximity and the permanence at the Neonatal Intensive Care Unit: overcoming obstacles and revealing motivations, b) the inclusion of fathers in caring for pre-term children: limits and possibilities. Nurses should favor the proximity of fathers and newborns to strengthen their relationship. The intensivist care neonatal practice should include strategies to support male parenting in pre-term birth considering the perspective of gender equity.

DESCRIPTORS:
Father-child relationship; Neonatal nursing; Neonatal intensive care units; Paternity.

RESUMEN

Este estudio objetivó analizar los significados asignados por el padre para el cuidado de hijos prematuros en la unidad de cuidados intensivos neonatales y discutir cómo estos significados influyeron en el cuidado paterno. Estudio cualitativo con enfoque etnográfico realizado en una unidad neonatal de Rio de Janeiro. Fueron entrevistados 22 padres cuyos hijos estaban hospitalizados. Los datos fueron recolectados a través de diario de campo, observación participante y entrevistas semiestructuradas. A través del análisis temático, las categorías deducidas fueron a) la proximidad entre padre e hijo en la unidad neonatal: superación de obstáculos y revelación de motivaciones; b) la inclusión de los padres en el cuidado de prematuros: límites y posibilidades. Los enfermeros deben facilitar la proximidad entre padres y prematuros para fortalecer la relación. La práctica de la atención neonatal debe incluir estrategias de apoyo a la paternidad considerando la perspectiva de equidad de género.

DESCRIPTORES:
Relaciones padre-hijo; Enfermería neonatal; Unidades de cuidado intensivo neonatal; Paternidad.

RESUMO

Objetivou-se analisar os significados atribuídos pelo pai ao cuidado do recém-nascido pré-termo na Unidade de Terapia Intensiva Neonatal e discutir como esses significados influenciam o cuidado paterno. Trata-se de estudo qualitativo com abordagem etnográfica realizado em unidade neonatal no Rio de Janeiro. Foram entrevistados vinte e dois homens, pais de recém-nascido pré-termo internados. Os dados foram coletados através de diário de campo, observação participante e entrevistas semiestruturadas. A análise temática dos dados originou as seguintes categorias: a) A aproximação pai-bebê e a permanência na Unidade Intensiva Neonatal: superando obstáculos e revelando motivações; b) A inserção do pai nos cuidados com o filho pré-termo: limites e possibilidades. Os enfermeiros devem facilitar aproximação do pai para fortalecer a relação pai-filho. A prática assistencial intensivista neonatal deve incluir estratégias de apoio à paternidade em situação de nascimento pré-termo considerando a perspectiva de equidade de gênero.

DESCRITORES:
Relação pai-filho; Enfermagem neonatal; Unidades de terapia intensiva neonatal; Paternidade.

INTRODUCTION

In Brazilian culture, the mother remains the primary companion and caretaker of the hospitalized child,¹ while the father plays the role of provider for the family and maintains more of a distance from the children in hospital situations. The inclusion of fathers in health services appears as a new challenge because traditionally the responsibility for the health care of children is attributed to women.²

During pregnancy, fathers idealize the birth and the first contact with a healthy full-term newborn baby, thus the birth of a preterm baby is usually unexpected.^3-4 Consequently, fathers are not prepared for the birth of a preterm newborn, which generates feelings of guilt, frustration and fear arising from the baby's health status and the separation between mother, father and child, when the baby needs hospitalization.^4-5

Prematurity and long hospital stays are risk factors for infant abandonment.⁶ Preterm newborns have up to three times more risk of suffering violence and abuse in childhood and adolescence.⁷ There are, long term effects, regarding the long separation between preterm newborn and its family and the difficulty of creating parent-child relationship in this early period of life. The whole family dynamic is changed with the birth of preterm newborns requiring hospitalization. Authors⁸ highlight the need to rethink the insertion model for fathers of preterm newborns in the hospitalization process, to promote changes in the routines established for parental participation in the context of the care of the premature newborn and to develop studies on the subject.

In the Neonatal Intensive Care Unit (NICU), it is of utmost importance that, in addition to technical care, health professionals give emotional support to parents of preterm babies at this time of crisis caused by the premature birth and hospitalization, starting from the first contact with the child in the NICU. The fragile appearance, the clinical condition, the NICU environment and the lack of interaction with the staff may hinder bonding between father and preterm newborn.^4,9-10 Thus, it highlights the importance of the professional health care assisting the father of the preterm newborn.⁵

This study aims to analyze the meanings given by the father to the care of the hospitalized preterm child in the NICU and discuss how these meanings influence paternal care in the NICU.

METHOD

This is a qualitative research with ethnographic approach. The classic method of ethnography is guided in "look, listen and write," these being the three stages of apprehension of the social phenomena.¹¹ Ethnographic approach was chosen considering that fathers of preterm infants are a cultural group sharing knowledge, values, symbols and meanings, whose gender identity is socially constructed. Thus, it was possible to understand the meanings attributed by the father to preterm infant care and understand how such meanings influence paternal care in the NICU.

The study was conducted in the NICU of a maternity hospital caring for pregnant women and newborns at high risk, in the municipality of Rio de Janeiro, certified under the title Unidade de Saúde Parceira do Pai (Health Unit Partner of the Father). The neonatal unit has 45 beds of which 14 belong to the NICU, 25 belong to the intermediate unit (UI) and the other six make up Kangaroo Infirmary.

The study participants included 22 men, parents of hospitalized preterm newborns in the NICU. Inclusion criteria were: being over 18 and having a hospitalized preterm child for more than 24 hours in the NICU, during which it was possible for the father to have contact with the baby. Adolescents under 18 were excluded for being part of a distinct cultural group. Also fathers of babies with congenital anomalies were excluded due to the double grief experienced by them.

Data were collected through semi-structured interviews, participant observation and field diaries,¹² in which the impressions of the researcher of the environment, the actions and behaviors of social actors involved were recorded. To "listen to" the participants, an interview based on a semi-structured script, was recorded by MP3 audio. The interviews were transcribed verbatim and subsequently submitted to thematic analysis.¹²

"Looking" was through the participant observation technique and allowed to seize effective action and overcome the limits of the interview, as well as to understand and know the neonatal units, their routines and confrontations between what participants say and what they do. Thus, during the study, participant observation occurred for a period of four to six hours in the NICU, starting in the afternoon until the early evening; times when the fathers' presence is more frequent.

"Writing" occurred by using a field diary for making notes on the researcher impressions of the environment and social actors involved in the context of care in the NICU.

The data analysis required repeated readings and notes of interview transcripts on the observations, identifying the differences between actions and concepts to organize the data in units of meaning.

To assist in the thematic analysis, we used the Atlas.ti, version 6.0, qualitative analysis data tool that allows better organization and access to data generated by the survey. This program provided a means to manage, extract, compare, explore and add significant fragments of testimonies and records of the diary, in a flexible and systematically manner.

Fathers were invited to participate in the study during the stay of their children in the unit. To ensure the anonymity of the participants, respondents were identified as respondent 1 (E1), respondent 2 (E2), and so on. The study was approved by the Ethics Committee of the Municipality of the City of Rio de Janeiro under number 243/11. All ethical precepts required by Resolution 196/96 of the National Health Council were respected.

RESULTS

The thematic analysis¹² of the data yielded the following thematic units: "the father-baby approach and staying the NICU: overcoming obstacles and revealing motivations"; and "the father inclusion in the care of the preterm child: limits and possibilities".

The father-child approach and stay in the NICU: overcoming obstacles and revealing motivations

Men, parents of preterm babies, who are admitted to NICU, face several obstacles during their stay in the unit during the hospitalization of their children. Among the most common, we can cite, time constraints imposed by the routine of the institution, the obligation to return to work in less than a week after the birth of the child and the absence of the right to paternity leave, as shown in the following statements.

[..] I am always here. Entrance is allowed at eight and six in the morning, I'm already out there waiting to come here and see how he is [...] to see if someone took something from him, if anything changed (E18).

[...] And another thing which is very bad for the father, it is in point of law. The law only gives five days for us to be close to our children. [...] There is only me to stay here with my son (E18).

[...] But... currently I am unemployed. Making extra. I go and do my work and I come here, when I can (E4).

Fathers seek to organize the time to accompany the preterm child in the NICU without effecting their work activities.

[...] I was even talking to her [the mother] about it yesterday. To have a little patience, I know I'm missing a bit. [...] Someone has to work. And that is my part, to work (E3).

[...] I want to be here all the time. I just can't be here 24 hours a day. Unfortunately I have to earn money. But if I could, I'd be here 24 hours with my wife and my daughter (E10).

While highlighting the obstacles to be overcome in order to be close to the child, fathers reveal their motivations to face them and stay with the baby in the NICU. They report the importance of supporting the baby with a paternal presence. According to them, the child knows when the father is present. In general, fathers believe that the father and mother's presence helps in child development and accelerates discharge.

[...] I think it influences it. I think he develops more. I always come here, stay close to him, talking to him. Father to son talk. I think he develops, yes. It's clear to see that the baby feels when his father is close or not (E17).

[...] I think that all that matters is the warmth of the father and mother. You always have to be present (E6).

[...] It is good for her. It's very good. As I just said: living every day with her, talking, touching her, she felt the touch of the father and mother. This helps her to get out of here (E14).

[...] But every person she feels she gets to know that person, the touch yes. It influences something. That thing, an emotional treatment (E4).

Another motivation enunciated by the research participants was to go to the NICU and stay beside the child in order to help the baby to recognize him as a father from the beginning of life, thus demonstrating the feeling of fatherhood.

[...] It Influences, yes. If the child recognizes the father, the mother, you know? This, the child feels for sure. If I were a 100% absent father, the child wouldn't know me yet, maybe not influencing anything (E4).

[...] I think it is essential for the child. I cannot explain, so ... I do not know. Like, the child, even though she does not understand, she feels, right?So, the child will know who the father is (E10).

[...] I am here, I put my face they see it. I put my ugly face there, I think this is valid. I am the father, right? (E1).

Fathers feel happy to be with a premature infant. Staying with the child in the NICU arouses feelings of pleasure and affection and brings benefits to the father, and on the contrary, not being beside the child brings negative emotions.

A father came to the sector alone. Meeting with him in the antenatal room, where there is a sink for handwashing. The father was washing his hands, arms and face. [...] He seemed eager and happy. He entered the department and said, 'I'm going to see my babies!' I stood watching from the nursing station. He touched, he talked and cried when he saw his babies (Excerpt extracted from the field diary).

Fathers also commented on the times when the baby is stimulated by the father's presence and how important it is for them. They interpret the responses of the baby to its stimulus as a sign of recognition that demonstrates building an emotional connection with the preterm newborn.

[...] Ah, it's great as well. For me it's great, excellent. For me to stay with him a little, to speak to him I'm here next to him. Oh, I think he misses his father close by (E2).

[...] And to see them every day, that is good. I come every day, every day, every day [...] for me to see how they are, but if I don't come, I'm not well. If you go a day without seeing them I'm already distressed [...]. It's good to come! (E16).

[...] There is much influence for me and my daughter! I like to be with her, to touch her. We love, we wanted a child. [...] For me, it makes me feel good to be here. I came to see my daughter [...]. For me it is super important! [laughs]. Super! Super! To see her, talk to her, hear the screams, crying, upset until she opens her eyes. It's good, I consider it very important. It's good! (E12).

[...] It doesn't seem like it, but children like this, newborns, they hear, yes. Because you go there, you talk and they move, cry. It's quite moving (E6).

Fathers also revealed that the need to go to the NICU was for the health team to realize that the baby is important to the family and, from that, invest in their intensive care.

[...] Because I, at least I think in my head, you know? I think when we participate more, doctors will see that we are concerned. And I think they focus more on that. I think it's like that (E6).

[...] Have I thought of leaving the baby there? Stay a week, two, without coming? Leave it as the hospital's responsibility? How would it be? (E8).

You can identify that, according to them, if the parents do not attend the NICU during the hospitalization of the baby, the team will probably not invest the same time in the treatment and care of the child.

The father's inclusion in the care of the preterm child: limits and possibilities

The fathers revealed that they felt unable to take care of the preterm child. They prefer to participate by observing the care provided by health professionals or helping the mother in body care tasks. So, fathers understand that having a hospitalized preterm child often means being prevented from giving body care to the child, because they feel they have "tied hands". They perceive the care work as competence of the staff and believe that only they have the capacity to do so. Thus, they remain at the side of the incubator, as spectators during the performance of care procedures.

[...] I don't participate! [surprised] I participate just by watching there. Only watching [...]. Yesterday afternoon, I stayed here. This morning I also stayed with him. Just watching for myself is participating (E2).

[...] I participate. During the time I'm in the hospital, I participate. I see them, care ... Just looking and not asking a lot of question no. [...] watching. We only participate in observation. Both I and the mother (E8).

[...] But as in this case, we don't do much. We just watch. We only see. We just stand there. Because the team itself, they do everything (E12).

[...] So I participated. I participated only Friday and today, I saw the girl there change diapers and give milk using that thing. I participated because I was by her side. So, I was assisted a bit. I was just watching it. I'm finding it a bit difficult (E17).

Fathers reported the need to be taught to perform the body care of the baby. They feel afraid to touch the baby, due to lack of ability, and the tiny, fragile preterm infant body.

[...] Even if I had a free pass to be able to take care of it, I'd still have to have a little class because I do not understand anything. I am even afraid of touching. Because it is very fragile and I'm kinda rough with things (E1).

[...] I'm afraid to touch it [laughs] and I don't even open the incubator. I'm just look (E13).

[...] So what can I ... I still haven't picked her up yet. But what I can do to help, I do. [...] It's good, good, good, to take care of them. But you're nervous! (E16)

Culturally, the role of physical child care is essentially feminine. Thus, the statements indicate that the person who participates in the care of the hospitalized preterm newborn is the mother.

[...] Who participates more is my wife. Only when I come. [...] She is around more than me. She participates more in these types of things (E5).

[...] The mother is the person who gives the greatest care (E4).

Even though they felt unable to provide physical care, fathers spoke about the importance of assisting mothers in the care of the preterm baby. From E3 father's testimony, it is clear that their participation in pre-term child care was to help build the mother-infant relationship.

[...] The participation of the father improves the mother and baby relationship, it greatly improves it. It helps in the sense of maternal warmth. Mother and son approach. Lactation already here. [...] Then I get her, put her in my arms. She goes down, drinks a little water. And we stay together, communicating with the child (E3).

[...] Well, I go over there and help her to try to breastfeed, right. Because she has to latch on to the breast. [...] I'm with her, she's in my arms while she's having her food. Because she is taking breastmilk through the tube. I'll stay with her, holding her, I talk to her. Although she does not understand, but we will talk, we will play with her. And this is it (E10).

DISCUSSION

The difficulty for the release from work activities constitutes as an obstacle to the approach and the father's stay with the preterm child, as cited by respondents. In a study of teenage parents in a basic health unit, they reported following the routine appointments of their children, with willingness to understand the guidance regarding the necessary care, even reporting that, at times, were unable to go with their children to the consultations on account of work activities.¹³

Performing the task of providing financial help is also a way to identify themselves as fathers and with fatherhood. However, free time to participate in the child care and to build an emotional connection becomes reduced.

In Brazil¹⁴ paternity leave of five working days after the delivery was granted by the Constitution/1988 in Article 7. However, the five-day period is not enough for the father to stay close to the mother and child, especially in situations such as prematurity. The importance of the father's presence in the first days of life of the newborn was recognized in the presidential approval of the Legal Framework for Early Childhood (PLC 14/2015), which provides the extension of paternity leave from five to 20 days, included in cases of adoption for the companies who participate in the program Empresa Cidadã.¹⁵ However, the law does not mention the special extension of paternity leave in cases of premature births.

Working relationships were identified by the participants in this study as an extra difficulty which fathers face during the hospitalization of the child in the NICU. However, fathers who participated in different studies see the work as: a) a therapeutic tool to deal effectively with the crisis situation because through work they find consolation and coping methods;¹⁶ b) social support, in which they are released for part of or for all work activities to accompany the hospitalization of their children; ¹⁷ and c) the way to positively contribute and to support the family, by playing the role of financial provider, which reinforces their sense of control.¹⁸

Another obstacle revealed by parents was the limited entry time into the unit, which is shown in the report of E18, for example, waiting two hours to see the child. Parents have the right to remain full time with the child in case of hospitalization, According to the Federal Constitution of 1988 and the Statute of Children and Adolescents (ECA),¹⁹ which in Article 12 states that the health care establishments must provide conditions for the full time stay of parent or guardian, in case of hospitalization of children and adolescents ", and also according to the Order no. 930 on May 10th 2012,²⁰ for the complete and humanized attention to the seriously or potentially fatally sick newborn. Furthermore, the Legislative Assembly of Rio de Janeiro enacted Law no. 5831 on October 28th 2010,²¹ that features a fixed disclaimer in the hospital setting stating the right of the father, mother or guardian to stay with the child, in case of hospitalization.

Despite the existence of the legislation^19-20 which guarantees the child the right to parental guidance in NICUs, full compliance of what is legally determined is often not observed. In many hospitals, the entry and stay of the parents have restrictions, such as prohibiting the presence in times of invasive procedures and time of the doctor's rounds or shift changes of the nursing team. It is also impossible for the parents to stay at night. In such cases, the time that parents are allowed to stay in the NICU is not 24 hours a day.

In the context of health services, the lack of reciprocity in the development of interactions between health team and fathers is evident. Health services are perceived as disorganized regarding the inclusion of the father, both in prenatal care, and aiding the experience of fatherhood.¹³

From the testimonies of the participants, it was revealed that fathers are in an affective paternity construction process, experiencing a cultural transition. A father model who is involved in the preterm child where the relationship with the child is cause for satisfaction and pleasure was revealed. In this affective paternity model, the father has a greater emotional involvement with their children and with the care and education of children, unlike the hegemonic paternity model, which is centered on the male figure, with the man's role as the provider of family and head of the household and rigid distinctions between the roles of each gender. ²

The feeling of being absorbed by the baby's presence, to worry and take an interest in it and express intense emotion with its birth are characteristics that are connected to the concept of engrossment.³ This concept arose from the observation of men who participated in the birth of the child. In this group, it was observed that parents are deeply connected to the newborn and the contact provokes strong emotion and pleasure. Fatherhood is experienced as a pleasant event, as the parent becomes aware of the existence of the child, perceiving it as individual.² Realizing that the baby is more than its prematurity condition and the need for enhanced support for the maintenance of life, fathers can express engrossement reactions and feel satisfaction in fatherhood. We conclude that the need for early and frequent interaction with the preterm baby motivated the confrontation of difficulties in relation to staying with the child.

The loving dedication to children is beneficial for men because, in exercising the affective fatherhood, it broadens their male experiences beyond the social role of providor.² An affective parental involvement contributes to the intellectual, social and emotional development of children. The quality of interactions with the child can be considered a predictor of child cognitive development. Moreover, men who are dedicated to caring relationships with children decrease their involvement with the use and abuse of alcohol and violence, contributing to the welfare of the family and society.²

For the man, being next to the child is an important action and is a way to represent the father's social role. However, the physical care of the preterm baby is challenging due to clinical fragility and decreased body size, as well as cultural issues that the care is primarily a female task.

Often during hospitalization, even without touching the baby or performing body care tasks, while providing support to the mother, men experience fatherhood and understand that they are taking care of the child in a broader perspective of care. Other fathers seem to understand care as carrying out tasks to meet basic human needs such as food and hygiene. They revealed the need to learn how to perform the care which is routinely performed by mothers or by nursing staff.

Just as in this research, study conducted in the United Kingdom²² demonstrated the social construction of gender can influence the relationship of mothers and fathers with their babies in the context of the NICU. Fathers have more difficulty interacting with preterm baby and their care, both as the cultural aspects related to the hegemonic paternity model, and as the need, at the same time, to provide support to the family and stay in the NICU supporting the women and learning to care for the child. In this sense, the participants of both studies strive to play the role of provider, protector and caretaker of women, the family and the baby. On the other hand, the confrontation of a premature birth is an experience that can promote changes in gender identity, deconstructing a binary model of male and female social roles, leading us to think in terms of a continuum of experiences among men-parents and women-parents.

It is important that women give space and support to the man, allowing them to play their role. However, these women could suffer the consequences of social judgments, in which they are open to criticism about not assuming the culturally imposed tasks such as the maternal responsibility of taking care of children.²

Still, we must emphasize that the man usually stays in the neonatal unit for short periods of time. Thus, opportunities for the nursing staff to approach them and encourage them to care for the preterm newborn are reduced. Moreover, it is necessary that the nursing staff take advantage of the times when the father is present to encourage them to become close and perform the body care of the babies.

It is extremely important that the father is encouraged to interact with the preterm infants in all dimensions of care. The nursing staff should encourage paternal touch, to enhance the features and potential of the baby and create opportunities to include the father in the care, encouraging their participation and support to the mother during breastfeeding.

It must be remembered that, at first, fathers may be subject to restrictions due to the risk and clinical instability of newborns and may even be prevented from taking the child in her arms, which can delay the approach and the physical contact between father and baby.

Fathers need to share the time of contact with the child with the health team, who has the technical knowledge to maintain the life of the pre-term newborn.²³ Thus, depending on the clinical status of the newborn, it is possible that the nursing staff includes the man in the child care procedures, allowing them to change diapers, give food, even by tube, or practice skin care.³ It is especially important to encourage touch, showing its qualities and its influence on the clinical improvement of the newborn baby. Showing the interactive capacity and its consequences is also a way to involve the father and promote effective bonding.³ Thus, the father gradually reduces the fear of touching the baby and his sense of inability to care.

Another important aspect to be considered by the NICU team in the father's inclusion in preterm baby care is the encouragement for them to talk about their emotions and feelings, as when constantly putting themselves in the role of protector of woman and baby they tend to hide their worries and woes, reinforcing the model of care with greater focus on the mother and baby, which exposes them to high levels of anxiety and stress.²⁴

A study in Sweden²⁵ showed that encouragement of the father to spend more time in the treatment unit is a way to promote their familiarity with their preterm child and let them learn how to care for the baby. With the help of the care team, the fathers feel better prepared to be instructed by health professionals during hospitalization in the NICU and thus stronger and better equipped for the time of discharge. The researchers also found that men who perform care tasks feel great satisfaction, including the relationship with his wife and family. Another study conducted in Germany²⁶ with fathers of very low birth weight infants showed that they feel the need for educational activities that are taught in other areas, in addition to the NICU, such as courses, focused workshops and seminars for fathers of premature babies.

CONCLUSION

The meanings given by the father in relation to the care of pre-term babies in the NICU revealed that physically following the recovery of the child, feeling happy to be next to the baby and being recognized as a parent are motivations that lead them to face all obstacles and difficulties to remain as long as possible in the NICU. However, fathers often feel unable to perform care, such as bathing, changing diapers, feeding, and taking the baby in her arms, particularly for preterm infants.

The culture of the father's inclusion in child care as just to play the role of provider, to support the mother and interact with the baby without actually participate in care makes the father stay in visitor or viewer mode for the majority of the time that they are present in the NICU. The nursing team has a fundamental role in changing the culture surrounding the role of man in prematurity situations, from a gender perspective .The traditional family care model, where maternal participation is still the focus should be rethought for the inclusions of fathers in search of humanization of care. One must learn to work with the new cultural reality where men take care of the home and children along with women and where they, in turn, work out of the home, as men.

Further studies that address the vision of nursing professionals on the inclusion of the father in the preterm baby care are necessary.

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• 1
  Article extracted from the thesis - Os significados de ter um filho prematuro para pais homens: contribuições da enfermagem neonatal, presented to the Programa de Pós-Graduação em Enfermagem, Escola de Enfermagem Anna Nery (EEAN), Universidade Federal do Rio de Janeiro (UFRJ), in 2013.

Publication Dates

• Publication in this collection
  2016

History

• Received
  09 Sept 2015
• Accepted
  05 May 2016