RESEARCH ARTICLES

Empowerment of premature newborns’ mothers in the context of hospital care

Nicole Dias dos Santos^I; Maria Aparecida Thiengo^II; Juliana Rezende Montenegro Medeiros de Moraes^III; Sandra Teixeira de Araújo Pacheco^IV; Liliane Faria da Silva^V
INeonatal nursing specialist. Pedro Ernesto University Hospital nurse. Rio de Janeiro, Brazil. E- mail: nic.nds@gmail.com
^IMaster degree in Nursing from the College of Nursing at the State University of Rio de Janeiro. Nurse of the Outpatient Tracking Newborn at High Risk of Pedro Ernesto University Hospital. Rio de Janeiro, Brazil. Email: m.thiengo@gmail.com
^IIPhD in Nursing. Associate Professor, Department of Maternal-Child Nursing Anna Nery School of the Federal University of Rio de Janeiro. Member of the Center for Nursing Research in Child. Rio de Janeiro, Brazil. Email: jumoraes@ig.com.br
^VPhD in Nursing. Associate Professor, Department of Maternal-Child Nursing, member of the Faculty of Graduate Studies and the Graduate School of Nursing at the State University of Rio de Janeiro. Brazil. Email: stapacheco@yahoo.com.br
^VPhD in Nursing. Associate Professor, Department of Maternal-Child and Psychiatric. Nursing School Aurora Afonso Costa, Universidade Federal Fluminense. Niterói, Rio de Janeiro, Brazil. Email: lili.05@hotmail.com

ABSTRACT: This study describes the empowerment process of premature newborns’ mothers in the context of hospital care, through a qualitative piece of research with 16 premature newborns’ mothers at a University Hospital in Rio de Janeiro, RJ, Brazil. Data collection occurred through semi-structured interviews from October to November, 2012. Data treatment with thematic analysis gave rise to three categories: the challenge of mothering a premature newborn; learning about the care of premature newborns in the process of maternal empowerment; and special care required by premature newborns in the process of maternal empowerment. In the hospital care context, the process of empowerment of mothers enabled meeting the reality of caring for a premature newborn. Nursing care went beyond techniques and/or technology and nursing professionals developed an efficient communication potential, contributing to individual maternal empowerment.

Keywords: Newborn; premature; mothers; neonatal nursing. 

INTRODUCTION

The birth of a premature newborn (PN) and in need of intensive care generates the experiences families governed by feelings such as suffer, insecurity, worry, frustration, disappointment, anxiety and lack of confidence in the ability to take care of their baby¹.

The world of the hospital and in particular the neonatal intensive care unit (NICU) is different and full of technological devices, which do not belong to the common sense of family and eventually push them physically child. Additonally, the small body of the newborn requires special care and complex to be carried out by a specialized team reinforces the gap between the PN and its family².

In the hospital setting, particularly in the NICU, parentes are living with anxiety by clinical stabilization of their child, and the gain and weight maintenance, and finally, with the period prior to discharge^3.4.

Family members overcome after the hospitalization phase, they deal with a new challenge: the rise of premature newborns, which, although it is a time of great expectations, is associated with greater accountability accompanied by insecurities and fears of caring for baby at home, it will no longer have the support of the hospital staff⁵.

In this sense, scholars point out that PNs have increased risk for a chronic physical condition emotional, developmental, behavioral, or and require a type and amount of care by health services, beyond that generally required by other children. Such characteristics make them members of a new emerging children's group in society, internationally identified as children with special health care needs, and in Brazil as children with special health needs (CRIANES)⁶.

Therefore, the discharge of premature newborns in the family household requires special care related to medication administration, monitoring in psychomotor rehabilitation services, monitoring of growth and development, change in the family routine and habitual way of caring beyond adaptation to the use of technologies⁶.

The hospital discharge planning should be strategic and individualized, considering the specific clinical features of the baby and the biopsychosocial conditions of the family. Proper preparation of parents during the period of hospitalization, improving their skills to the general and specific to baby care, and make them more confident to high household, provides continuity of care in the home, increases the rate of outpatient follow-up after high and decreases, including the frequency of unnecessary readmissions⁷.

In the housing context, studies show that is socioculturally determined that the woman is the provider of care to its family members^2,3.8. In the task of caring being an essentially feminine activity, it is the mother learn to care for preterm infants at discharge from the NICU and demand special care. To this end, these mothers need to acquire scientific knowledge pertaining to the professional knowledge of nursing and interaction with the social environment begins the process of empowerment for care. In this sense, empowerment is a process by which individuals, organizations and communities take resources that allow them to have a voice, visibility, influence, capacity for action and decision^9,10.

Given the problems exposed, the objective was: to describe the process of empowerment of mothers of preterm infants in the context of hospital care.

THEORETICAL FRAMEWORK

To support this study, we adopted the theoretical framework of empowerment of Gibson process¹¹.

Empowerment is a process of social recognition, promotion and use of personal skills to recognize their own needs, solve their own problems and mobilize the necessary resources in order to feel control in their lives.

The following prerequisites are required for the establishment of the empowerment process are necessary: the development of attachment and commitment and responsibility between the mother and child¹¹.

The empowerment of mothers of children is a process that can be developed in four stages, namely: discovering reality, critical reflection, taking control and keeping control of the situation. In the first stage, the mothers come in contact with reality and may experience frustration in relation to family, health system and eith themselves. In the second stage, the mothers reflect critically and discover their strengths, skills and resources available for care. In the third step, they feel confident to advocate on behalf of children, interact with the health system, negotiate carefully and establish mutual partnership with health professionals. In the last stage efforts alternative strategies to secure and ensure proper care are maintained and established¹¹.

With the process of empowerment mothers feel stronger and able to care for, besides acquiring sense of mastery and choice and decision of what is best for their children.

METHODOLOGY

This is a qualitative study, descriptive type. Participants were 16 mothers of preterm infants, who were attended at the outpatient follow-up.

The inclusion criteria were: being a mother of PN egressed from NICU and at the time of participation in the study should have a child under one year old. The exclusion criteria were: mothers under 18 years old, mothers with children older than 1 year old, mothers who had children who died.

The study setting was the outpatient follow-up, located in a university hospital in the city of Rio de Janeiro, reference in atendance with high-risk pregnancy and consequently in fetal and neonatal medicine.

Data were collected in October and November 2012 through semi-structured interviews with four open questions, namely: What are the guidelines did you receive from the nursing staff at the hospital, which facilitated the care of your child? For you how was to receive such guidance from the nursing staff? After receiving the guidelines of the nursing team, did you feel more empowered to take care of your child? Why? Talk a little about how do you see the participation of nursing in your life and your child´s during the first year of his life.

The project was approved by the hospital's Research Ethics Committee under number 125,060 and all participants signed a consent form, after being informed of the objectives of the study protocol. To ensure anonymity of the participants, we used ficticius names¹².

Two criteria for the closure of the fieldwork were used. The first, internal validity, in which we sought theoretical saturation in the interviews of the subjects; and second, external validity, the quantity of participants in studies of qualitative approach previously developed, with the subject mothers of newborn premature¹³.

Data generated from the interviews were analyzed in three steps following the thematic analysis of Minayo¹⁴. The first step consisted of brief reading of the transcript of the recorded interviews in digital media, with this material identification of the research corpus. In the second stage was held on material exploration with identification of thematic units. In the third and last step the data were grouped into three categories: the challenge of being a mother of a premature newborn; learning about the care of premature newborns in maternal empowerment process; and required special care for premature newborns in maternal empowerment process.

RESULTS AND DISCUSSION

It was attempted to describe through the testimonies of mothers of premature infants hospitalized after birth in a NICU, the process of empowerment in mothers of hospital care setting, to be presented in the following three categories.

The challenge of being a mother of a premature newborn

When I got there [in the NICU], I could barely look, I could not believe it, I did not want to hold me. I thought everything would go wrong, because he had already begun wrong. My dream of having a baby and can take it home all happy, she had fallen in front of me. (Maggie May)

It was hard in the beginning. I did not want to hear anyone, actually I did not hear anyone because when I arrived in the ICU, I was so nervous about the whole thing that happened to her, it seemed that everything around me erased. (Valerie)

At first it's all very strange, all too unfamiliar, it is like to be blind in the street, or walking a labyrinth. (Mona Lisa)

The expectation to have perfect and healthy children is common for all mothers, however the birth of a premature child, under conditions that result in hospitalization in the intensive care unit, represents a rupture in the dynamics of the birth of a healthy baby and be able to take him home in a few days¹⁵.

The child comes into the world with a place now marked by desire and imagination of parents, in na symbolic way¹⁶. In this sense, deconstruction of hte imagery baby generated by real baby in mother Maggie May the feeling that would be all wrong, because preterm birth was unplanned already a fact.

The fact that the child hospitalized in a neonatal intensive care unit was characterized as a hard moment to Valerie, which did not want to listen or talk to people.

For mothers of preterm infants, the NICU is demarcated by the imminent threat of death. When they are hospitalized and children requiring specialized care, mothers experience ambivalent feelings such as fear, anxiety and insecurity about the uncertainty of his son's life¹⁷.

Many mothers who have experienced premature birth, experienced many negative feelings such as apprehension resulting from uncertainty of the clinical evolution baby, sadness triggered by early separation imposed by hospitalization and guilt for not having discovered the reality before the birth of children¹⁵. The discovery of reality, touched upon the feelings expressed in maternal speech, constitutes the first step of the process of empowerment of mothers to care for their children in the neonatal intensive care unit¹¹.

Learning about the care of premature newborns in the process of empowerment

Thus, I was told [nursing staff] to  touch her [PN] to be happy and want to fight to stay here with us. There, that's how I started to get harder and get closer to her [PN]. (Nikita)

[...] But the nurses told me that he was small, but it was not breaking down. (Corinna)

I think the way to get my son was not the most important in the beginning because then I could do other things later. (Martina)

During the interviews, the mothers of preterm infants spoke to the nursing staff encouraged them to approach the premature child, touching and picking up the child. With the approach of the body from premature, mothers re-signify their fears, guilt and insecurity, taking care of the baby and gradually establish a body contact hampered by the small size of the body and the presence of the incubator. This action aroused the nursing strength, security and power in mothers for creating bond and care of premature, this being a prerequisite for the process of maternal empowerment^9.11.

In this context, the mothers of preterm infants showed the importance of interaction with members of the nursing team to develop the care of their children.

It was weird at first because I had to get used to a lot of stuff, a lot of names I did not know they existed [...] then at first I went in there [NICU] and I thought that spoke they Greek, but then people from nursing explained to me in a way I understood. (Susan)

I noticed that it's easier for nursing try to explain things in a way that mostly mothers, the families understand. They spend more time around, so it is important to have a good relationship with us because from nursing we learn a loto f things to care of the child. (Mandy)

 [...] Sometimes I thought that I could not take care of it [PN], then I saw it was the opposite, I needed to learn some things, to take better care. (Corinna)

The NICU environment is revealed as a new reality for mothers of premature infants, who had to learn a few things to take care of their children and get used to a lot of things and names¹¹.

With the explanation of the names (technical terms) and the approximation of the cultural universe of the subject, it became easier for Susan, Mandy and Corinna mothers understand what happened to their premature children. The care of premature newborns is different from the others, it is paramount that the mother learn this new way of caring. Training from mother to home care should occur during hospitalization in preterm infants, with emphasis on skills, competencies and knowledge that she will be able to learn. Preparation for discharge helps to reduce anxiety and increase maternal confidence in home care¹⁸.

In this context, the difficulties of communication in a formal support are configured as a problem when the language used does not reach the level of understanding of mothers and families, to be guided by technical terminology and restricted information. This difficulty in communication may the guidelines provided by the team^15,16.

When the health care team, which includes nursing, makes use of excessive technical language, communication with mothers is considered unsatisfactory and inadequate. However, when these professionals explain so that mothers understand the health status of their hospitalized child humanized care practice and contribute to the process of individual empowerment. For nursing in their workday and care activity remains enough time with the child and his mother/family, establishing bonds of trust, acceptance, guidance. Nursing transmits information and guides mothers in the care of children and mothers learn that caring^15.19.

The nursing care is seen as a practice that transcends the use of techniques and/or technology and therefore implies a effective potential communication²⁰.

As a NICU nurse spends more time close to the customers should facilitate early contact between mothers and premature infants, aiming at continuing the bond and attachment, considering it is a gradual process that can take longer than the first days or weeks of postnatal child born at term. The support and security given to mothers of preterm infants by nurses are essential for them to understand the risk to the baby is exposed to and to know how to care for him at home¹⁸.

These mothers need to be considered as unique and individual beings, endowed with feelings and values ​​and whose physical, psychological, social and affective should be stimulated and maintained by human contact welfare. Thus, the call to the mother-son should be humanized and welcoming, so that mothers also perceive themselves as the focus of attention and care by the neonatal team^19,20.

The special care required for premature newborns in the process of empowerment

The bath and kangaroo position nurses taught me not to lose too much weight, not to lose heat and not get cold. (Dani California)

Everything that a mother makes her daughter but in a special way because it was premature. Like, bath her, without letting her lose temperature, the best positions she had to get the milk in the probe, how I had to do to give, since breast could not at that time. (Roxanne)

The first probe was feeding her, and I was holding, but there was always someone supervising nursing to see if it was good saturation, it was not having problem, I felt driven. (Corinna)

The care of the premature infant in the NICU environment is special and does not belong to the common sense of the mothers. Nurses taught them mothers the autonomy to make the bath, the kangaroo position, and power were acquired by probe under supervision.

Maternal care was stimulated and mediated by the nursing staff, focusing on the enhancement of contact and bonding between mother and preterm infants, promoting growth and development of healthy children, aiming to balance their psychological, social and spiritual dimensions²¹. The contact can be developed through daily maternal child care, such as feeding, bathing, kangaroo care among others. Thus, caring for premature newborns means for the mother an act of responsibility, going beyond the execution of learned tasks, is an exercise in (re)cognition of her son, acceptance and emotional attachment^11.21.

The members of the nursing staff to orient, supervise and teach maternal care directed to the newborn in the hospital and provided access control to the resources needed to care for, so contributing to the empowerment of individual mothers of preterm^10.11.

CONCLUSION

Mothers of preterm infants showed bond, commitment and responsibility in caring for children, these being prerequisites for the empowerment process.

  In the context of hospital care, the mothers of preterm infants were encouraged to approach the child and participate in the care. However, the testimony was not made decision making and skills for problem solving and critical thinking about concrete situation of care in the hospital setting.

In this context, the process of empowerment of mothers of preterm infants was initiated in the first stage and remained in contact with the concrete reality because his speeches revealed no critical reflection nor the scope of control of the situation and maintenance.

The nursing staff was valued by staying longer with their mothers and premature newborn, and also for guiding, teaching and supervising maternal care in the hospital NICU. Nursing care transcended the use of techniques and / or technology and nursing professionals have developed a potential for effective communication, contributing to the process of individual empowerment of mothers to propagate the remaining steps.
           
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