ORIGINAL RESEARCH

Interactions between health personnel and mothers of preterms: influences on maternal care

Natalia Custodio^I; Bruna de Souza Lima Marski^II; Flávia Corrêa Porto de Abreu^III; Débora Falleiros de Mello ^IV; Monika Wernet^V

^I Nurse. Master's in Nursing, Nursing Graduate Program at the Federal University of São Carlos. São Paulo, Brazil. Email: custodionati@gmail.com
^II Undergraduate Student of Nursing at the Federal University of São Carlos. São Paulo, Brazil. Email: bmarski@gmail.com
^III Nurse. Master's in Nursing, Nursing Graduate Program at the Federal University of São Carlos. São Carlos, São Paulo, Brazil. Email: flavinhacpa@yahoo.com.br
^IV Nurse. PhD in Nursing, Associate Professor in Ribeirão Preto, University of São Paulo. São Paulo, Brazil. Email: defmello@eerp.usp.br
^V Nurse. PhD in Nursing, Adjunct Professor of the Nursing Department at the Federal University of São Carlos. São Paulo, Brazil. Email. monika.wernet@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.11659

ABSTRACT

Objective: to understand interactions between mothers and health professionals from birth of preterm children until the first month after discharge. Method: this qualitative study was conducted in 2013 with Symbolic Interactionism and Interpretive Interactionism as its frame of reference. Data were collected by in-depth interviews of eight mothers living in a town in São Paulo State. Results: development of the relationship with the professional over time is portrayed by three categories: a trustful and obedient relationship; an insecure and questioning relationship; and a thoughtful and emancipatory relationship. Conclusion: it was concluded that professionals have adverse effects on mothers' autonomy in child care, and breaking emotionally with that dependence would increase mothers' autonomy in care.

Keywords: Patient discharge; family; premature infant; professional-family relationships.

INTRODUCTION

The hospitalization of a preterm child in the Neonatal Intensive Care Unit (NICU) is a common situation for mothers, either by pregnancy outcomes or by unnecessary cesareans¹. Such experience affects parenting ^2,3 and coping with the arrival of a child, it is critical phase of the family and individual life cycle².

In this context, there are issues in the reception of health professionals with relatives generating dissatisfaction, insecurity and compromised maternal and family autonomy^2-4. It is therefore appropriate to explore the health care practices with this profile, in order to prevent vulnerable situations.

Given the above, emerged the following question: how does the relationship with healthcare professionals interfere in the care of premature children in the first month at home, in the mother's perspective? To answer this question we aimed at understanding the mother's interactions with healthcare professionals from the birth of preterm child until the first month after hospital discharge.

THEORETIC REFERENTIAL

This study adopted Symbolic Interactionism (SI) as a theoretical framework for understanding the interaction processes between mother and professionals from different healthcare and maternal child care assistance levels. The SI emphasizes social interactions and claims to be the dynamic interaction that the situation, its constituent elements and behaviors are defined and processed⁵.

In this sense, the recognition of the importance of interactional history between mother and professional determined the Interpretative Interactionism (II) as a methodological framework. The II explores biographically relevant meanings and that drive routine actions⁶ . It goes back ti the biographical experience and their narratives⁶.

METHODOLOGY

Depending on the reference and objective of the study qualitative in-depth interview was the data collection strategy. We used the placement: Imagine that since the birth of his (her) child you found several professionals. Tell me about your relationship with them and how they interfere with the way, you take care of (child's name)? To start the narratives.

All interviews were audio-recorded and suffered analytical processes II ⁶, i.e. delimitation of the study question; interviews with mothers, accompanied by the transcription, followed by reiterative readings for deconstruction and critical analysis of central concepts; new readings for contextualization of the phenomenon and its epiphanies (meaning milestones in biographical experience that change meanings and actions); reducing the phenomenon by tracking keyword phrases and link them with the whole; formulation of a new structuring of the phenomenon from its constituents and analytical elements identified in the previous phases; phenomenon of relocation in the context of participants⁷.

Eight mothers participated in the study who used the NICU due to the prematurity of their child and who were with them at home in less than a month. Another inclusion criterion was the child at birth had a gestational age between 24 to 34 weeks and without any congenital malformation or genetic disorder. The exclusion criteria were mothers under 18 years old; deafness and those with and those with impairment to understand the narratives. The number of participants was determined by the criterion of theoretical saturation of data, situation in which no new conceptual elements emerged for the description and understanding of the phenomenon in question ⁸ . All mothers were residents of a city in the interior of Sao Paulo and were interviewed during the year of 2013.

The study followed the ethical recommendations for research with human beings, with approval in the Ethics Committee under the opinion of number 115/2012. The preservation of the identity of the participants was respected and the use of identification speech excerpts are performed from the letter M (mother) followed by Arabic number translator of the order of inclusion in the study.

RESULTS

The results show the narratives of eight mothers, of which six were living with the companion and two were single, five were primiparous and multiparous three, being two mothers of twins. All were experiencing prematurity for the first time. As for the age range: five were in the range of 18-25 years, two were aged between 25-30 years and one was more than 40 years old. The gestational age of birth of the child ranged from 26-30 weeks for five of them and of 31-34 weeks for three of them. The time of permanence of the child in hospital was between 20 to 120 days.

The analysis reveals that relations with the professionals influence the maternal autonomy in care for the child. The central category identified was: Review of dependence and professional competence for the care, process that required the (re)signification of the maternal role and the relationship with the professional, presented in the categories: Relationship believer and obedient; Relationship insecure and inquirer; Reflexive and emancipative relationship.

Category: believing and obedient relationship

The care trajectory starts in the ICU under submission to the professional who leads the mother to be a spectator-apprentice. The strengthening of the frailty of the premature neonate in the relations maintains the mother obedient and a believer to the professional, under an important physical distance between the child and their care.

The historically established concepts of premature neonates are resumed and expanded in the current social interactions in the NICU, especially in the relations with the health professionals. The premature neonate configures itself as a fragile child, at risk of death, with special needs and, now seen as critical, vulnerable to infections, with attention and differentiated care, zeal and surveillance. The ICU is considered a controlled environment, with high technology, where there are children who require specialized care. Alongside these understandings, they behave obediently and submissively to the professional as a spectator of their actions. Such a fact is an epiphany to reveal, in its current path, be the premature fragile, unstable and with vulnerability to infection, meanings that they will guide their actions for some time.

[...] this premature baby is already complicated I knew it. There I was seeing what it was. [...] In the beginning, I could not touch him, because he was very fragile and they (professional) said that if I touched him, he could pick up an infection (M3).

[...] I really wanted was to be able to pick him up at least touch him, but I could not and had that only staying there looking. Because they [doctors] said, it was the best for her and I believed it and stayed there just looking (M5).

The professionals regulate the relationship of the mother with the child by means of the rules of the NICU and the stability of the child. It is usual to have denied participation in decisions, which brings feelings of coercion, not part of the child and being that NICU is the professional's space. They understand that they must be obedient and has the role of observing and learning the care.

[...] There in the [NICU] we were only visitors [...] The responsibility was theirs (professional), they that did everything, because while I was there, I could not even touch, couldn't do anything, nor touch them. Only obey and look (M7).

From the door inward was their place [professional], that's how I felt (M2).

This interactional context brings reflections about the sufficiency of their knowledge and skills to take care of the child. They feel fear, especially by hearing professionals repeatedly, being a mother of responsibility of the childcare, enhanced by the placement that should be afraid and be vigil to take good care as well.

I learned that I always needed to be careful with them [children] and that always have to be afraid, because when we are afraid we take more care (M1).

Since birth, the professionals emphasize to them that should follow their rules and guidelines to ensure health and child's recovery and use the fragility of the child as a justification. Reinforce be the NICU space of them and they are suitable for the premature childcare, which contributes to remain in subjection to them.

I wish I could do something for her [...] they [professionals] said that I could not take care the way I take care of a normal baby, which at that time only they could take care of. Therefore, we accept and follow (M8).

They identify who should be perceived positively by the professional to have detailed information and differentiated possibilities of contact with the child. As a result, in a first repressing up time and avoid confrontations.

[...] I had to go very quiet, because sometimes, depending on what I heard, I want to fight. In addition, I had a lot of mother who fought, who wanted to disagree, and there stayed barely seen. But I knew that my son depended upon them, they that had to take care of him, and I wish I could also caring and I also depended of them no longer, they let me pick him up, put milk the probe. There, I was with an open heart (M3).

Category: relationship insecure and questioner

Be submissive to the professional and to be in the position of spectators rather than participants of care to the child brings suffering to the mothers. Initially tolerate such a context; however, they seek proximity to the child and greater authenticity and fulfillment in motherhood. The conversations with other mothers in a similar situation intensifies the reflections and point out as a path to the rupture with the blind submission to the professionals. That become aware potentiates interactional inner processes to women, suffer and question imposed rules, their blind obedience and intentionality professional in care.

There were moments when it seemed that neither was my son, [crying] because only they [nursing professionals] did everything and I was just there to visit. I wanted to be able to care, but could not because they said that my son could worsen or catch infection, I complied. It was hard, I had to show him [son] who was his mother, [...] sometimes had to face them [professional NICU] [...] and was in talks with other mothers who have been getting stronger. (M2).

They go through, the interactions with professionals, call for further information and details about the child's situation. They verbalize desire for physical proximity with them. However, they are not matched, a fact that intensifies the suffering and instigates questions about the desire of professionals to empower mothers to the care. They realize that they conceal information and avoid them. Such fact intensifies the desire of proximity of the child, the understanding of care actions developed with them.

In the visit, I tried to talk with them [nursing professionals], [...] and I wanted to know better, was my son who was there. When I got some explanation, I felt a little better. [...] almost always was ignored. Hurts. (M5).

I was serious I knew, he could die too, but it lacked more [crying]. Then it did was get right on schedule on duty in passing, that was when I heard it as they had spent the night. Actually they don't tell you everything, I heard our the baby of xxx wept the whole night gave much work and then when they spoke to the mother spoke that she had stayed calm. [...] When I was listening to the name of them paid any attention to learn how they were. However, this gave me a problem once, [...] they gave me the run around, and the nurse came to tell me, that I could not [...] listen to the conversation of others. Then I said: if it is about my kids I have every right to listen yes, the child is my and not theirs. It was complicated, but I continued arriving at the shift change (M2).

Despite the clinical evolution of child and maternal tension, professionals maintain an attitude focused on power and reinforcing that she be their apprentice. Specifically in the studied scenario, days before the child's discharge, the mother was practically forced to remain hospitalized with her child in a place called External Nursery, to be trained in care. Initially, this action was considered positive, however, with time, they realized that the dependence of the professional brought limits for their safety and autonomy in child care.

In the external nursery I learned to care, there they [nursing professionals] taught everything to me, they demonstrated once and then I had to do the same and they kept looking to see if it was right. [...] afterward, when I left, I wanted them with me, I was afraid (M4).

After discharge, in the follow-up, the professional follows centered in the supervision of the mother in childcare. They seek evidence in the child for the quality of maternal care, as well as numerous questions, such as a ' check list '.

When they arrive, they want to see: did he gain weight? How much? Are you breast feeding, how many times? You realize that are they looking at how your care is. [...] That is, they are watching how we care (M1).

Category: reflective and emancipatory relationship

Even with the improvement of child's health and his departure for the home, the mother replicates the care observed in the hospital and is vigil. She feels insecure for the same and seeks to prevent health problems and the child's readmission. She becomes involved in a solitary routine, a fact that promotes reflections and leads the mother to seek safety, authenticity and autonomy in care.

The service professionals follow to strengthen the fragility of the child and the need for a meticulous maternal care, when they come to emphasize that they should be afraid, because this will make them provide good care.

It was difficult the first week was complicated. [...] because for me anything could happen with them, I would be sleeping, and I went to sleep and then would not see... Oh those horrible people, it's horrible, horrible, [...] I felt very afraid [...] My biggest fear was they die or have to go back there [hospital] (M2).

The mother follows the feeling of mistrust and helplessness in the professional care. Verifies with several professionals and services simultaneously in order to confirm if the care prescribed is appropriate, correct. They check the differences and similarities to decide how to they will provide care.

I will not lie not, I have 3 doctors. I see what each one says. [...] so I see what coincided and what does not, and decide how to care. [...] It is difficult, you get scared, the baby is premature, and you have to care for them. I think that all mothers that I know they do this. We need to make sure that we are taking care of right [...] you know how they [professionals] are (M3).

The mother, given the opportunities in the hospital, is signified by family, friends and by them self, as the responsible one and possessing a differentiated knowledge the premature situation. Thus, assumes the responsibility of care and is limiting the participation of friends and family in this care. The professionals in turn strengthen such responsibility. As a result, are solitary and overloaded, in addition to undergoing family conflicts.

Only I learned how to take care of him, I only I give him a bath, only I give food, he only sleeps with me. [...] They [family] were not there, they do not know. I feel that I am alone always. This tiring, leaves us exhausted (M3).

I feel frustrated because you care, care, care and it only yourself. There, then come the relatives and even my husband I asks for his weight, saying that I to give more food to grow faster, things like that. I just end up fighting with them all (M4).

At the household level in living, they perceive peculiarities of child and deficiencies in the professional care received. For them this is a reflection of the transmission protocol guidelines and little individualized to all mothers. Such fact promotes questionings about the pertinence of care oriented and begin transformations in the same sustained by knowledge ensues of living with the child and the evidence of their comfort, seeking autonomy in care. This process promotes attachment, feeds back their sensitivity to the child and keeps imbued to be authentic, sensitive and autonomous in care.

They perceive themselves able and skillful to care for their child, which promotes disruptions with the need for approval of a professional in their actions. Professionals replaced by another level of relevance in conducting the child care, for now it was meant as someone who did not treat the situation with the required specificity, another epiphany this trajectory.

Here [Home] everything was different; I could not do the same [hospital]. [...] Today I see the need for them and I know what is best. I think that I did almost everything different than they [professionals] said. In addition, improved. Then, it lacks this, professional's look to you and your case (M1).

DISCUSSION

It is perceived that the interaction and support of health professionals in the studied scenario adversely affected the maternal face on the child's prematurity, both within the hospital as at home, as noted by some authors ^3,4 . This occurs by the sustained relationship in the power of the professional on the mother and informational axis when there is continued strengthening of the child's criticality and maternal duty for their care. There are consequences for the autonomy, security and confidence in the child care performance, which had been pointed out in the literature ^3,4 .

It points out that the professionals do not achieve partnerships with the mothers, reception and of their family and the adoption of the family-centered care precepts^7,9 . Above all recognize to be the same as important in the establishment of a shared care and responsive to the particularities of the situation, sustained by complete and impartial information ⁹.

The interaction of professionals and the mother was aimed at safeguarding and advice to her, with questions about their skills and abilities for the care, which denotes the need to invest in the valorization of the alliance between mother, family and professional. Opening and ethical commitment recognition of subjects involved are indispensable. However, the relational history revealed in this study brings partings and lack of confidence, honesty and security in the relationship.

The formative processes of professionals need to discuss about the ethics, integrality ¹⁰ and humanization in healthcare practices. In addition, searches may densify the understanding about the formation and education of the professional and the conjunction with their praxis. It identified here that the professional practice is dissonant with the guidelines put to the care with a devaluation of humanities in health and social constructs involved with them ¹¹. It is the latter that streamline health care, family and community role, among others, and exclude such elements in practice is to deny the subject, their community and culture and value the helplessness and suffering.

To appreciate the horizons in this way, we identified recommendations for: positive verbal and non-verbal communication between professional and family¹¹; informational support to mothers and families ^12-14 ; training for home care ¹⁴ , family and child with delivery of direct care to the child, including in critical care units ^15,16 ; home visits pre and post-discharge ¹⁷ ; the use telephone contact ¹⁸ ; joint actions between The services and sectors in the healthcare network¹⁸ ; the expansion of the social support network¹⁹ . However, such recommendations are not materialized in relational contexts without interest, respect and sense of responsibility. The relationship with the professional is put in the practices in health, and has contributed with the complete acceptance ¹⁰, humanized and ethical.

Identify and strengthen the fragility and child clinical instability and their risk of death associated with emphasis on maternal duty in the care proved central the interactions of a professional and mother, and promote vulnerability to the care performance, attachment and mothering, fact that has been reinforced in studies on the topic^{3,4, 12,13,15-20} .

Professionals explain the impracticality of time to guide and provide emotional support to families and have maternal surveillance of their uncomfortableness ²¹. This surveillance is aroused in the way that they provide care. The discomfort and threat felt makes some of them explicitly defend behaviors as the isolation of the NB and disease-based assistance ^10,21, aspects which go back values of the discourses of Pediatrics of the nineteenth century. Studies that seek to which ideologies sustains the professional practices and how they are handled can reveal paths for changes.

The Solitude and helplessness has characterized the trajectory of maternal child care ^7,22 , while the knowledge and commitment ensues in this care contributes to its qualification ^14,20,22,23 . To have and feel fullness and successful maternal role to mobilize in the care of child^14,20 and contribute to their autonomy in the same performance.

All subjects involved in the care are responsible for the established relational atmosphere, and this study was limited to looking at the perception of mothers of a single city that did not use national humanization strategies in neonatal care. Studies in scenarios that use these strategies could complement the findings obtained, contrasting them or not. It is also noteworthy that all mothers were experiencing premature birth of their child for the first time, which brings questions of how it would be such a relational framework of prior experience of ownership in this context. Longitudinal studies are interesting for broadening the understanding of the phenomenon, as well as those who are returning to the voice of the professional.

CONCLUSION

Professional affect the development of maternal care to premature child to behave with supremacy over mothers, strengthen maternal duty to care for the child and instigate fear by emphasizing being the fragile premature, unstable and at risk of death and infection. There is no demonstration of listening and consideration to the particularities of each situation with incipiencies in maternal reception. In addition, it was through the review of dependence on the professional that the mother gained authenticity and autonomy in the care of her child.

The study has a limit of portraying a care context specific to a city in the interior of São Paulo state. However, identifies central elements to professional care practices with possibility of redirecting their interactions.

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