ORIGINAL RESEARCH
Using music in a pediatric unit: helping to humanize the hospital
Karla Gualberto SilvaI; Gunnar Glauco de Cunto Taets II; Leila Brito BergoldIII
I
Nurse graduated at Universidade Federal do Rio de Janeiro. Rio de Janeiro,
Brazil. E-mail: karlagualberto@hotmail.com
II
Nurse and Music therapist. PhD in Science. Adjunct Professor Universidade
Federal do Rio de Janeiro. Rio de Janeiro, Brazil. E-mail:
oenfermeiro2007@hotmail.com
III
Nurse and Music therapist. PhD in Nursing. Adjunct Professor, Universidade
Federal do Rio de Janeiro. Rio de Janeiro, Brazil. E-mail: leilabergold@gmail.com
DOI: http://dx.doi.org/10.12957/reuerj.2017.26265
ABSTRACT
Objective: to describe child inpatients' perceptions of musical activities in the hospital environment, and to analyze the relationship between music and humanization in hospital. Method: in this exploratory, qualitative, descriptive study, data were produced by the care-convergent research method. The subjects were 20 child inpatients at a public hospital in northern Rio de Janeiro State. Bardin content analysis was performed. The study was approved on April 20, 2016 by the research ethics committee of the Rio de Janeiro Federal University, Macaé Campus (CAAE 53392116.8.0000.5699, No. 1.509.506). Results: evaluation of the activity through interviews and drawings showed that all the children reported feeling more lively, cheerful, and happy after musical activity. Conclusion: music can contribute to humanizing the hospital, is applicable to children in different age groups, provides pleasure, reduces anxiety and promotes health in the hospital environment.
Keywords: Music; pediatrics; pediatric nursing; humanization of assistance.
INTRODUCTION
Music and its therapeutic effects can influence health and human behavior. For centuries, the therapeutic use of music has been recorded in various historical documents of different cultures1.
Music can be a resource for nursing care, to be used for diverse purposes such as encouraging interaction and participation. Some advantages of using of music are the reduction of anxiety, pain, irritability, fear, increasing self-esteem and memory, social integration, among others2-3. Moreover, it can contribute to better communication between the professional and the client. This becomes more evident with children since playing is fundamental for their development.
From this perspective, it is important to think how the use of this tool can contribute to the children's health. Physiologically, it is known that it can influence heart rate, blood pressure and breathing. It can also change the perception of pain, stimulate communication and establish therapeutic relationship, and it may therefore become a resource for nursing care5.
It is important to note that in 2000 the Hospital Assistance Humanization National Program (HAHNP) was created, which aims to improve the quality of hospital care, focused directly on the relationships between users and professionals in the field of health4. In 2003, the National Policy of Humanization (NPH) was launched, which proposes to establish in practice the principles of the unified health system (SUS), involving users and health professionals and promoting changes in managing and caring6.
In this sense, the focus is ambience in health, that is configured as the treatment given to the physical, social and professional space and interpersonal relations, basing the interventions on a friendly, resolutive and human care and ensuring the construction of actions from an integral and inclusive approach, with a perspective of equity. It is also used the approach of expanded clinic as a theoretical and practical tool that aims to contribute to a perspective that considers the ill person as unique and the health-ill process as a complex phenomenon.
According to the National Policy of Humanization (NPH) the host refers to the relationship between the health staff and the population, and it is built collectively from the working process analyses with the goal of building relationships of trust, commitment and bonds between the teams and the population6.
It is important to stress that humanization means to value the various individuals involved in the health production process, and that according to HumanizeSUS, the values that should guide the practices of health professionals are autonomy and the role of the subject, co-responsibility between them and the supportive links7.
In this perspective, the use of music with hospitalized children can encourage communication, interaction and host, contributing to humanize the hospital environment. The objectives of this study are: to describe the perception of children hospitalized on musical activities carried out in the hospital environment and analyze the relationship between music and hospital humanization.
THEORETICAL FRAME
To support the assistance and strengthen it as a profession, nursing is based on theories to systematize the care. Nursing theories propose the discussion and improvement of healthcare practice that guide the action of caring the other8. This research used as a theoretical frame, Caritas Processes (CP) of Jean Watson.
Care is something precious, carried out with love, and the Latin word caritas, symbolizes affection, cuddling, appreciation, giving special attention. In this way, Caritas Processes represent a process of care that goes beyond the traditional models of nursing9.
Watson believes that the heart of this new theory are the elements of CP, an evolution of the care factors of Transpersonal Care Theory (1996). The author states that CP explains better the connection between Love and Care, and the process of the human living. In this way, the theoretical foundation of this research is focused on nursing care in the context of the elements of Caritas Processes of Jean Watson10.
CP establish the relationship of care with the creative attitude of the nurse and the use of innovative practices. Through this approach it is appropriate to register that developing musical activities can be a form of care, using music as an artistic expression to stimulate group interaction, and the process of clients and families' reconstitution in the hospital context11.
It is needed a reciprocity between the patient and the nurse so that care must be considered the essence, since the nurse participates in the assistance as a person. Thus, the interaction allows the development of interpersonal relations between the nurse and the client. However, it is up to the nurse, the supply of protection based on the technical-scientific knowledge12.
There are many points of contact between HumanizeSUS guidelines and CP, such as the attention to interpersonal relations, welcoming and human attention and assistance perspective that considers the uniqueness of the subject in the perspective of integrality. We reiterate that CP provided support to implement musical activities within Pediatrics, contributing to humanization in this environment.
METHODOLOGY
This is a research of exploratory and descriptive type, and qualitative approach. Data production took place through the method of Convergent-Assistant Research (CAR). The CAR proposes to investigate a situation at the same time the healthcare practice is being developed. It means searching the care know-how through a methodology based on a direct relationship between theory and practice, during its construction, with moments of greater ties with care and, in others, with the research 13.
Data were collected in the pediatric ward of a public hospital of northern Rio de Janeiro, between April and June 2016. The study subjects were 20 children hospitalized in the pediatric ward. Inclusion criteria were: children hospitalized with mental and physical conditions to participate in these activities and answer the questionnaire at the end, who had agreed to participate. Exclusion criteria were children under the age of four years old, because they have less ability to express themselves orally and to describe their experience; or older than ten years old, because they are almost preteens; and children with medical conditions that would impair them from participating in the activities, such as infectious diseases, or children who had difficulties to go to the research location.
The techniques used for data production were: semi-structured interview with the parents or guardians; participant observation by a Research Assistant; individual semi-structured interview and drawing to assess activities with the children. It was applied with the children and their parents a term of authorization and informed consent, respectively.
The activities were performed by nurses, who together with the nurses of the unit selected which child could participate. Then, children traditional songs were played when the researcher sang and played guitar for the children. If the child asked for some music different from the chosen repertoire, they were encouraged to sing it accompanied by the guitar. Parents were encouraged to participate in the activity, and to sing along with their children.
After the development of musical activities held in the playroom, children returned to their wards, where the semi-structured interview and the drawing were carried out, to stimulate the process of evaluation. After the data organization, the Bardin analysis of content was done.
The project kept the ethical research behaviors, according to the resolution 466, obtaining first the authorization of the institution, and then submitting it to the Research Ethics Committee of the institution, having been registered with the CAAE 53392116.8.0000.5699 and was approved on the day 20 April 2016 with the opinion number 1,509,506.
RESULTS AND DISCUSSION
Of the subjects of the research, 8 (40%) were male, 12 (60%) female. The children participating in the research were between four and 10 years old, with a predominance of 6 (30%) with five years old, followed by 5 (25%) under nine years old.
15 (75%) of the children interviewed participated of the musical activity, whether by clapping or rocking the body or even dancing. During the activities, 17 (85%) sang along. The parents also sang along with their children, showing interest in encouraging their child's participation, maybe to reduce the impact of hospitalization.
When the children were asked to draw something about the activity developed, children up to 7 years showed more pleasure in drawing compared with the older ones. The children tried to draw what they requested about the musical activities, but at the same time tried to express something related to the moment they were living.
Some children drew, for example, cartoons characters, the solar system, among others. About 5 (25%) of the children drew the guitar, 5 (25%) included the researcher in their drawing, and 8 (40%) drew other things, and said they were related to music, which shows the importance of musical activity at the time. The use of drawing is an activity that allows the expression of feelings. Hospitalized children should be encouraged to express their feelings. It is up to the Pediatric nurses to enhance drawing as a valuable tool for the promotion of feelings and the interaction between professionals, children and family14.
Data analysis occurred by triangulating data that were obtained through the initial conversation with the parents, by the observations record and through Bardin content analysis in the interviews with children. In this process of analysis, we identified two categories: stimulating playing through music; and promoting well-being from positive changes in the music.
Stimulating playing through music
In this category, we identify the different forms the children participated through playing, in this case involving singing, drawing activities and playing with other children.
In the Pediatrics environment, musical activities favor the approach among children, who play together. This possibility of playing during hospitalization promoted a therapeutic, warm and pleasant environment for the children and for their parents, favoring health promotion and prevention of diseases related to hospitalization.
Music enables to reduce levels of anxiety and improve sleep, it helps on learning, communication, speech and motor development. It can be seen as a hospital low-cost, non-pharmacological and non-invasive intervention, that contributes to the health of children hospitalized and may be used therapeutically as a resource for nursing care15-16.
We highlight the therapeutic potential of music to act directly on blood pressure reduction and cardiac frequency17, as well as reducing pain and anxiety in children treated with chirurgical procedures 18. Interventions with music can also help significantly in reducing stress, anxiety, pain and fear3.
"I like to sing and be with friends." (C6)
"Because you have to share the music with other kids." (C9)
In addition to the musical activities, children also reported they liked to draw, which initially would be a strategy to assess younger children and turned out to be one more ludic possibility developed. Drawing in hospitals can be integrated to musical activities, to potentialize resources to play, since these activities are part of their daily life, and make them to remember home and rescue the joy, as can be seen below:
"Cool, because I sang and drew. I felt better, the best thing that ever happened." (C16)
"I like to sing, I sing in the Church, and to draw. Because it's good for the kids"(C10)
"I liked it because it was joyful. I liked drawing because I do it at home. I was happier." (C18)
"I think it's cool. I liked music and drawing, I liked everything." (C13)
By means of this research it was possible to include the child in musical and drawing activities that can be offered to them even outside the hospital environment, but ends up being a rich activity to stimulate the children interaction with others and the express feelings caused by hospitalization.
In this perspective, ludic music activities promoted the hospital humanization by stimulating autonomy choosing the songs, the interaction through playing and hosting children and their parents participating together, which favors the integration with the environment7. It is important to consider different artistic expressions in the process of humanization of care, and the music can be an important therapeutic resource together with nursing care16.
These aspects linked to the humanization of the hospital environment also relate to some of the elements of Caritas Processes that were used as a theoretical basis, such as: using the presence with creativity and with all forms of Being/Doing; creating a reconstitution environment at all levels; giving assistance to basic needs with the intention of caring10.
Promoting well-being from positive changes of music
This category was evidenced by the change in the emotional state from the music, when feelings from fun to happiness and well-being were perceived. Children showed excitement, joy and happiness. We can observe in the following lines the enthusiasm of participating children about developing activities in the hospital:
"Great, because I love music and singing, and I think it is a cool activity. I felt better, more joyful and excited to be in the hospital. I was more excited to be here, I liked to learn." (C4)
"I liked a lot because it was cool, I was excited. I liked to listen to the songs because I like music. I was happy, laughing. I stopped crying to laugh." (C8)
"Because there are children who get bored being here a long time. So, there should be more activities to cheer the child, making them happiest" (C 20)
From these evaluations, it is possible to realize the importance of inserting ludic activities with the use of music as a way of helping children to express their feelings and experience pleasurable moments, reducing the anxiety to be experiencing an environment that was previously seen as a source of suffering.
Several studies point out music as a resource that can supplement nursing care and contribute to the reduction of harms arising from hospitalization19. The reduction of aggravations relates mainly to the reduction of anxiety, pain, stress, and the extension of bonds and the processes of communication, especially when the child is subjected to chirurgical procedures18.
In this perspective, it is important to highlight that supporting feelings expression is one of the elements of CP which based the activity, as well as being authentically present to allow the expression of the other's subjectivity10. Thus, the presence of the researcher/nurse promoted, through musical activities and the time of the evaluation, the experience and the expression of feelings that they caused well-being and pleasure.
As seen, children report they like musical activities and emphasize the importance of performing such activities with other children. At the end, during the evaluation, it was noticeable the children wanted to continue singing.
"I liked everything. All the songs. I felt more lively, cheerful and happy. I liked the guitar, I wish the songs would continue here to cheer up the others. " (C2).
"I felt happy, excited. It's cool to cheer up children and participate with other kids. I felt happier, it's good for the kids to feel better and also to sing like me". (C6).
In this sense, some strategies can be used for a humanized hospital assistance to children, including games, music therapy, art and painting. In this way, the child fantasy their reality with freedom to express and act providing fun and tranquility during hospitalization20.
The use of music is one of the ways to promote children's health providing comfort, communication and improving the relationship between the health professionals and their clients making care more humanized. It is important the children listen to songs present in their everyday life, to facilitate the development of the activities15.
Thus, the development of musical activities in the environment of Pediatric hospitalization also related to the application of another element of CP, using the presence with creativity and with all forms of Being/Doing as a part of the care process, engaging in artistic practices of care-reconstitution10.
This element also relates to the humanized assistance with a view to enhancing the work of health professionals and their expectations in the face of the need for change to finally reduce the negative effects of hospitalization. By targeting strategies and joint actions, methods, practices and subject knowledge, we can effectively enhance and ensure comprehensive, determined and humanized care7.
The results show the importance of music to stimulate the participation of the family in child's care and promote host by reinforcing the bonds between the professional and the child, which is also part of the guidelines and strategies of Hospital Humanization National Policy6. In this design, the HumanizeSUS is a policy that allows possibilities and concrete experiences to be enhanced and multiplied7.
CONCLUSION
Musical activities developed at the pediatric hospital showed that the subjects of research showed great interest in participating in activities and it was noticeable the family participation, which provides host to the users and creates bonds enabling a creative resource for care in Pediatrics.
Music can contribute to the hospital humanization in Pediatrics, applicable with children in different age groups, providing pleasure and reducing anxiety and promoting health in the hospital environment.
The use of Convergent Assistant Research provided, at the same time, the implementation of the activity and the production of data. The method allowed flexibility to add various search techniques which, at the same time, contributed to promote humanized care in the inpatient pediatric unit.
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