Revista Enfermagem UERJ

ORIGINAL RESEARCH

A protocol for hospital discharge of premature babies: input to building a proposal

Marly Veronez^I; Ieda Harumi Higarashi^II

^I Nurse. Master student in the Graduate Nursing Program at the State University of Maringá. Paraná, Brazil. Email: marlyveronez@gmail.com
^II Nurse. PhD in education. Master student in the Graduate Nursing Program at the State University of Maringá. Paraná, Brazil. E-mail: ieda1618@gmail.com
^III Part of the Master's dissertation entitled Discharge protocol in neonatology: the importance of educational action in the context of care for preterm babies. State University of Maringá - Paraná, Brazil.

DOI: http://dx.doi.org/10.12957/reuerj.2016.7505

ABSTRACT

Objective: to analyze the development of a discharge protocol for newborn premature babies, taking into account the mother's participation during the baby's hospital stay. Method: this descriptive, convergent-care study of six mothers with babies in neonatal units of a university hospital in Maringá, in 2011. Data were collected through participant observation, field recordings and interviews of mothers, and were submitted to thematic content analysis. The study was approved by the research ethics committee, Protocol No. 296/2011. Results: pointed to eight thematic areas – involving the baby's hygiene, breast-feeding, clinical progress and care routines – which should be considered during preparation for discharge. Conclusion: it is extremely beneficial to alternate situations of individual and collective learning, depending on the content and proposed objectives of the interventions, to schedules designed for each pair involved.

Keywords: Nursing; premature; patient discharge; health education.

INTRODUCTION

The birth of a preterm newborn^III (PTNB) causes mixed feelings to the family, feelings permeated by hope while witnessing the baby in its struggle for life and due to the constant anxiety caused by clinical instability of the child. In this situation, parents are deprived of the provision of care to the child who is hospitalized right after birth, making them feel insecure and unable to meet the needs of the baby after the hospital discharge.

Holistic care to hospitalized premature babies and their families should focus beyond the routine hygiene, feeding and encouraging the bond between parents and children, tasks usually covered by the health team. The aspects of the clinical condition of the child, as well as psychosocial and cultural perspectives of the family unit, should also be considered when preparing parents for the discharge¹.

Because of this reality, the present study aimed to analyze the development of a discharge protocol for preterm newborns, considering the participation of the mother during the baby's hospitalization.

LITERATURE REVIEW

It is known that the involvement of parents as well as their participation in the care of premature infants in neonatal units is favorable to the clinical evolution of these babies, helping to advance the discharge process².

Preparing the family for the discharge of the premature newborn from the neonatal intensive care unit (NICU) is extremely important to ensure the continuity of care to the newborn (NB). The participation of the parents in the whole process, since the moment of planning, integrating their suggestions to the care plan, is recommended for the success of this step. It is observed that strategies used to ensure the continuity of care when the NB is discharged from the NICU and from the hospital are insufficient ³.

In fact, some difficulties are reported in the literature regarding the assistance to PTNBs, and the lack of written routines and systematic information on medical files hinder the family follow-up. Lack of systematization of this process linked to absence of records on the information provided results in repeated and fragmented guidelines with possible misunderstanding or trivializing of the instructions. There is, therefore, a need for a discharge protocol to direct the resolution of this problem^4,5.

In this sense, the planning of systematic actions through a protocol addressing guidelines for discharge represents a strategy to resolve inconsistencies between the team members, as well as for the optimization of care and educational activities.

In nursing, protocols are intended to contribute to unification and standardization of the assistance guidelines⁶.

METHODOLOGY

Descriptive study taken from the research entitled Discharge protocol in neonatology: the importance of educational action in the context of care for preterm babies developed in the Graduate Nursing Program, Master's level, at the State University of Maringá (UEM).

For implementation, we used the methodological framework of the Care Convergent Research (CCR), whose main characteristic is its intentional articulation with care, which mainly occurs during the collection of information when research participants (researchers and components of the sample) interact in the care and in the research, with the intention of causing qualifying changes in that assistance⁷.

The study was conducted at the University Hospital of Maringá (UHM) and the participants were mothers of infants with less than 37 weeks of gestational age (GA) and birth weight equal to or greater than 1500 g. Babies were eligible when they had been hospitalized at birth in the NICU or in the intermediate care unit (ICU) of the UHM for at least 72 hours. Because the UHM is a reference hospital for care of infants at risk, mothers living in Maringá or within the ​​15th Regional Health Area were included in the study.

Data collection took place between October and December 2011. The record of the orientation process was based on participant observation and on reports of interventions registered in the field journal of the researcher. The evaluation of this process of teaching and learning was consolidated by conducting interviews after hospital discharge in the homes of the mother-child binomial and during meetings held in the specialized outpatient clinic on the return.

Whereas CCR allows the use of various methods, both for gathering and for analyzing data, it was decided to use the Bardin content analysis8 in the thematic analysis mode for the treatment of data . After transcription of all records and interviews, texts were repeatedly read, starting with an overview of the general content and then passing to the exhaustive and systematic reading of the corpus. At this stage, segments of the texts were highlighted, identifying the sections that correspond to the objectives of the study, in order to group similar records to encode them and organize them into categories.

The study was approved by the Permanent Ethics Committee of Research with Human Beings of the EMU, under Protocol nº 296/2011 , and all ethical precepts required by Resolution nº 196/96 of the National Health Council were considered⁹. In order to ensure the anonymity of the subjects, the authors of the reports were identified with the initial letter M referring to mothers, followed by an Arabic numeral in sequence, according to the participation of the same research (M1, M2 ... M7).

RESULTS AND DISCUSSION

The study included six mothers aged between 16 and 31 years, with one single and all the others married or living in common-law marriage. In relation to the NBs, the gestational age (GA) at birth ranged from 31 to 36 weeks and birth weight from 1560 g to 2460 g. The hospital stay ranged from 10 to 49 days; only one of the babies did not require intensive care. Admission diagnoses included, besides prematurity: Respiratory distress syndrome, Neonatal infection, Adaptive tachypnea, Small for gestational age and Gastroschisis.

Mothers received the first home visit (HV) between the third and fifth day after discharge of the baby, as shown in Figure 1.

Figure 1 - Characterization of mothers, NBs and data on the length of stay and number of meetings held. Maringá - PR, from October to December 2011.
Acronyms: M = Mother; W = weight; GA (no) = Gestational Age; Apgar score = 1 ^st and 5^th minute; ♀ = female; ♂ = male; N = Normal; C = Cesarean; NICU = Neonatal Intensive Care Unit; ICU = Intermediate Care Unit; MCW = Minimum Care Ward; HV = Home Visit; OV = Visit Outpatient.

The testimonials gave base to three categories which are analyzed below.

Guidance for discharge and home care

In the first approach to the mothers, an evaluation was carried out in order to know the family context, raising the obstetric history and investigating whether they had received any information or guidance after the baby's birth. Among the six mothers, one was instructed about hand washing, another was instructed about changing diapers, milk supply in cups and breastfeeding (BF), while four of them had not received any prior information.

From the first contact onwards, the subsequent meetings were scheduled, as mothers could not stay full time in the unit and some lived in other municipalities. Mothers were gradually inserted in the care of NBs in a systematic manner adapted to their individual demands and needs, always taking into account the learning pace of each participant. During their stay in the sector, various guidelines were given, with demonstration of care. This step proved to be a rich period for the consolidation of the bonding of the binomial mother-child, and for the achievement of confidence by the mother regarding providing care and for the relationship of trust between the professional researcher and the mother.

The implementation of guidelines was based on a script developed specifically for this purpose in the form of check list contemplating contents considered of paramount relevance to prepare mothers for the care of NBs and based on protocols used by neonatal care services, as well as other specific bibliographic and educational materials focused on maternal guidance^10,11.

Eight thematic groups were outlined from the process of guidance and preparation for hospital discharge: Care with hygiene and comfort (shower, diaper change, dressing the umbilical stump); Breastfeeding (importance, management of the BF, grab, milking, storage, most common problems); Weight monitoring (weight gain and loss, reflections on the general state of the NB, growth process of the NB and nursing infant); Hand hygiene (importance, correct hygiene); Specific care (related to the diagnosis or clinical state of the NB, dressings and other relevant procedures); NICU care routines (organization and assignment of duties, schedules and operation, technological tools and assistance procedures, examinations and vaccination guidelines); General home care (guidance on personal contact, agglomerations, sunbathe, sleep and rest); Information on clinical status of the baby (General framework, clinical response and therapeutic procedures).

It was observed that four out of eight thematic groups (care with hygiene and comfort, breastfeeding, hand hygiene, general home care) were included in the script of the original guidelines, and four (specific care, NICU care routines, information on clinical status of the baby, weight monitoring) were not part of the previously prepared script, but were derived from questions and needs identified during the process of preparing mothers.

Among the thematic groups set out in the script, the ones that were worked most often during the meetings at the hospital included the guidelines on hygiene and comfort of NBs, such as bathing, changing diapers, care of the umbilical stump and body temperature control, totaling 20 educational interventions. This thematic group was followed by guidelines relating to breastfeeding (16 interventions); general child home care (13) and hand hygiene (4).

With respect to the guidelines that were not included or planned in the script, these include issues related to the care routines of the sector, which required 15 educational interventions and were followed by approaches to weight loss and gain, specific care to the NB and information on the clinical status (health-disease condition) of the child, with three interventions each.

The sequence of content covered and the time required to address each one of the themes or thematic groups varied according to the clinical condition of the PTNB, the specific needs of mothers and routines established in the sector.

In the case of teaching care, the steps of the procedure were initially explained and, then, the mother would carry out the care along with or under the supervision of the researcher. Over the days, it was observed that the mother was acquiring skills and she would perform care more confidently.

In the case of addressing issues related to the child's condition or clarification on the usual routines and service procedures, the process of giving instructions occurred individually, avoiding to overlap these themes to the simultaneous realization of care. Themes related to general care were treated collectively whenever was possible. Therefore, a more convenient time and a specific location were selected so that mothers could have their questions answered.

Addressing these issues or discussing doubts, in common with the participation of the greater number of mothers, was quite appropriate. This is because in these conditions the participants felt more comfortable to express their concerns, given the possibility of exchanging experiences and information with other mothers.

The literature points out that weekly meetings with groups of parents promote the exchange of experiences and, for this reason, such meetings are seen as a source of support for families. They give space for the clarification of doubts about pathologies, procedures and routines of the sector that are shared by different families^10-14.

Contributing to maternal autonomy for care

During hospitalization in the NICU, the direction of intervention was guided by the clinical situation of the child and the availability of the mother and her specific learning needs. Most often, mothers were not fully aware of their need to learn, but they would conform to the direction proposed by the guidelines script. Spontaneous questions in general were due to some complications in the evolution of the hospitalized child.

The guidelines directed to teaching techniques and care procedures, even on basic issues such as bathing and changing diapers, were the ones that demanded greater repetition, because of the sequencing of steps required for this type of education and the gradual gain of confidence for the realization of care. Breast milking and oral milk supply were guidelines that also required special attention and more time for teaching.

Another aspect to be considered in the preparation for discharge was the lack of the possibility of the mother to stay full-time monitoring their children. Only two out of the six mothers who participated in the training process lived in the city. Although this did not affect the implementation of the CCR, as the anticipated schedule of all meetings, it is surmised that, before the adoption of a systematic protocol of preparation for the discharge in service, this absence of the mother could negatively affect the character of continuity of the instructional process.

Difficulties of social, financial or family nature, as well as the presence of other young children at home may hinder the trip to the hospital and should be worked at the process of discharge^. The health team should investigate these factors early in the hospital, in order to enable possibilities of intervention, directing formal or informal support networks^13,14.

It is noteworthy in this context that health professionals should be prepared to approach the mother when she is present in the unit next to the child by encouraging her participation in the care. The early insertion of the mother reduces anxiety and increases self-confidence, thus facilitating the care at home¹⁵. Furthermore, the type of assistance offered by the health team can lead mothers to express their deepest feelings, those that distress them, allowing to establish an effective channel of communication between professionals and parents, strengthening emotional bonds, and this is a strong ally in the process of providing care to premature babies¹⁶. However, long periods of distancing of the mother may generate opposite responses, such as increased sense of insecurity in relation to the monitoring of the newborn, detachment, disinterest, reflecting a greater delay in the acquisition of autonomy for care.

Evaluation of the mother: guidance for discharge

The results showed that, once at home, many problems and difficulties emerged on the guidance process carried out during the hospitalization of the baby. Thus, three out of the six mothers interviewed mentioned doubts related to bathing, feeding and body temperature control.

Other problems identified were common problems related to environmental adaptation of the NB, such as the management of colic, cited by five mothers and nasal obstruction, cited by four participants. These results are consistent with the literature17,18, where families of premature babies followed after discharge referred doubts particularly on hygiene/comfort, as well as diverse signs and symptoms of the babies, which included body temperature, nasal congestion and NB's crying.

It is noticed that the knowledge acquired and skills developed within the hospital are important allies for the effectiveness of the care in the home context. However, these are not enough to overcome the fear and insecurity completely, as more time is required for the mother and the family to adapt.

When mothers were questioned about the guidance for discharge carried out during hospitalization, and the rescue of the information received, all of them had difficulty remembering the content, the amount of topics covered. In this perspective, the adoption of educational materials and conducting reserved meetings with the mothers to develop health education seem to be interesting alternatives to strengthen the learning process¹⁹.

Another important aspect was related to problems with the scheduling the return to clinic specialties, which was pointed by four mothers. Despite the coincidence of discharges and schedules with the end of the year, which led to observe longer intervals between the discharge and the return, it appears that there were some flaws in the communication process between the medical staff and mothers.

Home visits, in turn, make possible to help families to overcome the initial difficulties in the home and is also a very appropriate time to encourage the maintenance of breastfeeding¹² and to identify any gaps arising from the discharge process. This shows clearly that the preparation for the discharge should not be an action carried out as occasional or punctual, but should begin with the arrival of the baby in the unit, be extended during the hospitalization period, and even extended to assistance provided in the home through the outpatient follow-ups or specialized support services⁵.

Problems relating to the process of communication, interpersonal relationships and dynamics of members of the health team were highlighted in a negative way in the interviews.

It is known that the simple fact that professionals are open to listening alleviates anxiety felt by parents and humanizes the environment. The correct information is the shortest way to calm the family^20,21. Professional attitudes that are unmotivated to welcome can be interpreted as neglect, disinterest towards others, or even as a lack of preparation for the establishment of the therapeutic relationship.

Given that among the thematic groups that were not included in the guidance script the most cited referred to the guidelines on the care routines of the sector, the need for revising the whole orientation process for discharge becomes clear. To overcome this difficulty, it is necessary to improve the welcoming attitude, providing opportunities for parents and for the family as a whole to express their doubts so that the team may provide guidance taking into account the particular needs of each case²². Still, it is necessary to maintain a permanent communication channel that may turn the participation of the family in the hospitalization process possible. Humanization is encouraged through educational activities, highlighting here the importance of the nurse working in the NICU when dealing with family members, who are active subjects in the care process and also an extension of critical customer^23,24.

CONCLUSION

The results confirm the importance of adopting a guiding protocol to the discharge of PTNB as a strategy for the systematization of the assistance aimed at the achievement of maternal autonomy to care for the child as well as to the standardization of conducts adopted by the caregiving team.

Protocols used in other neonatology services were important references for implementation of the present field research study. The CCR associated with interviews in the period post-discharge allowed the identification of other important aspects, pointing out gaps to be addressed in order to further qualify this process of orientation.

There was a need to implement an individualized educational-care process that may respect the learning pace and the state of readiness for learning of each mother or family member. The initial stage of theoretical and operational input offer was the starting point for the procedure to be taught, passing then through the practical demonstration of this care until achieving the involvement and active participation of the mother. With the purpose to make mother acquire autonomy, the participation of the mother primarily occurs in an assisted-oriented manner, progressing up to the realization of comprehensive care under the supervision of the team.

Given the demands presented by the participants of this study, the basic care with food (BF and others) and hygiene of the newborn were the topics that required more educational interventions. The guidelines covered the main topics: breastfeeding, hand hygiene, general home care, special care, NICU care routines, information on clinical status of the baby, weight monitoring. We conclude that alternating situations of individual and collective learning is extremely beneficial, depending on the content and objectives to be achieved with assistance and according to a program directed to each binomial.

Because this is a specific study involving the care reality, the results and conclusions cannot be generalized to other contexts. Despite this limitation, this research contributes to the systematization of neonatal care and encourages the strengthening of educational and care practices aimed at reception and preparation for discharge of premature NB, consolidated on a participatory and family-centered approach.

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