Nursing in neonatal intensive care : the look of the families Enfermagem neonatal em cuidados intensivos : o olhar das famílias Enfermería neonatal en cuidados intensivos : la mirada de las familias

Exploratory, qualitative and descriptive study aimed at identifying the perception of the Neonatal Nursing of mothers and/ or parents of newborns in intensive care. Data were collected from May to July/2012, with seven couples of parents and two mothers of neonates hospitalized in intensive care, through semi-structured interviews. Data were analyzed from categories. The results showed that parents see the nurse as responsible for the health of humanized night-watch; perceive nursing as a substitute for maternal care; relate negative feelings about the Neonatal Intensive Care Unit and perceive the technical skill as a care factor. Despite the short contact of parents with nursing at the venue of the study, it was possible that parents recognize the figure of the nurse emphasize the humanization of care, but do not realize managerial skills and use of scientific knowledge in nursing practice. Descriptors: Intensive Care Units, Neonatal; Neonatal Nursing; Nursing Care.


Introduction
During pregnancy the woman wants to have a well succeeded delivery, with the birth of a healthy baby who can be by her side from the first moments of life.However, not all gestations are completed with the delivery aimed by the families, many times the anticipated arrive of the newborn (NB) and/ or intercurrences of the gestation itself or delivery postponing the meeting of the mother, baby and family on account of the need of intensive care for the neonate.
This fact generates emotional conflicts producing many times contradictory feeling in the puerpera (1) .
The birth of a premature neonate and/or the presence of diseases provoke physical separation between the neonate and his mother, once his clinical situation requires immediate assistance in order to guarantee survival and prevent sequels.Such stressing situation can cause distance of the parents and fear of the future.Once they are caught by surprise by the situation causing alteration in the planning of their lives (2) .The hospitalization in a Neonatal Intensive Therapy Unit (NITU) stops a dream idealized by the parents, bringing disappointment, feeling of incapacity, guilt and fear of loss, feeling that create stress and take many times to the distancing between parents and child (3) .
It is in this critical phase that the NITU team works, helping the parents to overcome this difficult phase, with actions in the process of the healthdisease of the sick NB under intensive care, and this care is both for the child as well as for his family (2)(3) .
The NITU has the objective to save the life of children, who are in the eminent risk of life, allying technology to scientific-technical knowledge of the professionals, so that the NBs can have the best possible assistance, progressing in their development and improving the clinical picture they present (4) .
The condition of frailty and vulnerability of the NB admitted in a NITU is expressed through his real clinical conditions, which required invasive procedures, in the validity of technological devices, and this environment causes fear and insecurity, marked for feelings of anxiety.
The central focus of the work of nursing is the care, a fundamental element in reestablishment of health which must be direct to the NB and his family.
The care of nursing to the fathers of the NB cannot be reduced to his relational non-technical aspect.The widening of scientific and technical knowledge and the presence of a well prepared health professional is important for the balance of the technological and expressive care (5) .
The care is configured in a relation of care and empathy, besides being considered as a vital phenomena and essential in the life of all human beings.It is a way of being with the other, concerning the special question of his life, like the birth, the death, the preservation and the recovering of health (6) .
The crescent complexity of the neonatal assistance and the search for a humanized and quality care provides a need of reflection about the question related to the competences of the nurses for the acting in a NITU, including the managerial competence (7) .This research is justified by the fact that nursing is the team that stays longer with the patient, and that is why they have the greater knowledge on the necessary care to the patients and their family member.Being aware of this perception of the parents on Nursing it is possible to reflect and question the way in which care has been rendered, which makes possible the proposition of adequate strategies in the assistance, facing the needs of health of the NB, directing the focus of the care to the family, improving the indicators of child morbi-mortality, as well as the help in the construction of competences of Neonatal Nursing.Therefore, the present study has the objective to identify the perception on Neonatal Nursing of mothers and/or parents of neonate in intensive care.

Method
It is a descriptive study of qualitative approach made in a NITU of a hospital institution of average size located in the county of Guarapuava, in the centralsouthern region of de state of Paraná, Brazil.
The subjects of the study were seven couples of parents and two mothers of NBs hospitalized in a NITU.These were the criteria of inclusion adopted: being a father and/or a mother of a neonate under intensive care for at least five days; and as criteria of exclusion: being a father and/or a mother of a child older than one month, hospitalized for at least five days in the NITU and family members with other degrees of kinship of the neonate.
The data were collected from May to July 2012, in the hospital, in a reserved area, with previous scheduling.The data collection was directed by semistructured instrument with the following guiding question: 'How did you perceive the Nursing taking care of your child during hospitalization in the NITU?'Besides that, a question of support was used, in order to instigate the subjects of the research, the perception on Neonatal Nursing in intensive care: 'Which are the responsibilities of the Nursing when taking care of your child?'The interview was recorded as a means to file the reports for a later transcript.After the discussion of the data the recording were erased.
For the discussion of the data, the technique of theme analysis was used, which approaches the nuclei of sense made evident from the theme discussed, and three steps were followed.The first was the pre-analysis, in which there is the determination of units of registration, units of context and general theoretical concepts which will guide the analysis, considering the object of the research.The second phase, called exploration of the material, consists in the transformation of the initial data, having as objective the comprehension of the text from its nuclei of sense.The third phase referred to the treating of the results, in which the interpretation of the obtained data occurred, now in theme categories, correlating them with the literature on the theme (8) .

Results
The statements of the interviews were transcript and grouped according to their similarities of meaning, emerging from the following theme categories: The nigh-watch of the doctor permeated by the humanized care; Nursing is the very substitution of the maternal figure; Negative feelings are present in the hospitalization in a NITU and highlights for the technical abilities.

The nigh-watch of the doctor permeated by the humanized care
In the perception of the parents researched, Nursing in the NITU acquires importance because it is responsible for taking care of the neonatal uninterruptedly, for following him in this phase and rendering care for the (re) establishment of this health.

However, it was verified that this perception
shows acting as a support of the doctor, once the subjects perceived the nursing team as a substitute for the absence of that professional during the whole period.There is a nurse there 24 hours taking care, without her, it wouldn't work, the doctors couldn´t take care all the time (Parents of Sleeping Beauty).There isn't a way they can go there, turn back and leave, and then no one stays there, there must be a person there, and in this case it would be the nurses (Parents of the Little Prince).

The Nursing keeps looking and follow exactly what the doctors say, and without them who would do it? I don't know, there isn't another professional who could assume this function (Mother of the Little Mermaid).
Despite this reduced vision regarding the cares of Nursing that the child receives in the NITU, the parents don't see it as being something negative or bad, once what prevails in the statements is the perception of a care permeated by caress, dedication and attention, which characterizes a humanized care that comforts the family of the neonates in intensive care.People depend on the nurses, if they didn't stay there taking care, providing assistance and attention to the children´s need, nothing would happen, so I think that they are quite important (Mother of the Little Mermaid).Even during the visits they are always watching and checking how the baby is, she pays attention to the devices there, and I think they take good care, both when we are there and when we are not, I believe that they do everything right This category revealed that the parents have a perception of the nursing linked to acting doctor, but what prevails in this relation is that the team of neonatal nursing is outstanding for transmitting a unique posture which leads to humanized care, and this is the evident perception through the statements.

Highlighting the technical abilities
In this theme category the technical care and the environment of NITU emerged, keeping in mind the importance given by the parents to the medication, to the use of equipment, to the management of the environment of intensive care and how all of this influences in the treatment of the NB which depends on this range of resource of the survival.In terms of care and attention to our child, the most important things are provided by the nurse, the assistance, the exams, the devices, the medication (Parents of Aladdin).I think if she weren't here, if we couldn't stay here assisting, the nurses taking care of the equipment, at home she couldn't stay, and it wouldn't be the same thing.(Parents of the Little Mermaid).The doctor comes here, he examines, he prescribes the medicine, passes by quickly and leaves what has to be done, the procedures, the devices, they are all left for the nurses to take care of (Parents of Little Prince).The activities which are usually made by the mother at home when the NB is born on time, in the case of neonate under intensive care they are made by the nursing team.Such fact is an important tool for the strengthening of the link between the nursing team and the mother.Facing that, it is important that the nursing provokes the insertion of the parents in the cares to NB, in order to strengthen the links between the families and promote his autonomy.This theme category also reinforces the vision the parents have on Nursing as delicate, attentive and kind professionals, once the recognition of the managerial function of the nursing is not verified in any statement.
The perception of Nursing as a substitution of the maternal figure provides a feeling of security in the parents, which is essential during hospitalization, once it is from this point that they become less apprehensive, when they need to go back home, once they see nursing as a reference, reliable, and they know that it is in this cenario their son will have all the necessary care, to his survival, recovering and to the maintainance of this health condition.

Negative feelings present in the hospitalization in a NITU
Despite the expression of feeling involved by tranquility and security on the internalization of the child in a NITU, provided by the Nursing to the subjects of the research, it was possible to observe that the negative feelings also emerged in the statements.However, it is highlighted that such negative feelings present in the statements refer to the hospitalization in a general way.The feeling of security previously discussed is related to nursing, once it was perceived in this study that the professional act sin order to minimize the situations of stress among the family members of the neonates.
The fear of death was an expressive feeling in the statements.Because it is a pejorative term and at the same time very strong to be used regarding babies, especially when these are your babies, the word death is only presumed in the statements, not clearly or directly expressed.Fear that something happens to her.Fear of bad news (Parents of Cinderella).Fear he wouldn't return anymore, you know (Parents of Aladdin).To lose, to lose, fear that God may take him away (Parents of Peter Pan).We fear for the worse.I don't even want to talk about it(Parents of Little Prince).

Now I fear that something bad happens with him, that he gets worse, even fear of losing him (Mother of Lion King).
Supporting these people that are experiencing the situation, is of extreme importance, once, from this support, they can feel more secure and face the fear of dying in a less traumatic way, besides taking him away from evidence, making him wait for the hospital discharge and for life of his son.

Discussion
The perception of the night-watch of the doctor is permeated by humanized care, it is noticed that the nursing is structured in function of what has to be assisted, and the historical vestige of the profession links these professionals to their clientele through dedication and love, once they suffer the influence of religious behaviors and concepts (9) , besides the clear subordination of the nursing to the doctor, and this fact is also resulting from the birth of nursing and the difficulty deconstruction of the conception of people.
The data analyzed revealed that being sympathetic with the other, establishing a relation of help with empathy, valuing the human aspect, rendering assistance, within a holistic view, constitutes the humanistic basis of nursing.Affection is one of the characteristics of the profession.The nurse is the professional who most interacts with the patient, therefore, he must establish a way of contact which transcends the technical procedures and for such, pursuit an empathic relation (10).
Nursing is generally defined as the science of care, symbolized by the image of a smiling nursing hand in hand with the patient, which describes the work in terms of love and abnegation, making nursing a personal work and not a profession in a certain way, this situation minimizes education and a training acquired by the nurses to become a profession (11).
In rendering care of Nursing to the sick neonate, the parents point out the characteristics of gentleness and attention, which are important and characterize the profession.However, they are not sufficient, nurses must prioritize the high qualification, they must describe what they do, showing the articulation between education, knowledge and abilities (11) .
The work of Nursing extrapolates the charity characteristics, once it involves management which is fundamental to organize the process of work of the Nursing team in order to develop actions and to assist the need of health of the population, but these people do not have any knowledge of such function.The nurse, who manages neonatal units, as well as the other ones, makes prevision, provision, maintenance, control of human and material resources, besides the management of the care with the diagnosis, planning, execution and evaluation of the assistance as well as delegating activities, supervision and team orientation (7) .
It is important to highlight that among the subject researched, there is no distinction in the technical division of the work of nursing: nurse, assistant and technician.It is noticed that for the parents all the members of the team are nurses, and this is also a historically build vision.The clear distinction refers to nursing professional and the doctors.
Regarding the technical abilities, many times these overlap the other needs of the patients, once it deals with the highly technical and objective environment.There are moments in which the patients are taken care of in a routinely and mechanized way, oriented by a biologist model, in which the professionals worry more with the technical procedure and with the functioning of the devices than with the patient.However, this environment is not enough anymore (12) .The care requires joint actions from the nurse, such as: the person being taken care of, interaction, emphatic relation, involvement, responsibility and not only restraining to the technical procedure, although this is essential (13) .
Among the intensive activities it is necessary to articulate technological and relational advancement, in order to promote the interactions among the subjects and make humanized assistance available.For that, the conception of technology needs to be enhanced, once in the environment of attention to health, besides the hard technology presented by machines, instruments and devices which are essential for the assistential activities, there is the light technology, which comprehends the human relations and it is based on the assistential approach and is aimed at the process of relations and of the encounter among people (14) .
The technical actions are necessary to cope with the needs of NB, but they are not sufficient.It is fundamental to associate humanization, caress, communication and, especially, insertion of the family in the care to the neonate.So, the assistance will change from fragmented into integral and the parents will start perceiving the son as a subject who needs care, so that the equipment/medications/exams are seeing as tools for the care and not the center of actions of the NB.The health professionals will start developing a work each time more competent in its attributions, thus significantly contributing for the survival of the baby who is in the intensive unit.
The effective presence of the nursing team with sensitive listening is as important as the technical procedure, once not always the technical knowledge responds to the situations of stress.Only seeing, listening and feeling the NB and the family as a whole, we will be able to assist and understand the essence of human care (13) .
The vision the parents have on nursing is linked to the technical work, the daily reality of the nursing work shows that it is not enough to have human talent and equipment, this must be available in adequate place and moments with an acceptable level of coordination and directed for the success of their actions (7) , and these data corroborate with the present study.
Besides the essential technical care rendered in the permanence of the NB in the NITU, the Nursing also acts as a substitute of the maternal figure, once they take the essential care of the baby.The literature shows that the nurses feel moved, involved and feel in the position of the mothers (15) projecting themselves as a member of the family.
The inclusion of the family in the care of NB is not something easy to be established, once what is noticed is the provision for the specialized care directed for techniques, procedures and sophisticated equipment, and so it is difficult to include the family in the care to the neonate, and the worry to insert the family in his environment is recent (3) .
The participation of the parents in the basic care with the NB must be valued by the Nursing team through reliable methods and interventions.
This practice must take part in the planning of care of the NITU, once the parents need to recognize themselves as important and acting in the process of reestablishing the health of their son, to feel useful, thus strengthening the affective link among them.
The involvement of the parents in the care promotes approximation and provides a sense of participation which identifies them in the role of the parents and also provides meaning to the visits (3) .
A study made in a NITU in which the parents of the hospitalized children, even uncomfortably installed, prefer to stay next to their children, once this way they feel more secure regarding the treatment and the team, testifying that for the parents the care transcends the techniques used and when a link of confidence is created with the team, and feelings of gratitude and affectivity ends up permeating the environment (4) .
The severe condition and the hospitalization tend to cause distancing between the neonate and his parents, which makes difficult the formation of the affective link and the attention which should be provided in the care to the baby.So, including the family in the care during hospitalization is important to favor the preparation, the emotional maturity, besides stimulating the security of the parents to do the adequate management of their children after hospital discharge (6) .
Puerperium per se already presupposes a problematic context in which adaptation in the woman occurs.Adding to it, the need of hospitalization can cause a lot of suffering among the puerperas.So, it is possible to presume that several types of feelings, behavior and attitudes can emerge from these situations (16) .
At this difficult moment, despite being physically and psychologically shaken, the mother gives up her own need of care, to think about the son.
These situations need to be perceived by the health professionals who take care of these women, once they will make the rendering of integral care easier, besides allowing the establishment of trust, acceptance and satisfaction of the mother (16) .
During the hospitalization it is necessary that the nursing team keep an effective and continuous communication with the family members of the NB in the experience and also facing situations of stress, so the orientations will adequately be provided and the emotions experienced in the intensive environment will be minimized.
The hospitalization in the NITU generally constitutes a situation of crises for the whole family, above all for the mother.It is a strange and frightening environment; the real NB is different of the imagined being, and the feeling of guilty due to the problems of the child acts as an inhibiting factor of spontaneous contact between parents and children (13:768) .
In this sense, the sheltering to the family members is of fundamental importance so that the emotional experiences which happen during this period can be understood, accepted and so, the suffering of the parents will be consequently minimized.So, because the parents need orientation as to the hospitalization of the child, the health team must also be orientated in order to adequately shelter the family and the unit (17) .
The feelings present in the life of the parents during hospitalization of the child in the NITU oscillate among frustration, fear and hope.The frustration is manifested, once they are not prepared to experience the separation of the child, the fear happens because they know of the risks which can attack the patient who are in intensive care, and the hope occurs because they know that it is the only place which is prepared to assist the needs of the baby and increase his survival.
It is important that links between fear and hope are established and the sense that the team that assists the NB needs to offer opportunities, intermediate and favor the meeting of the mother with the child (18,13) .
It is convenient to highlight that feelings which generate suffering expressed by the mother of NB hospitalized in a NITU can negatively interfere in the reestablishing of the Puerperium, once in certain situations they generate minor psychiatric disorders, such as psychosis or puerperal depression.It is a competence of the nursing team to spare the puerpera of anxieties and negative feelings through orientation, stimulus to her autonomy, respecting her singularity as well as offering support for the process of psychic organization (2) .

Conclusion
The time of contact of the subjects of the research with the nursing team was limited to the schedules of the visits standardized by the institution, so, there was no sufficient time to completely identify the perception on all the managerial and assistential competences of the Neonatal Nursing and this fact is a limitation of this study.However, it was possible to identify the perception of the parents on the neonatal nursing in intensive care.

of
Ethics in Research by the Universidade Estadual do Centro-Oeste through legal opinion number 090/2012.All the steps of the study were according to the Resolution 196/96 of the National Council of Health.In order to preserve the identity of the subjects of the research, those statements were differentiated in the texts attributing names of cartoon characters to the hospitalized neonates.
Parents of Peter Pan).In my opinion they are very dedicated, they are careful and I liked their work a lot (Parents of Sleeping Beauty).

For
the procedures they have to do, with care, the nurses can provide stability for the babies and they are indispensible, to catch a vein, and to check the probe, to provide medication on the right time, provide serum, they do everything (Parents of Lion King).So, in the care of the NB and his family, it is necessary to overcome the barrier of technical care, which is the use of hard and light-hard technologies, that is, it is fundamental to ally the light technology making them equally important in the execution of care.This attention rendered to the neonate is revealed when the subjects of the research exemplify with merely technical care.I think her attention is important, we can see during the visit that there are always checking how the baby is, the devices, always dealing with the medicine, we see (Parents of Peter Pan).At least, there is one to look at the baby the whole day, see what´s going on, and there is the medicine to give, which is very important (Parents of Little Thumb).And then even in the serum, the serum whistled because she had a device with serum that whistled and then the nurse said: the serum is over, don't worry, it's nothing, it is the serum that has finished (Parents of Snow White).The team which acts in neonatology needs to develop the necessary competences to care and management of excellence, widening them beyond the technical knowledge, reinforcing the abilities and the behavioral attitudes which are differentiated, with subtlety, a really competent assistance.Nursing is the very substitution of the maternal figureThe permanence of the NBs in the NITU is responsible for giving the Nursing an image of protection to the children, once they experience a process in which the parents are away, and newborns sometimes need not only the technical care.The nurses also act as subjects that momentarily have the functions of the parents who are forced to experience the process of abrupt separation of the children.Actually they perform our role when we are not here, they talk to her, they play with her, and I think this is fundamental for the child (Parents of Cinderella).I consider them like mothers, because the remaining time of gestation that the child had to stay in my belly, he will spend with them, they are the ones taking care of him, what they do, is as if the days left for him to be born, the responsibility of taking care of him in order to have discharge is hers, that's how I see it (Father of Peter Pan).I, mother for the first time, would know what to do with my child to make her well, the nurses already know how to deal with the child and I wouldn't know what to do with her at home, they are being her mother for the time being (Mother of the Little Mermaid).The affection and the care which involves the work of the nursing professionals in the NITU is seen as the similar care to the one the mother provides her baby in the first days of life.They do what we can't do.It is up to the nurses: the bath, the change of diapers, even feeding, I have the milk, but they give it to her, so it is like that, I totally trust her (Mother of the Little Mermaid).My little baby is in their hands, they do everything, they bath, change diapers, they put the milk in the probe, and the other things they have to do (Parents of Peter Pan).
The perception the families have on Neonatal Nursing in intensive care is based on the terms of dedication, admiration and abnegation, certain vestiges of the Traditional Nursing are present, as the subordination to the doctor.The need of the nurse to rethink this vision is observed, once the profession exerts not only assistential function that are marked by a strong humanistic relationship, but also managerial functions, which require scientific knowledge, development of abilities and competences.The assistance of Neonatal Nursing goes through modifications in the sense to include family in the care, but there is a lot to be done yet.If on one side, we agree in the insertion of the mother in the care of neonatal in intensive care, on the other hand we have to retake the responsibility of taking care of the binomial mother/son, once at this moment the woman still needs care, however many times the needs of NB are considered as priority.In order to reach a model of neonatal care, in which the focus of the care of nursing is the family, with the valorization of the link between mother and son, with the objective to relief tensions, some changes are necessary.Such alterations range from the modification of the assistential and the managerial models, developed by the nurse, which permeates the daily practice of the whole team and the use of different technologies, to structural and physical changes in the sector, which must favor the presence of the parents in the unit as well as understand the other members of the multidisciplinary team.Therefore, it is a change of organizational culture involving all the health professionals rendering intensive care.The modification of the dynamics of the NITU, when valuing the family in the care, will bring positive points to the clients and to the profession.First of