THERAPEUTIC COMMUNICATION BETWEEN HEALTH PROFESSIONALS AND MOTHERS ACCOMPANYING CHILDREN DURING INPATIENT TREATMENT

Objective: To describe the communication process in advice given by health professionals to the accompanying mother regarding the illness and inpatient treatment of her child. Methods: Descriptive research with a qualitative approach, undertaken in Ceará in a public hospital which is a center of excellence in pediatrics, in August 2011. Data was collected via semi-structured interviews and, using the technique of thematic content analysis, three categories were selected: The mother's need to feel well-informed; Health professionals who provided information on the child's illness; and, Barriers found in the communication between the health professional and the accompanying mother. Results: It was observed that all the mothers were anxious to receive information on their children, but that therewere some obstacles in the communication with the professionals, such as the technical language that these use. Conclusion: Based on the understanding of the importance of providing information to those accompanying the children, the health team needs to improve its performance, so as to produce a more efficient therapeutic communication. 1 Universidade Estadual do Ceará. Fortaleza CE, Brazil. 2 Universidade Estadual do Ceará. Fortaleza CE, Brazil 3 Universidade Estadual do Ceará. Fortaleza CE, Brazil 4 Universidade Estadual do Ceará. Fortaleza CE, Brazil 5 Centro de Ensino Unificado de Teresina. Teresina PI, Brazil RESEARCH PESQUISA INVESTIGACIÓN Comunicação terapêutica entre profissionais de saúde e mães acompanhantes durante a hospitalizaçao do filho Esc Anna Nery (print)2013 Sep-Dec; 17 (4):690 697 Sarah Vieira Figueiredo1, Ilvana Lima Verde Gomes2, Viviane Peixoto dos Santos Pennafort3, Ana Ruth Macêdo Monteiro4, Juliana Vieira Figueiredo5 Comunicación terapéutica entre profesionales de la salud y madres acompañantes durante la hospitalización de su hijo Health communication; Humanization of assistance; Communication barriers; Child hospitalized.


INTRODUCTION
Based on the legal permission, through the Statute of the Child and Adolescent 1 , for the presence of a companion with the hospitalized child, health professionals and pediatric inpatient units have passed through a process of adaptation, learning to relate directly to this new subject, sharing care activities and, moreover, providing care in response to the needs of those accompanying the child.
The presence of a family member is important to the child, as he or she provides tenderness and security at a difficult time, when the child is experiencing a new atmosphere and is far from her home and family.It is also noteworthy that the family can become a mediator in the relationship between the child and the health team, facilitating both the work done by the health professionals and the child's recuperation, which reduces the cost and duration of the inpatient treatment 2,3 .
Generally, it is the mother who accompanies the sick child, or who visits her most frequently, as she feels responsible for her protection, as well as having an intense desire to care for her sick child while the latter is in hospital, as a way of transmitting love and minimizing the feeling of guilt which is often shown when the child becomes ill 4 .
Like the hospitalized child, the mother faces feelings of suffering and anxiety generated in this process.For the mother, the child's hospitalization constitutes a difficult and sad experience, which creates suffering and pain.This pain is related to the fact of having a child who is ill and in hospital, which prevents her from carrying out her routine activities.This suffering, furthermore, can be accentuated by the worry about the other children who remained at home, her distancing from her partner, her absence from work -her source of income -and by the physical and emotional strain, among other aspects which are specific to each mother 5,6 .
Based on this, one can understand the need for the mother to receive attention from the health professionals, so that comprehensive care may be established for the child, involving family members, such that the mother and child may be the focuses of care, given that both face the hospitalization together.
The humanization of the care may be described in terms of the quality of the relationship between the health team and the family, and the way that the partnership takes place.From the moment that the accompanying mothers perceive that the health professionals show attention to listening to them and understanding them, this situation is translated into a first step for the family to receive appropriate support and achieve this more humanized care 6 .
In this regard, it is necessary to establish a relationship of trust between the health team and the family, through respect and professional ethics, which means the possibility of making the hospital environment a place of less suffering for the mother-child unit 7 .
It is a relevant factor for these mothers to understand their children's situation, understanding the illness, the treatment, the procedures and tests necessary, and the child's clinical progression.For this, the mothers need to feel that the health professionals are available and willing to clarify their doubts whenever they want.
The absence of appropriate and coherent information is one of the aspects which worry the parents most, and creates great anxiety.Simple explanations, and the provision of information referent to the care for their child, through clarifying dialogs, are ways of minimizing the stress and worry that are felt 6 .
However, there has been little discussion of the communication process between health professionals and the mothers accompanying hospitalized children.When searches were carried out in the Scientific Electronic Library Online (Scielo), Medical Literature Analysis and Retrieval System Online (Medline) and Latin-American and Caribbean Health Sciences (Lilacs) databases, using as descriptors the words "communication", "hospitalized child" and "mother", some articles were found from the last five years describing the process of communication between the health team and the child -but only two which focussed on the family member accompanying the child, and these described the communication of bad news, revealing that research on this issue remains incipient.
Thus, with the aim of deepening discussion on the communication between the health team and the mothers accompanying their children, and providing support for improving care centered on the child and family in a more comprehensive and humanized way, this study was undertaken, with the objective of describing the process of communication in the provision of guidanceby health professionals to the accompanying mothers in relation to the illness and hospitalization of the child.This research's data is a source of support for health professionals working in pediatrics, facilitating their understanding in relation to the experience of the mothers accompanying the children, the importance of the therapeutic link between them, and the establishment of effective communication.
This therapeutic link is established for the patient/ family member when this person believes that the health team can contribute to his or her improvement; feeling that the health team is concerned and co-responsible for the care provided.For the health professionals, the base of this link must be constituted by their commitment to the health situation and illnesses of those who seek their services 8 .
On the other hand, therapeutic communication, which is an instrument used to inform, dialog, humanize the care and maintain the therapeutic link, reflects the health professional's ability to use her knowledge regarding communication to help other people experiencing temporary Figueiredo SV, Gomes ILV, Pennafort VPDS, Monteiro ARM, Figueiredo JV Therapeutic communication between health professionals and accompanying mothers tension, contributing to these overcoming their obstacles to self-realization and managing to face their problems 9 .

METHOD
This is a descriptive study with a qualitative approach.This approach is set in the field of subjectivity, with the universe of meanings, beliefs and values, among others.In research with a qualitative focus, one seeks to understand a specific phenomenon in the perspective of the subjects who experience it, or part of their daily life, feelings or wishes, as well as in the perspective of the researcher 10 .
The research was undertaken in August 2011, in a tertiary-level state public hospital which cares exclusively for children and adolescents and is a center of excellence in the city of Fortaleza and the entire state of Ceará in the area of General Pediatrics and Emergency, Clinical and Surgical Services.Out of this hospital's sectors, the authors chose a 25-bed inpatient unit which receives patients in the specialities of gastroenterology and nephrology.
The research subjects were 14 mothers accompanying their children, and the strategy used was theoretical saturation of data, that is, interviews were ceased when the information obtained began to present a certain repetition or redundancy 11 .The inclusion criteria were: to be a mother, irrespective of age or number of children; to be with a child who had been hospitalized in the above-mentioned sector for at least one week, this being considered the time necessary for therapeutic communication to occur between the health professional and the mother; and for this to be, at the most, the child's third hospitalization, the aim being to identify the first experiences of mothers facing the hospitalization of the child and entering the hospital environment as a an accompanying person, this being believed to be different to the experiences of accompanying mothers who had frequently spent time with a hospitalized child and who had a certain adaptation to the functioning of hospital routines.
The exclusion criteria used were: for the mother to present some mental disability which would prejudice her participation in an interview, for the child to have suffered recurrent hospitalizations (to be beyond the third hospitalization), or for the child to have been hospitalized for a period of less than one week.
As the data collection technique, the authors used a semi-structured interview with one item for the characterization of the subjects (age, education, marital status, where they are from, number of children and the birth order of the hospitalized child in relation to the others) and one item with three open questions: do you understand the information received in relation to the illness and hospitalization of your child?Do you feel well-informed?Which professionals have provided you with the information?All the interviews were recorded, and were transcribed by the authors alone.
The research was started following the approval of the project by the above-mentioned hospital's Research Ethics Committee, with a favorable decision under number 031/2011.The study followed the norms called for under Resolution 196/96 of the National Research Ethics Commission.The subjects were informed about the study, and signed the Terms of Free and Informed Consent, being aware that they could withdraw from the research at any point.
In line with the requirements of research ethics, the mothers' names were substituted with different ones and the names of the professionals mentioned in the accounts were substituted with letters, so as to maintain confidentiality.
The content obtained from the subjects' accounts was organized into individual files.For the analysis of the information, the stages called for in thematic content analysis were followed, these constituted by: pre-analysis, (skimming and then reading the empirical material thoroughly, seeking to survey the meanings attributed by the subjects to the interview's guiding questions); analysis of the feelings, both expressed and latent (identification of the nuclei of meaning, with aggregation of the related content, that is, the excerpts or phrases considered representative for theoretical or empirical categorization); final analysis of the information with elaboration of central themes, through the synthesis of the empirical categories, and later interpretation of the thematic categories which emerged 12 .These were discussed in accordance with the researchers' reflections, grounded in the literature relevant to the issue.
For better comprehension of the process of communication between the health team and the accompanying mothers, the following categories were selected: the mother's need to feel well-informed; health professionals who provided information on the child's illness; and, barriers found in the communication between the health professional and the accompanying mother.

The socio-demographic characteristics of the accompanying mothers
The mothers' mean age was 32.6 years old, the majority being over 28 years old.The extremes of age were 19 and 45 years old.In relation to education, none of the accompanying mothers were illiterate, and the majority had studied up to Junior High level (1 st to 9 th grades).
The majority of the mothers (13) were from the rural parts of the state of Ceará, the distances between their towns and Fortaleza (the state capital) varying, which made the family members' access to the hospital difficult.In relation to marital status, five mothers were married, three were single, one was a widow and five were in stable relationships.Regarding number of children, nine had more than one, and for the majority of these, the hospitalized child was the youngest (6).It was therefore perceived that in accompanying the child, the mothers had had to distance themselves from their partners and other children.

The mother's need to feel well-informed
For the accompanying mothers, it is essential to know and understand what is happening to their children, the treatment used, the prognosis of the illness, and the therapeutic results evidenced.Based on this understanding, the mothers feel more active and involved in the treatment of their children, in addition to becoming calmer, due to having the information which they believe to be important regarding the children's state of health.
It is emphasized that access to this information is a right of the family members, stipulated by the National Council for the Rights of the Child and Adolescent, under resolution nº 41 of 1995, which stated that parents or those responsible for the child have the right to participate "actively in her diagnosis, treatment and prognosis, receiving information on the procedures which she shall receive" 13 .
The accounts below show how the mothers researched wish to obtain greater knowledge regarding their children's hospitalization, from the tests and medications through to the type of treatment established.They aimed not to miss details of the progression of the state of health of their hospitalized children:

I'm always asking, I'm curious, I want to know everything, if she's got an infection I want to know how she got it, what it is, where it came from, what can be done [...]. (Esther) I ask if the medication is for fever, what it's for, if it's an antibiotic, what it's for [...] I ask everything. (Miriam)
A separate study corroborates these findings, as, through evaluating the report of the histories described through the thematic design, it was observed that the accompanying mothers genuinely feel the need to know the situation and their children's treatment better, through effectively accurate information, continuously presenting an attitude of self-questioning in relation to the situation of the child's illness and hospitalization 7 .
In this context, one can understand the importance of the health professionals being more attent to the type of information that they have provided, so as to provide these mothers with not only complex knowledge of the child's state or knowledge which they consider they should present; it is necessary to be open to any type of questioning by these mothers, giving relevancy to any type of information that these may wish to receive, as they cannot receive too much information to feel active in their children's care.
In analyzing the accounts, it was found that six mothers stated that they had efficient understanding regarding the information received, and the remainder -the majority -stated that they understood little or only sometimes.One can consider, therefore, in a general way, that the mothers are being informed, in spite of there being a need to improve the provision of this guidance.

I understand, if I don't understand very well, I ask him [the doctor] again to explain it to me better, then I understand better. (Miriam)
I understand some things okay, but there are others which are not so easy to understand.(Noemi) Often, the accompanying mother's fear and insecurity result from insufficient or inadequate guidance during the child's period of hospitalization.It therefore falls to the health professionals to be more active with her, offering her real knowledge in a clear way of the child's conditions 3 .
The health professionals in the unit studied have sought to offer this information in a clear and appropriate way, as they understand better the mother's need to understand the child's state, a fact which -as the studies show -favors the reduction of the anxiety created by so many worries.

I understand, I understand, they explain very well, they try to explain in the best possible way, so that we can understand. (Deborah)
One study on this issue concluded that the majority of the family members of the research received little information during the admission, as the reason for the hospitalization, the treatment and the child's state of health are little addressed; in addition to this, there is little space for the family members to present their concerns and ask questions 3 .In this perspective, one of the mothers affirmed:

They just put the medication there, sometimes they explain, sometimes I just listen, but I don't understand much. (Maria)
As observed, the communication between the health professionals and the accompanying parents in relation to information on the child's state still needs to be improved.One important point to be stressed to achieve this objective is to re-think the care for this child, so that the health professionals become aware of the need for a more attentive focus on the accompanying mother.

Health professionals who provided information on the child's illness
In the accounts, the majority of the mothers asserted that only the medical staff provided information on the illness and hospitalization of the child.However, it is emphasized that the nurses and auxiliary nurses were also mentioned by some accompanying mothers.

Therapeutic communication between health professionals and accompanying mothers
There are the auxiliaries too, who I can ask, they care too (Esther)

Just them, just the doctors. (Sarah) No, not the doctor [...] it's the nurse who explains best. (Ruth)
This fact was found in another study, in which those accompanying hospitalized children asserted that, among the health professionals, the majority of those who provided information (53.2%) were doctors, and only 29.9%, from the nursing team.This result also deserved attention from these academics, given that the nursing team carries out an important role in this relationship, due to spending a lot of time with those accompanying and the children, also being responsible for most of the care provided 14 .
It is supposed, however, that the nursing team in the unit studied, in spite of having scientific knowledge regarding the illnesses, might have been more concerned about providing information on hospital routines and the care for the child, addressing other aspects apart from the illness per se.
Some mothers showed that they were satisfied with the information received, emphasizing that some professionals sought to give simple explanations and used some instruments to facilitate communication, such as drawing.The use of methodologies which facilitate the comprehension of the information provided is of great relevance, principally when the person accompanying the child has a low level of education, or when the patients are children.

I manage to understand, because they [the doctors] draw on a piece of paper for me. (Lia) I can understand, they explain it even for a child [...]. (Anna)
In addition to the observation that most of the information is provided by the medical staff, two mothers also stated that they placed greater trust in data provided by these professionals.This corroborates another study, in which the questions on the child's illness were, on the majority of occasions, centered on the doctor, due to the family members believing that this was the only person who could provide them with explanations in the most appropriate and thorough way.

The person who explains most about his problem, who I like to talk with, is his surgeon. (Miriam)
It is known, however, that the nurse has a wide academic background, with a curricular matrix covering a variety of disciplines addressing the physiopathology of the human body, including the process of physical and mental illness, as well as care strategies for the patient in all her phases of life, from birth through to old age.
Society is often unaware of this professional's real work and scientific knowledge, however, believing the nurse's role to be inferior to the other professionals'.Furthermore, the concept remains dominant that the nurses are mere helpers of the doctors 15 , forming in the popular imagination the idea of a hospital hierarchy, in which the doctors possess the knowledge and are above the other professionals, who are mere subordinates, possessors of little knowledge.
The positive fact found in this research was that some professionals in this unit understood the accompanying mothers' need to receive information, and made efforts to ensure that they could have a better understanding.In spite of this, the relationship between the child, the family and the professionals still needs to be improved, as all need to have this understanding, the aim being fully humanized care.

Barriers found in the communication between the health professional and the accompanying mother
Quality communication between the health professionals and people accompanying patients, through the therapeutic link, is able to create greater peace of mind for the mothers, as they begin to trust these professionals and know that they can rely on them whenever they need.It was observed in the literature that when the communication between the nurse and the parents is efficient, it can reduce anxiety and increase their acceptance in the situation of the illness and hospitalization of the child 5 .
The communication process is related to the individuals' creative capacity, as well as reflective thinking.When the communication process is established with the other, there must be an awareness that the act of communicating neither starts nor ends with the end of the word, as this is only part of the communication.Along with verbal communication, there is also non-verbal communication, body language, from the expressions and emotions.Both express the subjects who compose them 16 .
Based on this comprehension, one can understand the need for health professionals to pay attention to the type of personal impression that they give in the informationoften influenced by these individuals' social and cultural aspects -which may not be received and understood appropriately by patients or those accompanying them.
In the analysis of the accounts, barriers were perceived to effective communication between the health Figueiredo SV, Gomes ILV, Pennafort VPDS, Monteiro ARM, Figueiredo JV Therapeutic communication between health professionals and accompanying mothers professionals and the accompanying mothers, which hampered the understanding of information and the forming of a link between them.
Among the barriers observed to an effective communication process, one that stood out was the low educational level of the accompanying mothers.Thus, it becomes relevant for the health professional, in providing information to the mothers, to use straightforward, easily-understood language, appropriate to their cognitive abilities, benefitting the mothers' understanding of the information transmitted.
Sometimes I ask, it's just that sometimes we ask, she explains, it's just that I can't understand, because if you only studied until primary school [...] it's kind of hard to understand.Even people who studied a lot sometimes find it difficult to understand something.(Noemi)   From this mother's viewpoint, because she did not finish Junior High, it is normal not to understand the information which she is given, and as a result she accepts this.However: the mothers have the right to understand what is happening with the children they are accompanying and to participate in their treatment.For this, it is important that each professional cares for the mother-child unit specifically and comprehensively, knowing each family's peculiarities and difficulties, so that the communication and relationship between them may ease the mother's worries.
One of the mothers mentioned how she felt when, in another inpatient unit in the same institution, she asked about the purpose of a specific medication, revealing how some professionals have reacted to the questions of those accompanying patients.
They don't explain what the medication is for, it's just that when I was on another ward I asked what the medication was, and she said that one was for vomiting and the other an antibiotic, and the way she said it implied I was stupid.(Eva) The effectiveness of the communication process is assured as much in the empathy which is consolidated among the subjects, as through respect for the other, her knowledge, and her condition as a participant in this process 16 .For the communication to take place ethically and effectively, therefore, the health professional must understand and take into account the level of understanding of the patients and those accompanying them.
The nursing team, like the other health professionals, must value the family's conventional wisdom, so as to viabilize the guidance given, as once they have started to include the family members in the care process, it becomes easier to identify their biopsychosocial needs, which, consequently, favors quality communication between them 17 .Another important barrier observed was related to the difficult language (technical terms) used by some professionals, which made it hard for the accompanying persons to understand.The mother wishes to understand her child's situation better -so explanations of complex procedures can often be dispensed with, as they are more likely to confuse than enlighten her.It follows that when giving guidance, one must think about the mother's level of education, avoiding the use of scientific language as much as possible.
I understand more or less, because there are things we understand, and things we don't.Sometimes, they [the doctors] speak in a language we don't understand easily.(Martha) You can't understand it very well.Because they understand, because they're doctors and they studied for this, and there are lots of things about the human body that sometimes even the doctors don't understand.Because of that, I understand a lot of things, but there are also a lot of things I don't understand.(Noemi)   The use of this type of language may be due to the fact that there is overvaluing of the improvement of cutting-edge technology, and of the culture that the more complicated something is, the more it evidences the extent of one's knowledge, which is also valid for verbal communication, in which the more difficult words and expressions are used, the more the speaker indicates the extent to which the other does not know what she does -thus losing the opportunity for dialog and the sharing of knowledges 16 .
Another important factor which can function as an obstacle in this communication is the difficulty in building links between the health professionals and the accompanying mothers, due to the high turnover and large number of health professionals in specific categories.
It's because I don't know them by name, because there are a lot of nurses, those in the day, those at night, there are lots.(Deborah)

[...] I don't even know [their names], because there are so many of them[health professionals]. (Anna)
One of the participants stated that often, the factor which impeded the understanding of the information provided was the fact that there was disagreement between the data provided by different health professionals -that is, there may not have existed interdisciplinarity in this unit, as each professional presented the mother with his or her own way of knowing and thinking, which was not shared by the other health professionals, there being between them no exchange of ideas and concepts with the aim of presenting agreement in relation to the information.

.] because one [health professional] says one thing, and the other sometimes goes and says something different, so we don't clear up our doubts. (Esther)
Interdisciplinarity goes beyond a juxtaposition of different angles on the objects of analysis, which is defined as multidisciplinarity, in which, fundamentally, there is no coordinated teamwork.In interdisciplinarity, the disciplines communicate with each other, confront each other and present their perspectives, establishing a stronger interaction with each other.The complexity of the interdisciplinarity is in relation to its construction itself, because it is full of more intense articulations between the various subjects 18 .
Being aware of these obstacles to therapeutic communication, and reflecting on which attitudes have been created to contribute to its efficiency, it is possible to re-think the care, seeking to reduce these barriers and achieve a care which comprehensively encompasses the mother and child, through the respect for each family's specific characteristics and needs; as a consequence, this accompanying mother's anxieties and concerns shall be mitigated, thus enabling her, along with her child, to cope better with the adversities of the child's hospitalization and illness.
In the hospital environment, the focus of the attention of the care is often directed only at the patient; however, one can understand that the health team cannot be indifferent to the accompanying family member, as this is a co-participant in the process of caring for the child.Thus, in the hospitalization of the child, the health professional must be sensitive to the mother's presence, because she often seeks to overcome the pain, the fears and the limitations of this experience, by becoming closer to and understanding the multiplicity of feelings interwoven into hospitalization, thus favoring the exchange of information.

FINAL CONSIDERATIONS
Hospitalization represents a stressful situation for the ill child and her family, and the offering of information to these in relation to the child's state of health, diagnosis, treatment and prognosis allows the reduction of the anxiety and fear related to the process of hospitalization and illness, thus minimizing the stress.
The study shows that the mothers have a need to be informed about the illness and the procedures related to the hospitalization of their children.Nevertheless, there are times when the information offered by the health professionals is not understood by the mothers, while some health professionals do not even bother to provide information, carrying out the procedures in a technical way with no communication at all.The use of technical and scientific language by the health team is highlighted, which distances the health professional from the person being cared for, thus increasing the stress related to the hospitalization.
On the other hand, it is emphasized that some professionals from the health team have offered information to the mothers in a simple way, using teaching resources, such as drawings, to facilitate understanding.In a general way, this study provides scientific support which contributes to the pursuit of quality and humanization of the care for the hospitalized child, which must cover the universe in which the child in question lives, involving family members, with an emphasis on the mother who is directly accompanying the child's stay in hospital.This being the case, it is evidenced that the mother and child need attention and support from the health team which, following this understanding, must provide the mother-child unit with appropriate guidance and emotional support.
It is stressed that this study has some limitations, as it covers only the experience of the accompanying mothers in relation to the communication process -there being, therefore, a need for further studies which also include the universe of the health professionals, thus deepening discussion on the issue -of which there has been littleand providing a better grounding for the care given to the mother-child unit.