PEDIATRIC ENVIRONMENT: ASPECTS HELPING THE WORK PROCESS AND HEALTH PRODUCTION AMBIENTE DE PEDIATRIA: ASPECTOS QUE AUXILIAM NO PROCESSO DE TRABALHO E NA PRODUÇÃO DE SAÚDE AMBIENTE DE PEDIATRÍA: ASPECTOS QUE AUXILIAN EN EL PROCESO DE TRABAJO Y EN LA PRODUCCIÓN DE SALUD

Objective: to identify aspects of the pediatric environment helping the work process and health production. Method: this is a qualitative, exploratory and descriptive study, carried out in the pediatric units of two University Hospitals. The participants were professionals and managers of nursing, totaling 44 participants. Data collection was performed through semi-structured interviews, organized and handled by Nvivo 10 software. Results: data analysis revealed the following categories: << Organization of the unit >>, << Nursing team >>, << Profile of the nursing professional who works in pediatrics >>, << Relation between nursing and the family of the hospitalized child and Toy Library >>. Conclusion: it is imperative to look beyond the structural aspects, valuing the relationships established in the unit, be it between the nursing team or the nursing team with the child and his family for the pediatric environment to assist the work process and health production. Descriptors: Health Facility Environment; Humanization of Assistance; Pediatrics; Hospitalized Child; Nursing. RESUMO Objetivo: identificar aspectos do ambiente de pediatria que auxiliam no processo de trabalho e na produção de saúde. Método: estudo qualitativo, exploratório e descritivo, realizado nas unidades de pediatria de dois Hospitais Universitários. Participaram usuários, profissionais e gestores de enfermagem, totalizando 44 participantes. A coleta de dados ocorreu por meio de entrevistas semiestruturadas, organizadas e tratadas pelo software Nvivo 10. Resultados: a análise dos dados revelou as seguintes categorias: << Organização da unidade >>; << Equipe de enfermagem >>; << Perfil do profissional de enfermagem que atua na pediatria >>; << Relação entre enfermagem e o familiar da criança hospitalizada e Brinquedoteca >>. Conclusão: para que o ambiente de pediatria auxilie no processo de trabalho e na produção de saúde, faz-se imperativo atentar para além dos aspectos estruturais, valorizando as relações estabelecidas na unidade, seja da equipe de enfermagem entre si ou da equipe de enfermagem com a criança e sua família. Descritores: Ambiente de Instituições de Saúde; Humanização da Assistência; Pediatria; Criança Hospitalizada; Enfermagem. RESUMEN Objetivo: identificar aspectos del ambiente de pediatría que auxilian en el proceso de trabajo y en la producción de salud. Método: estudio cualitativo, exploratorio y descriptivo, realizado en las unidades de pediatría de dos Hospitales Universitarios. Participaron usuarios, profesionales y gestores de enfermería, totalizando 44 participantes. La recolección de datos fue por medio de entrevistas semi-estructuradas, organizadas y tratadas por el software Nvivo 10. Resultados: el análisis de los datos reveló las siguientes categorías: << Organización de la unidad >>, << Equipo de enfermería >>, << Perfil del profesional de enfermería que actúa en la pediatría >>, << Relación entre enfermería y el familiar del niño hospitalizado y Sala de Juegos >>. Conclusión: para que el ambiente de pediatría auxilie en el proceso de trabajo y en la producción de salud, se hace imperativo atentar para además de los aspectos estructurales, valorizando las relaciones establecidas en la unidad, sea del equipo de enfermería entre sí o del equipo de enfermería con el niño y su familia. Descriptores: Ambiente de Instituciones de Salud; Humanización de la Atención; Pediatría; Niño Hospitalizado; Enfermería. Nurse, Ph.D. Professor in Nursing, Nursing School, Federal University of Pelotas (RS), Brazil. E-mail: ju_ribeiro1985@hotmail.com; Nurse, Ph.D. Professor in Philosophy, Post-Graduate Program in Nursing, Nursing School, Federal University of Rio Grande (RS), Brazil. E-mail: giovanacalcagno@furg.br; Nurse, Ph.D. Professor (Post-Graduate in Nursing), Post-Graduate in Nursing, Nursing School of the Federal University of Pelotas (RS), Brazil. E-mail: mairabusst@gmail.com; Nurse, Ph.D. Professor in Nursing, Post-Graduate in Nursing, Nursing School, Federal University of Pelotas (RS), Brazil. E-mail: adrizerutzporto@hotmail.com; Nursing Student, Nursing School of the Federal University of Pelotas(RS), Brazil. E-mail: luiza-vargas@hotmail.com ORIGINAL ARTICLE Ribeiro JP, Gomes GC, Thofehrn MB et al. Pediatric environment: aspects helping the...

The outcome of the health and disease process as well as the overall well-being of children is closely related to the elements of the pediatric environment.As stimulating elements of the environment, researchers point out the possibility of the child having an escort; the encouragement of parents to take an active role in child care; receiving visitors; the dynamization of play spaces (for example, toy library); installation of computer networks; or the suitability of decoration to the pediatric public. 1study with the objective of knowing the strategies used by the family to take care of the child in the hospital revealed that in this environment care becomes limited, often to a bed and a chair.To better care, the family seeks to organize the care environment by occupying the ward space with their things to provide greater comfort for the child. 2 In this sense, it is imperative to observe elements that act as modifiers and qualifiers of the environment, enhancing the construction of comfortable pediatrics, which contribute significantly to health production.
It should be emphasized that pediatrics planning, specifically physical space, must comply with the norms established by the National Sanitary Surveillance Agency and the Brazilian Association of Technical Norms.These bodies establish the structure of an infirmary in the number of beds, size of rooms, distance between beds, insulation, and other specifications about the room or ward, such as washbasin, sink, flooring, ceiling, bathrooms, lighting, medical gases, outlets, doors and windows, furniture, corridors, signage and accessibility. 3wever, it is understood that efforts to build a child-friendly hospital environment find barriers from conception, since health spaces often reflect the decisions of an architect and the small number of managers about the ideal setting.Without complying with the norms standardized by the competent agencies and in the daily routine of the pediatric unit, it is probable to find inadequacies in the environment that hinder the child, family and nursing and health professionals to use and appropriate it.
In the construction of pediatric units, architecture cannot be thought of in isolation since its characteristics have direct implications in the routine of the workers and managers, but they can also influence the children's ability to use strategies to cope with hospitalization.In this sense, this study aimed to identify aspects of the pediatric environment that help in the work process and in health production.
• To identify aspects of the pediatric environment that assist in the work process and health production.This is a qualitative, descriptive and exploratory study carried out at the Pediatric Unit of two University Hospitals of southern Brazil.Twenty users, 20 nursing professionals (with representatives of the different work shifts: morning, afternoon, the night I, night II and night III) and 4 managers; totaling 44 participants participated in the study.
Participant selection followed the inclusion criteria and study objectives.The inclusion criteria for the professionals were to be a nurse, technician or assistant nurse, working in the pediatric unit for at least six months, and in the case of the managers, to be working in nursing and management services in health/hospital institutions.For the users, the criteria were: to be at least 18 years old, to be involved in the care of the hospitalized child and to be a family member of the child.Nursing professionals and managers on vacation or health leave were excluded from the study during the period of data collection.
Data collection took place in the second half of 2014, through semi-structured interviews recorded in audio.The data were organized and treated using the software Nvivo 10, which assists in the analysis of qualitative material, with tools for coding and storing texts in specific categories. 4solution 466 of December

 Characterization of participants
The users are exclusively women, varying between 19 and 48 years old, predominantly between 19 and 29 years old (n12; 60%).Of them, 19 are hospitalized child´s mothers and
Ten have a level of education corresponding to incomplete elementary education, four complete secondary education, three incomplete secondary education, two with a university degree and one with a first degree.Twelve have work activities and eight are engaged in domestic activities.
Nursing workers are predominantly female, with 18 women and two men, ranging from 35 to 55 years old, with a most age range between 45 and 55 years old (n=11; 55%).Of them, ten are nurses, five are technicians and five are nursing assistants; whose time in the pediatric unit ranged from six months to 23 years, with an average of seven years of performance.The managers are exclusively female, between 40 and 55 years old and academic nursing education.The time spent in management ranged from one to 20 years.

 Aspects of the environment of pediatrics that help in the process of work and in the production of health
Data analysis revealed the aspects that help the work process and health production from the following categories: organization of the unit, nursing team, the profile of the nursing professional working in the pediatrics, the relationship between nursing and the family of the hospitalized child and toy library.

 Organization of the unit
The participants point out that it is imperative to make the work process and health production effective for the organization of the unit, so the material and human resources are available to meet the needs of the work.The structure and space of the unit allow the workers to circulate with ease, helping in the identification of the places of storage of materials and speeding up the exercise of the labor activities.Also, the existence of an inpatient panel and its reports facilitate the identification of children and provides greater dynamicity to care.

I think you have to have everything organized, materials, scales, everything right, no lack of material, arrive and have everything in hand (E8_HA).
I think the center is well organized, well structured, well labeled, well neat (U10_HA).

All the devices are here. I think it's adequate and comfortable because I've never seen the nursing station too full (U4_HB).
The environment is extremely important because we know that if you have a harmonized environment, the workflows better (G2_ HA).
The organization allows the workers of the different work shifts to maintain a systematized and fluent care, respecting the characteristics and the idealization of the care in the pediatrics unit.
Certainly, the organization is important for the effectiveness of the work.Here we have four different shifts and if you do not have an organization, an ideal service, procedure, how it's done, how and where it's done, it turns into a babel tower, nobody knows where the material is, where it goes, we have to have an organization (E6_HA).

 Nursing team
The nursing team is identified as fundamental in achieving improvements in physical structure and materials.Therefore, when well integrated, they increase the possibilities to develop and increase strategies to improve the care offered to the child and the family.
For me, the basis is the team, because the team leaves the physical structure, the material structure, then the human resource, team, is very important in nursing.Thinking only about nursing, today we have a very well-trained team within pediatrics, which leverages a thousand strategies to improve the care of the child and the family (G2_HA).
Consequently, the difficulties that may occur, such as lack of structure and materials, are minimized in comparison to the attributes of the team: union and integration, which allow workers to envision humanized assistance.
Lacking resources is often inhuman for the nursing staff.But the greatest resource for humanization is still the team.Yeah, it's the team (E9_HB).
In a matter of enclosure, of material, it could be better, then, it is all question of teaming the same team (E7_HA).
This union that we have, an example, an urgency that we need material that does not have I go out to ask for a run, the other leaves and if the patient is mine, I am not alone, we are never alone with the patient, we are always protected (E4_HB).
The professionals themselves, one helps the other.It's a team (U1_HA).

 Profile of the nursing professional who works in pediatrics
To take part in pediatrics, the participants emphasize the professional profile, since it is a differentiated unit, they must pay attention to the specificities of the attended patients: the child and the family.Besides the technical knowledge, enjoy the profession, sensitivity and emotional involvement are required.
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5275-81, Dec., 2017 5278 The Among other characteristics, the profile described as desirable for professionals working in pediatrics involves calm, education, commitment, concern for the other, affection, affection and empathy (ability to put oneself in the other's place).These characteristics are pointed out as facilitators to the development of the work process, by adding fluidity to it.

I have the impression that each type of service requires a profile. Here in pediatrics, almost everyone has the same profile, they are calm, educated, committed people and this only contributes (E3_HB).
There, everyone is a mother, a grandmother and everyone puts themselves in the place of the family, and this most human side that we have.This causes the work to flow better (E4_HA).

People have a pediatric profile that is very important, affectionate and kind (E1_HB).
If a nurse arrives with four stones in her hands, she will not let him touch her.He gets scared (U2_HB).
You need to make a medication and arrive without pleasing that child she refuses to do, does not accept.Or, you come with a needle to do something.There, it has to be a way to treat that child so that you can do it there.The person has to pass a positive thing for that child, so she is quiet, for you to do the medication (U4_HA).

 Relation between nursing and the hospitalized child's relative
The relationship established with the relative of the hospitalized child reflects in the nursing work process.Therefore, the care should turn its attention to it, encompassing it in the actions of care and valuing its participation.In this way, the family member feels calm and relies on the care offered by the professionals.

You always have to put yourself in their shoes. I think the interaction is this, you do your professional job, but you always respect the family and the patient that they do not beat against you, your work will have a good result (E6_HA).
The first thing you have to have is the part of nursing, welcome well, to have a very quiet environment, even more, that it is with a child.I think the care by the nursing, they welcome you, you feel good in the environment you are.You are already here for a complicated situation, so you have to feel good in the environment, they welcome you well, host you well, I think this is important (U8_HB).

 Toy library
The toy library and the activities carried out by volunteers not only entertain children with fun but also assist nursing workers in carrying out procedures, providing a higher quality of care.
The room [playroom] is good for the child to play, he has a little fun, so she improves faster [...] she has more quality to take care of her right (U10_HB).

[...] there is a boy and a girl who come in the rooms, they entertain the children, for example, if the nurse is here wanting to make a medication and the child is crying they help (U 4_H A).
It is a moment of relaxation for mother and child, you go there to take medication and the child already receives you in another English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5275-81, Dec., 2017 5279 way, he does not receive with that distance, he receives you less armed (E8_HB).

Where the child feels threatened you do not work well. So, pediatrics has to be as stressful as possible for the children and for us. It has to be differentiated, it has to have a recreation room, it has to have games [...] (E4_HA).
The interviewees emphasize the need for the pediatric environment to be structured and architected to facilitate the development of care, with space, equipment, and materials adequate to the work process and health production for the child.Also, the way they are arranged and organized in the unit can favor their access and use by the professionals of the different work shifts, giving greater dynamicity and fluidity to nursing care.
Accordingly, the literature on the strategies that health institutions have implemented to humanize care indicates that it is important to have material resources (including architecture) and human resources to better assist hospitalized children. 6On the other hand, lack of such resources implies difficulties in the promotion and implementation of systematized care and, consequently, affects the quality of pediatric care. 7European study aimed at determining how good care organization can affect patient care found that the quality of the nursing work environment is significantly associated with patient satisfaction, quality and safety of care offered. 8The results of this study indicate that when organized, the pediatrics environment is considered to be pleasant, both for professionals and for users, since it preserves the functionality of the unit and the development of the work process, without any eventualities surprising the team and, consequently, shake the child and his family.
Besides the organization of the unit, it is necessary to organize the nursing teamwork, so the exercise of care, even in the face of a great demand, does not overwhelm the worker, because one helps the other.Regarding this, research carried out with nursing workers indicated that they perceive team interaction as favorable and convenient for the accomplishment of the work, for adding aspects such as cooperation and unity to the development of care. 9 The nursing team is explicit as an aspect that facilitates the work process, helping to overcome difficulties that may happen.The work with other nursing workers develops care actions with care and the necessary attention to health production in the child.
It was found that enjoying working in pediatrics and caring for children helps in the development of the nursing work process, since it unifies, produces cohesion and identification among the professionals of the unit, including giving strength to relationships to overcome adversities that emerge in daily work.For this, it is necessary to know how to combine the skills with the motivations, because it is not enough to have aptitude for the profession if it does not feel motivated to develop it. 10search with the objective of understanding the meanings attributed by the nursing team of a pediatric hospitalization unit to their daily life evidenced that doing what they like makes the day to day of the professionals rewarding, providing pleasure and satisfaction.It allows a coloring in the daily life that, even when faced with limitations, it is renewed with the experience of coming and going for a better do. 11 In the literature, the characteristics that make up the desired profile for nursing professionals are directly associated with their historical, religious, submission and silence trajectory.Besides the idea of religiosity, there is a mediatic dissemination of the nurse being as a profession of fragile and delicate character, associated to subservience, which does not correspond to the professional reality of Nursing.Therefore, there is a need for social recognition of Nursing and nurses, in particular, as a professional who has his own training has a specific field of action and scientific knowledge that underlies his action. 12nsidering that pediatrics is a differentiated unit, attending people with specifics, it is desirable for the subjects interviewed that the nursing professional has a profile to act in pediatrics, encompassing characteristics such as calm, education, commitment, caring for others, affection, kindness, and empathy (ability to put in the other's shoes).This does not mean limiting humanized care to the expression of sweet smiles, but rather to a broader context, such as direct attention to the patient and the family member in the sense of dialogue, clarification of doubts, acceptance, accomplishment of procedures with theoretical and practical knowledge, develop bureaucratic and administrative actions, relationships among the team, to qualify the assistance and achieve customer satisfaction. 13

DISCUSSION
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5275-81, Dec., 2017 5280 Family involvement has proven to be a valuable resource for calming the children and facilitating the development of caregiving actions, including invasive procedures.Thus, the care should turn its attention to them, involving it in the actions of care and valuing its participation, because when professionals trust their potential for care they obtain help in the handling and interaction with the child, bringing more fluidity to the child. 13erefore, in daily life in pediatrics, care is built through the interdependence that is established in the relationship between the health team, the child, and the family.This is fundamental to stimulate the family participation in the process of hospitalization because the child finds the strength and security necessary to face the fear, the pain and the other feelings generated by the disease. 14 a similar way, the toy library and the actions carried out by volunteers turned out not only as entertainment for children but also as an auxiliary resource that transforms the environment, making them feel threatened, facilitating the performance of procedures, reducing the distancing and stress so frequent in this relationship.Researchers point out that the toy is a valuable tool to meet these findings because the child when playing can better face the various situations in the hospital, often stressful and threatening, such as treatment, hospitalizations, routines, waiting times for care, among others.Playing/toy still allows exploring these situations with a certain distance as well as work difficult emotions experienced there. 15en exploring the environment of the pediatrics unit, it was identified that the nursing team is identified as fundamental in the implementation of strategies to improve the care offered to the child and his family.Therefore, it is necessary that the professional meets a specific profile, which adds, besides the technical knowledge, enjoying the profession, sensitivity and emotional involvement.Thus, it becomes possible to attend to the needs of the people served, as well as, to confer fluidity to the nursing work process.Also, the relationship established with the family of the hospitalized child, as well as the toy library and the actions carried out by volunteers provide tranquility and facilitate the accomplishment of procedures.These aspects, together with the organization of the pediatric unit, besides giving dynamicity to care promotes the trust of the family to the care offered by the nursing team to the child.
The results show that it is imperative to look beyond the structural aspects, valuing the relations established in the unit, be it of the nursing team among themselves, as well as the team of with the child and the family for the pediatrics environment helps in the process of work and in the production of health.