STRENGTHENING THE LINK BETWEEN THE FAMILY AND THE PREMATURE NEWBORN

Objective: to identify the Nursing interventions performed in a Neonatal Intensive Care Unit, which promote the strengthening of the bond between the family and the premature newborn. Method: this is a qualitative, descriptive study carried out in a maternity hospital, with the participation of nine nurses. The data was obtained through semi-structured interviews; the analysis was by transcription in full and organized into categories using the Content Analysis technique in the Thematic Analysis modality. Results: it was observed that the interventions that were most used to strengthen the bond between premature newborns and the families are: free entry of the parents in the Neonatal Intensive Care Unit; diaper changes; diet management; use of music and books to calm babies; and also the kangaroo method. Conclusion: it is concluded that the Nursing team that assists the high risk newborn tries to be attentive to the dimension of this phenomenon, seeking to develop the interventions of bond strengthening, in the best possible way, considering that the benefits are mutual for all those involved. Descriptors: Enfermagem; Unidades de Terapia Intensiva Neonatal; Recém-nascido Prematuro; Família; Humanização da Assistência; Método Canguru. RESUMO Objetivo: identificar quais são as intervenções de Enfermagem realizadas em uma Unidade de Terapia Intensiva Neonatal que promovem o fortalecimento do vínculo entre a família e o recém-nascido prematuro. Método: trata-se de estudo qualitativo, descritivo, realizado em uma maternidade pública, com a participação de nove enfermeiros. Obtiveram-se os dados por meio de entrevista ́s semiestruturadas, a análise foi pela transcrição na íntegra e organizando em categorias empregando-se a técnica de Análise de Conteúdo na modalidade Análise Temática. Resultados: observou-se que as intervenções mais utilizadas para o fortalecimento do vínculo dos recém-nascidos prematuros e a família são: a entrada livre dos pais na Unidade de Terapia Intensiva Neonatal; trocas de fraldas; administração de dieta; uso de músicas e livros para acalmar os bebês; além do método canguru. Conclusão: conclui-se que a equipe de Enfermagem que assiste o neonato de alto risco procura estar atenta para a dimensão desse fenômeno, procurando desenvolver as intervenções de fortalecimento de vínculo, da melhor forma possível, tendo em vista que os benefícios são mútuos para todos os envolvidos. Descritores: Enfermagem; Unidades de Terapia Intensiva Neonatal; RecémNascido Prematuro; Família; Humanização da Assistência; Método Canguru. RESUMEN Objetivo: identificar cuáles son las intervenciones de Enfermería realizadas en una Unidad de Terapia Intensiva Neonatal que promueven el fortalecimiento del vínculo entre la familia y el recién nacido prematuro. Método: se trata de un estudio cualitativo, descriptivo, realizado en una maternidad pública, con la participación de nueve enfermeros. Se obtuvieron los datos por medio de entrevistas semiestructuradas, el análisis fue por la transcripción en su totalidad y organizando en categorías empleando la técnica de Análisis de Contenido en la modalidad Análisis Temático. Resultados: se observó que las intervenciones más utilizadas para el fortalecimiento del vínculo de los recién nacidos prematuros y la familia son: la entrada libre de los padres en la Unidad de Terapia Intensiva Neonatal; cambio de pañales; administración de la dieta; el uso de canciones y libros para calmar a los bebés; además del método canguro. Conclusión: se concluye que el equipo de Enfermería que asiste al neonato de alto riesgo busca estar atenta para la dimensión de ese fenómeno, buscando desarrollar las intervenciones de fortalecimiento del vínculo, de la mejor forma posible, teniendo en cuenta que los beneficios son mutuos para todos los involucrados. Descriptores: Enfermagem; Unidades de Terapia Intensiva Neonatal; Recém-nascido Prematuro; Família; Humanização da Assistência; Método Canguru. Specialist, Santo Agostinho University Center/UNIFSA. Teresina (PI), Brazil. Email: silvelene15@hotmail.com ORCID iD: https://orcid.org/0000-0002-0403-2507; Nurses, Santo Agostinho University Center/UNIFSA. Teresina (PI). Brazil. Email: yvanamsm.26@hotmail.com ORCID iD: https://orcid.org/0000-0003-3541-875X; Email: kaio.castelobranco@live.com ORCID iD: https://orcid.org/0000-0001-7150-6373; Email: alinneibiapina22@hotmail.com ORCID iD: https://orcid.org/0000-0002-4090-2426; Master (PhD student), Santo Agostinho University Center/UNIFSA. Teresina (PI), Brazil. Email: karine_nogueira@hotmail.com ORCID iD: https://orcid.org/0000-0002-4682-3577 ORIGINAL ARTICLE Sousa SC de, Medino YMS, Benevides KGCB et al. Strengthening the link between...

English/Portuguese J Nurs UFPE online., Recife, 13(2):298-306, Feb., 2019  299 According to the World Health Organization (WHO), in the world, the birth of 15 million premature babies is pre-term, which makes prematurity a public health problem.In Brazil, there are 279 thousand preterm births per year, for every one hundred births of live children; there is a rate of 9.2%. 1 Prematurity is attributed to children whose birth occurs at gestational age of less than 37 weeks and weighing less than 2,500 grams.In relation to weight, the new born is typified in low birth weight (<2500g), very low birth weight (<1500g), and extremely low birth weight (<1000g).
It is known that as a result of the newborn's hospitalization in the neonatal unit, the early separation of the mother-child binomial occurs and the difficulty of approaching the other relatives with the new family member occurs.It should be noted, therefore, that both the mother and the family are partially or totally deprived of seeing, touching, speaking and caring for their baby during this period, whereas these actions are fundamental for the development or strengthening of affective bonds. It is extremely important to mention the need for recognition by the Nursing team of the promotion of humanized care. • To identify which are the Nursing interventions performed in a Neonatal Intensive Care Unit that promote the strengthening of the bond between the family and the premature newborn.This is a qualitative, descriptive study carried out in a reference maternity hospital in Teresina-PI, the Dona Evangelina Rosa Maternity.
This study was initially submitted to the approval of the Research and Ethics Committee of the Santo Agostinho College, and later, it was registered in the Brazilian Platform of the National System of Research and Ethics (SISNEP).The collection of data was initiated only after obtaining opinion nº 1,725,994 and the opinion of the Dona Evangelina Rosa Maternity is, respecting all the ethical and legal aspects of Resolution 466/2012.
The data was collected in October 2016, and the participants of the research, after the signing of the Informed Consent Term, answered a semi-structured interview that consisted of open-ended questions.
The research was composed of nine nurses, who agreed to participate and signed the Free and Informed Consent Term (FICT).The following inclusion criteria were selected: nurses who work in the NICU of the maternity hospital and who are registered in the Regional Nursing Council (COREN).Nurses who did not agree to participate in the study were excluded.
The analysis of data was done by means of the transcription of the interviews in full and the contents of the interviews were organized by categorizing them and employing the thematic analysis, according to Bardin,5 seeking to establish articulations between the information collected through the interviews and the theoretical framework adopted in this study, with a view to achieving the objectives proposed in the research.
The minimum risk for the study participants was considered in this study; however, it was identified that the work overload and time available were listed as a risk for the research, and it was used as a measure to postpone the interview, according to the participant's availability, so as not to interfere with their work process, however, their privacy was preserved, participation was voluntary, and there was no cost.
It should be emphasized that there was no direct benefit, the participant did not receive any financial advantage, however, there are indirect benefits, since they contributed to the scientific environment as a source of research for future scientific productions, besides contributing to the development of new interventions that promote the bond
The sample was composed of nine nurses, all female, with ages ranging from 23 to 53 years of age; 22.22% have been working for a year, 22.22% four years, 22.22% seven years, 11.11% eight years, 11.11% ten years and 11.11% %, and it was also observed that most have a reasonable amount of experience in neonatal care.
It should be pointed out that five nurses work in a shift regime, one day and one night shift, with rest periods, as well as four nurses working on a day basis, which consists of the morning or afternoon employment bond, as established in service shifts.
The denomination of precious stones was chosen to represent and guarantee the anonymity of the participants, since it is understood that, like precious stones, each nurse has its own characteristic, its own components and meanings, being valuable for its exclusivity and rarity.The information collected during the interview period of the participants was organized and categorized, from the reading and re-reading of these, in order to highlight the thematic nuclei represented in the words or phrases referring to the objective of the study.

Research participants
This data was grouped according to the similarity of meaning, thus forming categories of analysis, as will be presented below.

Interventions carried out by the Nursing team to promote the bond
The importance of parental/family participation in the care of premature newborns was emphasized by all nurses interviewed, and the main intervention to promote bonding by them is the issue of free access to parents within the NICU, with the intention of bringing them closer to their child.
[...] the entrance is open to parents, this mother participates in the care given to the newborn by the team and this mother is the protagonist of care within the unit.(Pearl) [...]  It was mentioned, according to the reports obtained, Order Num.930, dated May 10, 2012, which establishes the organization of comprehensive and humanized care for the seriously or potentially serious newborn and criteria for classifying and enabling beds in the neonatal unit in the scope of the Unified Health System. [...] according to this ordinance, the mother and father have free entry into the unit, as long as they feel they need to be inside; at that time they are there, we pass on some care that is important to the newborn, they help with diet management, diaper change, so it is already a preparation for when the newborn stays with them on a daily basis.(Pearl)   Although they recognize the importance of parents' insertion in the neonatal unit, they are also disadvantaged, as the presence of parents changes the environment.The excess of people within the NICU correlates with an increase in the occurrence of infections, a fact that can negatively affect the hospitalized newborns, leading to a worsening of their condition.

[...] you imagine, if everyone stays at the same time in the ICU, this is detrimental to the baby's development because of the noise, and also increases the risk of crosscontamination [...]. (Diamond)
The relationship between the premature newborn and the parents, especially the

RESULTS
English/Portuguese J Nurs UFPE online., Recife, 13(2):298-306, Feb., 2019 301 mother, is highlighted by all interviewees.This interaction occurs through tactile and auditory stimuli, so this frequent contact and the relationship between mother and child are important for the establishment of the affective bond.The kangaroo method is used as a way of promoting and strengthening the bond.The method is performed on all infants who have general conditions for this.
[...] we use kangaroo here; in the kangaroo position, the baby, who is stable, even the baby with tube and with artificial respiration, put him in the kangaroo position because we know and the whole literature points out the benefits of the earliest kangaroo position possible, so it is one of the interventions we provide to them.(Diamond) [...] the kangaroo, which is already done here inside the NICU, we put not only the babies that are without O2, but sometimes even baby intubated, we already put to do the kangaroo method, which is the moment of strengthening bond and of approaching parents [...] In all the interviews, a description of the benefits that these bonding interventions promoted in this process was reported, since all those involved are benefited, especially the newborn, who presents significant improvements in their status, such as: stability hemodynamics, biopsychosocial development, physical growth, weight and length gain.
[...] promote biopsychosocial development, in addition to improving the lung, circulation, temperature regulation, also promotes bond formation, affect, decrease O2 saturation drop; when we think of benefits, we think not only of benefits to the baby but also of benefits for the father and the mother because, in general, they are very anxious, and as we bring them to NICU, we reduce that anxiety [...].(Diamond)   The primary relationship between mother and baby for their psychic, affective and social construction becomes important. The benefits are the development of affective bonds between the mother and the newborn and the promotion of exclusive breastfeeding [...]  Attachment is of the utmost importance for the child's survival and development, since this initial bond between the parents and the newborn is the source of all subsequent connections of the child and the character of this attachment will influence the quality of all ties with other individuals.

Factors that interfere in the strengthening of the affective bond
The limitations faced by the health team in the practice of humanization in the NICU were analyzed by promoting the integration of parents in the care of their children, by the interview reports.
[...] many parents are emotionally shaken; they do not accept the gravity of their children's situation.There are parents who reject their children, they do not want to touch, they make quick visits, and they do not accept milk, that situation of abandonment.(Ruby)   It can lead to the manifestation of sadness, doubts, stress, fragility and insecurity about the life of the baby and the integrality of the child, due to the separation generated by the hospitalization of the child in the NICU.Guilt and a sense of responsibility for the child's condition, as well as hope and resignation, are generated.By the shock of the hospitalization of a child, the fragile bond created can be harmed. 13t was noticed that some professionals express the desire of the parents' participation in the newborn's care, but mention that, this is not always possible due to the lack of time and to the excess of activities that often hinders and interferes in this process.

[...]often because of their parents
The barriers are in the social issue of the mother, [...] they do not live here in Teresina, they have difficulty staying in the maternity, because she cites that she has other children and that they need to be taking care of these other children; the other question is with regard to the vacancies that exist here in the maternity hospital, because we have only two spaces that welcomes these mothers, which is the welcoming space and the donor mother, but the beds are insufficient [..

.]. (Pearl)
Although there is an effort by the institutions to guarantee accommodation for the mothers' stay, parents also have this need and seek alternatives, such as staying in the house of relatives or in a pension near the hospital. 14 was also pointed out by nurses that it is difficult to maintain a dialogue with parents, since some are introspective and it is difficult to maintain a calm dialogue.Significantly, because of this attitude on the part of the parents, the relation between them and the team, because some interventions to promote the bond are not used due to lack of parental collaboration.

[...] when these parents are many introspective, closed, sometimes we feel certain difficulty to approach; another thing that we always try to be very careful about is the question of religiosity because it weighs a lot, the culture; we have had Indians, it was interesting, sometimes this makes it a bit difficult, we respect and we try to make an impartial assistance so that we do not go head-on with the cultural issue. (Turquoise)
Obstacles to communication between nurses and mothers in the Neonatal Intensive Care Unit are often caused by work overload and lack of time. 13

Nurses' relationship with the family
It is observed that most of the participants interviewed emphasized that it maintains a good relationship with the families of preterm infants in the NICU, as can be seen in the following statements.It is noticed that the Nursing team is the link between the family and the newborn, because, through interaction with the members of the health team and the care provided to the child, the parents begin to see themselves in the process hospitalization, valuing the care and dedication of the professionals and, thus, building a partnership relationship. 11,14,16 is noted in the following testimonies that the interaction of the team with the family contributes to decrease the family's longings regarding the hospitalization of their children.

In my relationship with the family, I try to do my best, welcoming this family and taking some doubts, because they come full of doubts and fears [...]. (Turquoise) [...]I try to talk to the mothers, to pass on some information, sometimes just to stay on the side, because they feel very afraid and longing to touch the baby, being very premature [...]. (Amethyst)
Information about the child's condition, care and discharge is sought by the parents, and the Nursing team must act as the main means of connecting the family and emphasize the importance of their insertion in the participation of the care their child. 11e relationship is friendly, when they arrive, I explain the situation, they want to know if they are going to leave soon or not and we say that it depends on their picture [...].(Sapphire)

[...]I also make them very comfortable, any and all procedures that I will do with the baby I do not ask to leave; in the case of blood collection, which is a more invasive thing, they even prefer to leave. (Turquoise)
They are pointed out by the parents as positive points of the Nursing team, attitudes and activities such as education and respect in care; and as negative points, if the professional does not respond to expectations, English/Portuguese J Nurs UFPE online., Recife, 13(2):298-306, Feb., 2019  303  showing lack of attention or neglect.[19] [...] we try to pass on to the parents something they want to know, not to mention that we do not explain anything to them, that they know nothing.(Sapphire) It was allowed, by the data analysis, to capture the aspects where they were approached that the relationship with the family was not always easy to establish and that a more technical relationship with them had to be made, as can be seen below.

Sometimes it is a bit difficult because infants, when they arrive here, usually do not have family support directly, they are in the most critical phase, but little by little they are seeking information and becoming more present within the unit [...]. (Emerald) This relationship with the family has to be very technical, always tell the truth of what is occurring and provide the accurate information to them [...]. (Jade)
The interaction and communication of the team with the parents is done by welcoming, a fundamental role, so that the emotional experiences that occur during this period are more elaborated and the suffering of the parents is minimized.It is noticed, according to the reports below, that the team has this concern and performs it in conversation wheels, which are promoted in a meeting room of the NICU.

Conversation circles with parents providing psychological
support with institution psychologists, trained staff to listen and always strengthen bond with mother and child, parents and children.(Ruby)   [...]we have a meeting in which some situations are discussed, the mothers report their dissatisfactions, their insecurities with the supervision team, and in these meetings numerous occurrences and situations are debated, that favor resolving the conflicts without the mother being directly harmed with the team as, also, the team getting tired of family members [..

.]. (Emerald)
It is advisable to create and cultivate favorable conditions of relationships of the parents with the professionals, establishing a bond and points of support, since they need to know who to address when they need information.Parents should be encouraged and assisted by health care professionals in adapting during the hospitalization of their child in the unit, encouraging them. 14..] we realize that some feel that they do not have this right, they are afraid to ask, they are afraid to speak, they are afraid of asking questions, I think they still have to break those barriers because it is their right [..

.]. (Amethyst)
It should be recognized by the professional that the family of the hospitalized newborn also needs care and is part of a process under construction that involves creating alternatives to meet the biological and psychosocial needs of the premature newborn. 14..] we have to put ourselves in their shoes, if they were our own, when we are on the other side, I have never had a baby in the ICU, but I have been with my mother, we are totally vulnerable, imagine a totally helpless being.(Amethyst) Religiousness stands out as one of the most used forms by the population to express their reactions.It is noted, before moments of illness or loss of the loved one, that there is an appeal to the religion on the part of the relatives.Emphasis is given to the importance of respecting religiosity and culture within the NICU by a nurse.

Nurses' feelings about promoting bonds
It is noted that the great majority of the interviewees described how they feel fulfilled, satisfied, favored and gratified to be able to contribute to this strengthening of the affective bond of the premature newborn with the family.
It is developed by the nurse, in dealing with the fragility and the sensitivity, taught and apprehended with the premature baby, singular/plural abilities, that differentiate its assistance, instigating change of conducts and offering new looks on the process of living/surviving in Neonatology. 8It is observed in the following testimony that the participant emphasizes that she developed a method of not suffering from hospitalization and, in many cases, the deaths of these babies, on the other hand, she discusses how much she likes working with these patients.The fact that the nursing team still does not feel prepared to deal with death in relation to the support offered to the family, it has been seen that many do not know what to say, feel somehow coerced into being in contact with the family at that time.The acknowledgment by the families as something that reinforces the work developed to promote the affective bond is being effective, since it is known that this direct contact with the mother brings numerous benefits, thus contributing to a better recovery of these babies.The different actions of the parents while accompanying the children during the hospitalization in the NICU were identified.Such actions are related to demonstrations of affection and faith, to daily care such as offering a diet, bath, diaper change, skin-toskin contact and vigilance regarding the evolution of the child and the care performed by the multiprofessional team. 14e mother gradually acquaints herself with the good support of the NICU environment, as she gradually becomes closer to the child until she can be intimately with him in the kangaroo position.[21] The Humanized Care Standard for Low-Birth Newborns -Kangaroo Method was launched in December 1999, publishing it through Ministerial Order Num.693, dated July 5, 2000.][22] In this sense, by promoting the bond, a greater involvement of the whole family of the newborn, increasing their self-esteem, confidence, effectiveness and integrality of the care, prolonging periods of skin-to-skin contact and developing breastfeeding skills during the hospitalization and in the postdischarge period is entailed. It should be noted that the main factors found to be impeding the strengthening of the affective bond were work overload, lack of time, socioeconomic difficulties of the family, the emotional character of the family and abandonment of the newborn; However, despite all these difficulties, the nurses' relationship with the family is very satisfactory in most cases, and is considered by many to be a good relationship.
The nurses' relationship with the family should be respected since the hospitalization of the premature infant in the NICU is a crisis situation for the whole family, especially for the mother, and in this sense, the team should stimulate the encounter between parents and babies, since these parents need to feel supported to make the approach with the child, when they are prepared.It is believed that, when such a promotion of bonding takes place, nurses also develop an emotional bond with the family and the newborn, being considered the feeling of gratification which is most reported by all interviewees.
Nurses demonstrated a sense of accomplishment in working in the NICU and carried out interventions that favor the approach of the newborn with the family, and they addressed that the recognition of the family, when the treatment is successful and the overcoming of the crisis which occurred during the hospitalization of newborns, is what keeps them motivated to continue developing these interventions.
On the other hand, it was seen that most nurses still find it difficult to deal with the deaths of these babies, which can be understood by the fact that death is such a difficult time, especially when it comes to such helpless beings.
It is noteworthy that, based on the study carried out, it is well known that the nurses' team, which assists the newborn child at high risk in the NICU, seeks to be attentive to the dimension of this phenomenon, seeking to develop the interventions to strengthen the bond in the best possible way.Parents are encouraged and guided to participate in diapering, singing, storytelling, talking and touching their child, and they participate in observation during procedures and when the child is able to, the kangaroo method is performed.
However, interventions to strengthen the bond with total dedication, love and respect must be carried out, since these families are

CONCLUSION DISCUSSION
English/Portuguese J Nurs UFPE online., Recife, 13(2):298-306, Feb., 2019 305 in a delicate situation, which is to see their expected child in an environment full of equipment, and the nurse must be empathic with families, working efficiently and effectively to provide decent and quality care.
It is reinforced that, increasingly, nurses should promote and establish methods and interventions that foster a strengthening of the affective bonds between the premature newborn and their family within the NICU, since this measure only has mutual benefits for all involved.

I
try to approach families with receptivity, clarify doubts, bring the parents closer to their child, and clarify the gravity of the newborn [...].(Ruby) My relationship with the family is calm; I try to give as much information as possible to leave them with less anxiety and more informed about the situation of the baby [...].(Crystal)

[
...]I get very emotional, so I developed techniques not to suffer so much, but overall, it's very beneficial, you know; although they do not smile so much, [...] it's very sweet to work with children, I love it, and it's very satisfying.(Diamond)

I
feel, therefore, satisfied, when the mother leaves here satisfied smiling, because she saw the son, she was able to hold her child [...].(Sapphire) [...] when the family recognizes, it is rewarding for people [...].(Jade)