Introduction

Approximately 15 million preterm infants are born annually in the world, which constitutes an incidence rate of one to every 10 births.^1-2 Premature birth is the second leading cause of child mortality and is considered a public health problem worldwide.^1-2

The Neonatal Care Unit (NCU) is a critical sector which admits newborns who are in constant need of specialized and careful assistance. Usually, the birth of a preterm infant is an atypical and unpredictable experience. The support, relationship, comprehension and interventions planned by the multidisciplinary NCU team are essential during the hospitalization trajectory and care of the preterm infant and their family. As a result, a favorable environment is created and allows fathers to perform their roles as protagonists of this care.^1,3-4

In Brazil, the presence of the family in the hospitalization process of a child is a right secured by the Brazilian Child and Adolescent Statute (CAS). These laws state that the family’s participation in the care must be supported, encouraged, facilitated and taught by the nursing team, regardless of the patient’s clinical complexity.³ In this context, the family’s active participation in their child’s assistance has many purposes, such as to assure the emotional bond between parent and child, in which the paternal presence is as important as the maternal.^1,5-6

The Brazilian Ministry of Health (MH) ensures the paternal inclusion in the healthcare scenario through the design, insertion and execution of strategies, programs and public policies, such as the prenatal partner;⁷ the enforcement of the law nº 11.108 of 2005,⁸ which guarantees the presence of one companion (of free choice) during the woman’s early labor, labor and immediate postpartum process; and the free access of parents at the NCU through Kangaroo Care (KC).¹

Those accomplishments were related to the improvement of Public Health Policies due to the cultural transformation of paternal care. Before, labor and birth were both considered an exclusively feminine event in which the paternal participation was solely as a provider for the family, but in the last years this concept of paternity has been changed. Women’s insertion in the labour market also influenced this process, once it allowed men and women to share domestic chores and childcare.⁹ Even before birth, the father assumes his new role in society, including transformations and responsibilities that will consolidate the father-child bond. ^4,10 When childbirth is anticipated, the man may not be prepared to come closer, take care and attend the new family’s demands and dynamic.^4,9-10

It is relevant to research, study and to reflect on this thematic because it is fundamental that the nursing team becomes able to recognize the predictors of an affective relationship between father and infant – which can positively impact the newborn’s immediate and adult health. Fathers face better the premature hospitalization of their infant when they are included earlier in the assistance process, whereas the mothers feel more confident and less stressed.^11-13

Therefore, according to the KC Policy¹ and the ordinances nº 930¹⁴ and nº 3,389¹⁵ that regulate the participation of parents and the importance of humanized and integral newborn care, the following research question is raised: what are the father’s perceptions related to his participation and inclusion in the care of his preterm infant staying at a Neonatal Unit? Thus, the aim of this study was to describe the paternal perceptions about their inclusion and participation in the care of their preterm infant staying at a Neonatal Care Unit.

Methods

This was a descriptive study with qualitative approach performed at a Public Maternity that is a reference hospital in KC since 2013, in the North of Santa Catarina (SC), Brazil.

Eleven fathers of preterm infants who were hospitalized at the Neonatal Care Unit (NCU) participated in this study between June and August 2017. This NCU has 10 hospital beds for Neonatal Intensive Care (NICU), 14 hospital beds for Intermediate Care (IMCU), and three hospital beds for Kangaroo Care (KCU). The following inclusion criteria were used: be a father of a newborn preterm infant; be present at the NCU at the time of data collection; and be over 18 years of age. The Public Maternity where this study was conducted is a reference hospital; therefore, many fathers could not visit their children frequently because they worked and lived in distant cities. Thus, the researchers partnered with the healthcare team to identify fathers who could visit more often and provide care for their newborns. Exclusion criteria were: father of infants with syndromes, congenital disorders and other genetic diseases.

The researchers performed a semi-structured interview based on a script with discursive and multiple choice questions, which collected socioeconomic information from participants, as well as their perceptions of how it felt to become the father of a preterm infant; how was the admission process of the newborn at the NCU; and how was the inclusion of the father in the care of his preterm infant. A pilot test was conducted with three fathers at a NCU in another hospital to assure data quality. There was no need to modify the data collection instrument; however, those fathers were not included in the present study.

The interviews were performed in a room at the NCU to guarantee a private environment with minimal external interferences; in addition, all interviews lasted for an average of 30 minutes and had their audio recorded and fully transcribed. The approach to the fathers was done in random turns, without previous schedule, by convenience and according to day and night shifts. Data collection was concluded when theoretical saturation was achieved.¹⁶ The data were interpreted through thematic analysis according to the following steps: pre-analysis, exploration of the material, and treatment-interpretation.¹⁷

The ethical principles that guided this research were assured by the Resolution 466/2016. This study was approved by the Research Ethics Committee (REC) of the Instituto Superior e Centro Educacional Luterano de Santa Catarina – Bom Jesus (IELUSC) under the protocol number 2.071.706.

Results and Discussion

Eleven fathers aged between 19 and 36 years were interviewed. There was a prevalence of: finished high school education (four); married marital status (eight); residents of Joinville-SC (eight); protestant religion (seven); and fathers that experienced for the first time the birth of their first newborns (seven). The fathers’ occupation had a wide variety of areas, such as industry, services, civil construction, business or entrepreneurship, with a monthly household income of one to five minimum salaries. The birthweight of the newborns ranged between 590g and 1985g and the gestational age varied from 25 to 35 weeks.

After data collection, audio transcription and data analysis, four thematic categories were described: to be a father of a preterm newborn and its impact on the family dynamic; the first paternal touch; becoming a father: the participation and inclusion of the father in the care of his hospitalized infant; and the healthcare team actions to build a paternal leading role.

To be a father of a preterm newborn and its impact on the family dynamic

In this study, the participants referred no knowledge of the risk for a premature labor and preterm birth of their infants. Although, some fathers informed that they knew their wives had comorbidities that could lead to an anticipated labor and birth.

The anticipated birth of his infant and the newborn’s admission at the NCU are experienced by the father in a traumatic way. This is evidenced by reports of fathers describing no intention of having another child and feelings of unpreparedness, insecurity, fright and fear.

[…] it was a tremendous scare, it all happened so fast […]. (F4)

[…] I don’t want another child. I intended to have another, but now I don’t want any more children […]. (F3)

[…] we didn’t imagine this, we were completely unprepared. To speak the truth, we didn’t even know that this could happen. We’ve heard stories, but we didn’t know how any of this worked. We had nothing prepared; it was something that just caught us […] (F10)

The hospitalization of a newborn is a moment of change and of multiple experiences for the fathers. The unawareness of the hospital environment and care routines, the strangeness of the sounds and noises at the NCU, and the fear of loss and death of their newborns can precipitate insecurity and stress in the family.^3-4

The planning and expectation of having a baby is suddenly modified by the birth of a preterm infant and hospitalization of the newborn at the NCU. The limited time for psychological adaptation can lead to a trauma due to the vulnerable clinical picture or health status of the newborn, which changes the idealization of a healthy baby to the challenging feelings of the hospitalization period.³

The work routine of these fathers was a major aggravating factor for their continuous or lasting presence at the NCU. In despite of the fathers’ 24 hour free access to the hospital, the majority of father-infant contact happened at night time because of the participants’ working hours.

His birth was really turbulent. I wanted to be more present with my wife in this phase, with our baby, but it’s too complicated because my working hours makes it a little difficult. So, I can only come at night, and then it all falls on her. (F2)

The paternity leave in Brazil is only 5 days long, but there are extensions for state and federal public servants according to specific legislations.¹⁸ This work absence is considered too short when compared to all the benefits of father-child moments to the healthy development and growth of an infant. ¹²

Faith, religion and spirituality are resources to give support and design strategies for some fathers to deal with this situation. The trust in the assistance provided by the healthcare team and the emotional support given by these professionals are also strategies to ease coping during the hospitalization process.

[…] we have to trust the nurses and the doctors because even the nurse said that “here we do our part, but God rules it all”. We pray here and move on […]. (F9)

[…] It was just a miracle and we see that he can grow, become bigger and be an adult even if he was born that size […]. (F10).

The fathers were surprised by an initial shock due to the premature birth of a preterm infant and by the impotence feelings of having a hospitalized newborn at the NCU. However, they recognized that such moment/situation was a learning opportunity and described feeling optimistic in regards to the hospital discharge.

[…] it was scary, but at the same time it’s something that we ended up learning with the situation […]. (F10)

I don’t know, this is frustrating, but today I talked to the doctor and she said that they’ll start giving milk to the baby. This cheered me and my wife a lot. Soon we’ll be home. (F7)

The hospitalization of a newborn at the NCU impacts the whole family dynamic. Such situations demand a network support that aids the permanence of fathers in the hospital. The presence of a partner during the whole hospitalization process reinforces the relationships inside the new family and must be encouraged by the healthcare team.¹⁹

The first paternal touch

The fathers’ first visit is an opportunity for the nursing professional to promote interactions between the family, the newborn, the healthcare team and the environment. This reduces possible barriers that are frequently encountered by people who are unaware of the NCU environment. During the infant hospitalization at the NCU it is observed that the father wishes to become closer of the care process and to assume his role as a protagonist. Usually, this approximation with the child happens through the first touch. The fathers of this study showed the desire of touching their children, but the fear of hurting or harming the newborn intimidated and hindered their approximation.

[…] The nurse went there and explained to me “no, dad, you have to touch him, he needs to feel you, you can use the gel to clean your hands”. She encouraged me to touch him. (F3)

[…] We asked if we could touch him because we didn’t know, but she said “you can put your hand”, then we went there, slowly. (F4)

In some cases, there is limited encouragement by the healthcare team to promote the father’s first touch. There is no planning, no special care teaching, and no intervention that favors an adequate moment to include the father in the approximation and care of his newborn.

They [nurse technicians] said that we couldn’t, but then she [the wife] touched her and I thought: “if she can, then I can too”. This was on the second day, she grabbed my hand […] It was a very nice feeling. (F10)

I touched him after 4 days. It was the nurse that asked me to wait until I could touch him because his skin was still gelatinous. (F11).

In this context, we can highlight that the touch is an important tool to build a bond between the newborn and the father; therefore, the healthcare team plays a fundamental role to empower the father for this task.⁴

The touch had different meanings for the fathers because through it they could fulfill paternal feelings, perceptions and functions. The fathers who experienced fatherhood for the first time described that their inexperience increased the insecurity to assume a paternal role. However, they highlighted that such feelings were diminished as they learned and experienced the care for their newborns.

I didn’t touch him because I was scared of hurting him because we have a strength that is different when you need to touch a baby. It took me 3 days […]. (F6)

I touched him last Sunday [1 month after] father’s day. I am afraid of touching him because he’s too sensible. My wife touches him, but it scares me because he’s too small and I am clumsy. I just touched it a little on his hand because there was no one watching. I rubbed alcohol in my hand and took it away quickly. (F9)

[…] It was a beautiful emotion, a feeling of happiness that took me over. We have never had this kind of contact. (F6)

After the father’s welcoming at the NCU it is possible to achieve his approximation of devices and equipment used in intensive care. Additionally, the father can also be introduced to the sector’s routines, his rights and duties, and meet the multidisciplinary team that will act as a facilitator link to promote the care and bonding between the father and his newborn. As a result, the team can identify and characterize the family’s needs in order to stimulate a nurturing and affective interaction.^1,3-4

It is reasonable to encourage and orient the fathers to touch their newborns as a strategy to build an affective bond, to promote the recovery and development of the baby. In addition, this gesture reduces the feelings of impotence and insecurity sensed by the father because of the hospitalization and distance of his newborn child.^1,3-4

Finally, the touch performed by the father can contribute to the comfort and clinical evolution of the newborn, and still be a source of paternal empowerment.⁴

Becoming a father: the participation and inclusion of the father in the care of his hospitalized infant

This study observed that fathers showed insecurity regarding the fragility of their newborns. They preferred that all assistance to the newborn were given by the healthcare team because they either were unwilling or felt unable to perform it.

Some participants reported lack of competence to execute the care needed by their newborns and referred that the nursing staff were both knowledgeable and skillful to give assistance in their place. Others even demonstrated fear to hinder the work of the healthcare staff or to transmit some disease to their babies.

[…] Now, at this moment, I am very scared to do something wrong and, instead of helping, cause some harm; so, I rather avoid it, let it for someone who knows how to do it because I feel insecure. He’s too small and I’ll have plenty of time to hold him. (F1)

To tell you the truth, I didn’t want to touch him because I was afraid of the risk of infections […]. (F3)

I saw her [the nurse technician] put the milk there. If it was needed, in the last case, I would do it, but if there is someone to do it I’d rather not to do it […]. (F9)

The distinction between genders in the care of the newborn was shown in the speech of one participant that said “man seemed to not be born to do this”. The idea that only the mother is responsible to provide care for the newborn needs to be demystified to promote the inclusion of the father during the pregnancy and his active participation in the neonatal period. Additionally, the father’s participation in the pediatric period must be considered in order to develop the formation of an affective bond in the family’s interactions. Fathers perceive their role as less important in the care of their newborns and think of the mother as the exclusive source of care to the baby.

[…] I know that my wife is the one that needs to learn […]. (F6)

[…] I don’t know; man seemed to not be born to do this. There are some that do something over there, that help the women to pump milk. I watch that and, I don’t know, it seems weird. (F9)

The bond between father and infant can be associated to the personal experiences that the father had in his childhood, according to his culture and principles.^4,5,20 The intrafamilial dynamic and relationship will contribute to extreme situations, such as the hospitalization of a newborn at the NCU.^4,11,21During the hospitalization phase the father will become the mediator between mother and newborn and at the same time will respond to his child’s demands, learn how to grow up and how to become a father.¹²

The society’s views regarding the fathers’ participation in the care and development of their child varies from one culture to another. Sometimes, this participation is not well accepted and the care will be centered in the mother as the only source of assistance for the child.⁴ We reinforce that every way of paternal participation and inclusion in the assistance process is essential, such as the touch, the talk, the presence, the orientation, the encouragement, and the physical care.

According to the MH, the skin-to-skin contact favors the affective bond, the thermic stability, the support for breastfeeding, the development of the newborn, and more.¹ The KC method was also cited by two fathers as something positive that promoted contact, approximation and care between father and newborn. However, only two participants reported ever performing KC, which can be associated to the prematurity and clinical conditions of the newborns, the limitations of the healthcare team regarding the explanation and the broadness of the method, or the fears and uncertainties that were widely described by the fathers.

I give milk, change diapers, perform kangaroo, I do everything that needs to be done with him […]. (F5)

I gave milk and performed kangaroo, but it took a while for me to do it because of his prematurity […]. (F11).

The KC can impact an ambiguity of feelings in the fathers, such as the fear of holding their newborns and the emotional strength that comes from this contact.¹³ Success of KC depends on the support offered by the healthcare team; the orientation given by the multidisciplinary staff is also a determinant to build family security in this type of care.²² In despite of the importance of KC, which was established in Brazil nearly two decades ago, there are still peculiarities that restricts the implementation of this method.²²

Studies that evaluated the paternal participation in the maternal and infant health are growing fast in the academic field. Although, it is important to reinforce that in order to assume his paternal role the man needs to amplify his self-confidence, empowerment, maturity, family bond, responsibilities and demystify the culture that places only the mother as the protagonist of the newborn care. The construction of the “father being” needs to be largely redesigned to go beyond the biological determinants, so it can essentially include cultural changes and institutional practices.^5,10,20

Even though the focus of this study was to investigate the inclusion of the father in the newborn’s care, we reinforce that the nursing team must center its efforts on the family and should aim to involve all its significant members to improve the newborn’s health during his/her hospitalization.

The healthcare team actions to build a paternal leading role

It is essential that the multidisciplinary team knows and identifies the influencing factors in the construction of the affective bond between father and infant. We observed that proactive fathers or the ones that were given help and interventions from the healthcare team were able to perform the assistance needed for their newborns and saw the team as an ally during the hospitalization. However, the fathers who were insecure, unprepared or excluded by the healthcare team reported difficulties in the welcoming, in the comprehension of information, and in the moments of care with their infants. It is important to have protocols at the health institutions to promote inclusion of the father in the care of his newborn, so there is no divergence in the decision making process between the family and the healthcare staff.

I’d like to take care of him, but they didn’t give me an opportunity. I don’t know, I think that he’s with all that little devices, yet; the little bath light, the venous access and the little catheter. They must think that I am unprepared and that’s why they don’t offer me to do a diaper change or something like that, you know? […] (F3)

Yes, they give us a lot of freedom, mostly for me. “Dad, do you want to hold her?”, they didn’t even have to ask, just let me hold her. (F6)

There is that one [the nurse technician] that comes to talk, to ask stuff. She explains to you, she has a will to explain things, we are curious, we have no notion. She encourages me: “look, dad, you have to wake her up so she can stay active and breastfeed well”. And there is that one that comes early and says: “don’t touch her! Don’t take her cover because she can’t catch light!”. We feel powerless; we don’t know what to do. (F2)

The fathers demonstrated interest in their insertion in the care and interaction with their newborns. Initiatives and incentives given by the nursing team either facilitate or complicate the applicability of the assistance model preconized by the MH. Additionally, the nursing team actions can also ease or impair the implementation of KC in regards to the inclusion and encouragement of paternal participation. Although, in some cases there were limitations in the relationship between the father and the team, which made difficult to establish a bond with the newborn; but there were also positive aspects highlighted by the participants during the interviews. It is extremely important that the healthcare team welcomes the fathers in a way that allows them to receive information about their infants and also the opportunity to get closer to their newborns.^1,3-4

It was very good; they said what needed to be said, but in a way that did not scared us, but they talked about everything, all the risks. (F7)

We can’t complain because since we arrived the assistance was good, there was nothing to complain about. Here in the Neonatal, they come, they introduce themselves, the doctor comes… They explain everything, everything is good. (F9)

The NCU’s multidisciplinary team sympathy, knowledge, actions, interventions and promotion of an adequate environment are fundamental to provide the fathers a feeling of being welcomed and safe. As a result, the fathers can feel like a “family” in that environment, as odd as it seems.⁴ The programs of the MH are designed to provide assistance to the newborn and their family, although the biological model is still a reality in some NCU, which is centered in the disease and in the execution of technical procedures. As a consequence, there is a deficiency in the construction of an affective bond, in the inclusion of the father and in the special care teaching during the newborn’s hospitalization.^1,11 We need to rethink the assistance model used in the NCU, so the newborns and their families can become the center of care. Thus, the healthcare team’s aims should be the welcoming, the promotion of an affective bond, the active listening, the inclusion, the participation, the teaching of special care, the provision of information and clarification of doubts.

Final considerations

The study of the paternal perceptions about their inclusion and participation in the care of their hospitalized preterm infants at the NCU showed that the clinical condition of the newborns can influence the affective bond between father and infant. This research demonstrated that the paternal performance can be positive if the father finds support in the nursing team to assume his role, to become closer to his child, and even to be included in the care of his newborn in a more participative way.

The healthcare professionals need to welcome, teach special care, promote inclusion, favor the approximation between father and infant, pay attention and intervene when needed so the paternal role can be exercised at the hospital environment. Such actions will contribute to the improvement of the newborn’s health and bring immediate and future benefits for both the baby and the father.

Free access of the parents to the NCU allows for familiarization with the hospitalization process. It is necessary that the nursing professional develops a careful attention that permits the insertion of the father in the care of his newborn. The family centered care must be integral, individualized and practiced since the academic education years of the healthcare professionals.

The limitations of this study included the need to also investigate the perceptions of the healthcare professionals at the NCU about the importance of the paternal participation in the care of the preterm infant. If this gap is answered, it may be possible to design strategies to promote an inclusive paternal participation.

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Corresponding author

Eilane Carvalho

E-mail:eilanecarvalho.nane@gmail.com

Address: Rua Uirapuru 149, Aventureiro, Joinville - SC/ Brazil

Zip Code:89225-680

Author contributions

1 – Carvalho E

Conception; research project design; data collection, analysis and interpretation; writing.

2 –Mafra PPOC

Conception; research project design; data collection, analysis and interpretation; writing.

3 –Schultz LF

Conception; research project design; data collection, analysis and interpretation; writing; and critical review.

4 –Schumacher B

Research project design and critical review.

5 –Aires LCP

Conception; research project design; data collection, analysis and interpretation; writing; and critical review.

How to cite this article

Carvalho E, Mafra PPOC, Schultz LF, Schumacher B, Aires LCP. Inclusion and participation in the care of the preterm infant at neonatal unit: paternal perceptions. Rev. Enferm. UFSM. 2019 [Access in: Year Month Day];vol e31: P1-P19. DOI:https://doi.org/10.5902/2179769231121