Repercussions imposed by the pandemic on the care for children with mental disorders in a pediatric unit

Repercusiones impuestas por la pandemia en el cuidado de niños con trastornos mentales en una unidad de pediatría

ABSTRACT

Objective:

To understand the perceptions of nurses about the repercussions on the care for children with mental disorders in a pediatric inpatient unit amidst the COVID-19 pandemic.

Method:

Qualitative research conducted with 13 nurses in a general pediatrics unit in a large hospital in southern Brazil. Data were collected through semi-structured interviews and analyzed according to the Thematic Analysis.

Results:

Respondents perceived repercussions on hospital routines due to the pandemic, such as restriction of recreation activities; enforcement of social distancing; limitation of family visits; mandatory use of personal protective equipment and difficulty in counter-referral of care.

Final considerations:

The results characterized the moment experienced in the unit, providing the institution’s managers with tools for the construction and implementation of new practices, making it possible to meet the demands of mental health care for children with mental disorders within the premises of psychosocial care.

Keywords:
COVID-19; Child; Nursing; Mental disorders; Hospital care

RESUMEN

Objetivo:

Entender las percepciones de los enfermeros sobre las repercusiones del cuidado de niños con trastornos mentales en una unidad de hospitalización pediátrica en medio de la pandemia de COVID-19.

Método:

Investigación cualitativa realizada con 13 enfermeros de la unidad de pediatría general en un mayor hospital del sur de Brasil. Los datos fueron recolectados a través de entrevistas semiestructuradas y analizados según el Análisis Temático.

Resultados:

Los encuestados percibieron repercusiones en las rutinas hospitalarias debido a la pandemia, como restricción de actividades recreativas; cumplimiento del distanciamiento social; limitación de visitas familiares; uso obligatorio de equipo de protección personal y dificultad en la contrarreferencia de atención.

Consideraciones finales:

Los resultados caracterizaron el momento vivido en la unidad, proporcionando a los gestores de la institución herramientas para la construcción e implementación de nuevas prácticas, posibilitando atender las demandas de atención a la salud mental de los niños con trastornos mentales dentro de las premisas de la atención psicosocial.

Palabras clave:
COVID-19; Niño; Enfermería; Trastornos mentales; Atención hospitalaria

RESUMO

Objetivo:

Compreender as percepções dos enfermeiros sobre as repercussões no cuidado à criança com transtorno mental em uma unidade de internação pediátrica, em meio à pandemia da COVID-19.

Método:

Pesquisa qualitativa realizada com 13 enfermeiros em uma unidade de pediatria geral em um hospital de grande porte no Sul do Brasil. Os dados foram coletados por meio de entrevistas semiestruturadas e analisados conforme a Análise Temática.

Resultados:

Os entrevistados perceberam repercussões nas rotinas hospitalares devido à pandemia, como restrição das atividades de recreação; imposição de distanciamento social; limitação de visitas familiares; uso obrigatório de equipamentos de proteção individual; e dificuldade contrarreferência do cuidado.

Considerações finais:

Os resultados caracterizaram o momento vivenciado na unidade, podendo proporcionar aos gestores da instituição ferramentas para a construção e implementação de novas práticas, possibilitando o atendimento das demandas dos cuidados em saúde mental à criança com transtornos mentais dentro das premissas da atenção psicossocial.

Palavras-chave:
COVID-19; Criança; Enfermagem; Transtornos mentais; Assistência hospitalar

INTRODUCTION

The constitution of a specific mental health policy for children in Brazil was established only in the 21^st century. Before that, actions related to childhood mental health were delegated to the sectors of education and social assistance, with almost no participation of health care workers1.

Over the years, there has been an increase in the prevalence of mental disorders in the population, especially children, given the specificities of this stage of life. Approximately, the prevalence of issues related to mental health in children and adolescents can vary between 10 and 31%2. In developed countries, this mean ranges from 7.6% to 27.2%3.

In this scenario, there are community-based services specialized in the care for child and adolescent mental health problems, however, children may need temporary hospitalization in psychiatric beds to treat acute symptoms. Therefore, hospitalization in mental health, inserted in general hospitals, is considered an indispensable therapeutic resource for the care of these patients with several types of mental disorders, especially in times of aggravation of symptoms4.

Thus, the nurse, being the worker who most of the time accompanies the hospitalized child, must offer care that goes beyond the clinical perspective, above all, guided by biopsychosocial practices, based on embracement, humanizing care and promoting autonomy of children in the hospital setting5.

These aspects are fundamental, as they provide reflections on the commitment of recognizing the other as a singular subject, through the resignification of mental health care. In addition, it is extremely important that hospital institutions, as well as professionals, be able to meet the health needs of hospitalized children, in view of their particularities and specificities, including during the COVID-19 pandemic5.

During the pandemic, many community resources were temporarily suspended, increasing psychiatric symptoms and disorders in child mental health, leading to worsening and/or decompensation of cases. This fact can awaken uncertainties and insecurities in the health care team, especially in nursing team, in the care for children in psychological distress6.

It should be noted that we are not talking about any children, but those who have characteristics of a childhood crossed by the more general identification of a problem related to mental health or the more specific detection of a mental disorder, behaviors and needs for embracement, monitoring, and care in mental health.

In this direction and regardless of the pandemic context, setting rigid and static characteristics and criteria for this population is not so clear, due to this period present constant development/changes, that is, a phenomenon considered normal at three years old is no longer expected at eight years old. Similarly, behaviors considered inconvenient at ten years old are not a problem for a four-year-old child.

Therefore, characterizing suffering/psychological problem in children occurs by what is experienced by them, by their guardians and close people as something that limits their life, their creative and adaptive capacities. It requires a meticulous evaluation, in addition to the manifest symptoms, but its functioning, its relationships with the environment, place in the family, life history and experienced contexts2^,5.

Such perspective promotes reflections and questions regarding nursing care, given the pandemic context, which introduced new care routines and, possibly, had repercussions on the care provided. The study comes from the observation of one of the authors in the pediatric inpatient unit, during the pandemic period, in which it was possible to reflect that the health care offered to hospitalized children in psychiatric beds has undergone changes. On this journey, it was noticed that many nurses, children, and family members needed to adapt to the new requirements due to the health context.

Thus, the motivation for conducting a study that could characterize this unique moment and identify the main changes that have occurred arose. From this, the present research aimed to answer the following guiding question: “What is the perception of nurses about the care for children with mental disorders in a pediatric inpatient unit amidst the COVID-19 pandemic?”.

In addition to the theme being relevant in the academic context, conducting this study is relevant as a knowledge gap was observed due to the lack of materials that addressed the topic of nursing care for children with mental disorders in beds intended for psychiatry in the pediatric inpatient unit, from the perspective of nurses, in a single study. In this context only studies that addressed the repercussions of the pandemic on the mental health of children2^,6^,7^,8^,9^-11, nursing care in child psychiatric units1^,3^-5, and the impact of nursing care for hospitalized children in pediatrics were found12^,13^,14.

Thus, the objective is to understand the perceptions of nurses about the repercussions on the care for children with mental disorders in a pediatric inpatient unit, amidst the COVID-19 pandemic.

METHOD

This is a qualitative, exploratory and descriptive study15, conducted according the Consolidated Criteria for Reporting Qualitative Research (COREQ)16.

The research was conducted in a pediatric inpatient unit of a general hospital in southern Brazil. At the time of data collection, the unit had 34 beds, in which children were hospitalized with the several pathologies, providing clinical, pre-, and post-surgical care, and psychiatry, with two beds aimed to children with mental disorders.

Children aged between five and 14 years old were admitted to mental health beds. The average length of hospital stay was 31 to 49 days, which could vary according to need. The main causes of hospitalization were usually depressive symptoms, agitation/hyperactivity, suicide attempts, aggressiveness, followed by eating disorders17.

The selection of participants was intentional, upon prior invitation to all 13 nurses who worked in the mentioned unit and who were distributed in work shifts: morning, afternoon, evening, and weekends.

Inclusion criteria were established as follows: nurses who were working in childcare at the study inpatient unit and who had an effective contract of at least six months of work, considering their familiarity with care. Exclusion criteria included: nurses on vacation, maternity leave, or sick leave during the research. After applying the selection criteria, all 13 nurses were included.

For the collection of information, at first, the research project was presented to the head of the inpatient unit, remotely. After acknowledgment and permission from the management, a first contact was made with the professionals, via collective e-mail, with an invite to participate in the study. Once the nurses’ interest in participating was confirmed, by filling an individual form with the invitation letter, the Free and Informed Consent Form (FICF) was previously made available, and a day was scheduled for the interview, remotely, following the safety protocols of the hospital institution.

A pilot test was conducted before officially starting the research, with the application of the proposed guiding questions, to review and improve the necessary points, to reach the proposed objective. Subsequently, semi-structured interviews were performed by a nurse-researcher with experience in qualitative research, through the Google Meet virtual platform. The researcher had not had interpersonal contact/relationship with the interviewees before the study, so as not to compromise it and generate biases.

The interviews followed a semi-structured script with closed questions about the professionals’ profile to characterize the population, such as gender, age, category, time since graduation and specialization in mental health, for example; followed by the question “What are the care practices performed for children with mental disorders in the inpatient unit amidst the COVID-19 pandemic?” in which the interviewees discussed on the proposed theme, including the possibility of highlighting other aspects that they found relevant and that had not been contemplated in the triggering question.

The interviews took place in July and August 2021 and lasted between 10 and 50 minutes. They were conducted through a video call with the possibility of recording through the platform and transcribed in full, literally, for subsequent analysis. In line with the General Data Protection Law (Lei Geral de Proteção dos Dados - LGPD), only the researcher had access to the answers.

At the completion of the research report, the final version of the research was presented in a virtual meeting scheduled with the interviewees, to validate the study results. This moment provided the opportunity for participants to comment, correct and/or affirm the credibility of the interpretations. It is worth noting that no changes were suggested by the professionals, based on the analysis performed initially.

The professionals interviewed were coded by the letter “N” for Nurse, followed by the number according to the sequence in which the interview took place, such as “N1”, “N2”, “N3” and so on.

The information was analyzed according to the Thematic Analysis15, following three steps: pre-analysis, material exploration, treatment of the obtained results and interpretation. The first step consisted of resuming the initial hypotheses and objectives of the research, with a fluctuating reading for direct and intense contact with the field material, to learn about the content and constitute a corpus. The second step consisted of grouping categories, where the content was organized, aiming to achieve understanding of the text. The third step consisted of the process of reducing the text, resulting in the classification and merging the data, separating them into categories responsible for specifying themes. Finally, the information obtained was evidenced and, from them, inferences and interpretations were made, relating them to the new theoretical dimensions based on literature. After the analysis, the category: “Implications for care as a result of the COVID-19 pandemic” emerged.

The research started after consideration of the Research Ethics Committee (REC) of the referred hospital, having its approval under number 4,757,539/2021 (CAAE 46986021,0,0000,5327). Participants were ensured anonymity, respecting the items of Resolution No. 466/12 of the National Health Council (CNS), which provides ethical standards that regulate research involving human beings. The study also complied with the aspects mentioned in Circular Letter No. 2/2021 of the National Research Ethics Commission (CONEP), which provides guidance on research stages in a virtual environment.

Personal data were also handled in compliance with the LGPD, which provides for the processing of personal data, by natural or legal persons, public or private, with the aim of protecting fundamental rights of freedom, privacy, and the individual's free development of personality.

The FICF, read and clarified, was provided to each participant, who only proceeded to the interview phase after having confirmed their interest and agreed with it, filling in the option “yes” to accept via electronic form, with a copy in e-mail for the researcher and the interviewee.

The FICF provided information regarding the research project, such as objectives, risks, and benefits, as well as the assured the voluntary nature of participation, the maintenance of their anonymity and the possibility of withdrawing their consent at any stage of the study, without any penalty or prejudice, in addition to non-interference in their employment or relationship with performance evaluation. Risks related to participation were related to possible discomfort or embarrassment when addressing the content of the questions. There were no direct benefits to the participants, however, the results may contribute to increasing knowledge on the subject studied and, if applicable, may benefit future participants, contributing with strategies that qualify nursing care for children with mental disorders in the context of COVID-19 pandemic.

RESULTS

In the first part of the semi-structured interview, there were closed questions about the profile of the professionals that allowed to characterize the study population.

Thus, the age range of the participants varied between 35 and 57 years. Regarding the years of since training, it varied between 11 and 27 years, where five professionals had between 11 and 15 years of training, four professionals had between 16 and 20 and four had more than 20 years of training.

Regarding working time at the institution, all professionals had more than ten years of experience, where nine had between 11 and 20 years of work, and four professionals had more than 20 years of experience in the referred hospital. As for working time in the pediatric inpatient unit, it ranged from 6 months to 25 years.

Implications for care as a result of the COVID-19 pandemic

Due to the COVID-19 pandemic, there was a need for changes in hospital routines, which were perceived by professional nurses in the care for children with mental disorders admitted to the pediatric unit, namely: restriction of recreational activities; mandatory social distancing; limiting family visits; mandatory use of personal protective equipment (PPE); and difficulty in counter-referral of care.

The restriction on children’s recreational activities was implemented to prevent crowding and to minimize the risk of transmission of the virus through objects and toys in the room among hospitalized patients. This change had repercussions on the care for the children, as the nurses noticed that the activities and the recreational space were part of the mental health treatment.

I felt that, for the psychiatric patient, what changes care is recreation. At the height of the pandemic, there was no recreation due to the risk of contamination, which directly interfered with care. (N2)

One barrier was the recreational service, which was closed for a long time [...] I believe this is essential for these patients, so there was this big gap. (N4)

It is what makes the most difference to them, as perhaps they could be more agitated by the issue of not having recreation. (N8)

In 2005, Ordinance No. 2,261 made it mandatory to install these recreational spaces for pediatric patients in hospital, recognizing play as a need for healthy or compromised children12.

In the scenario of pediatric hospitalizations, this space is part of the health care and the use of playing becomes an instrument for the biopsychosocial well-being of these children. The hospital recreation unites playing with therapy, using dynamics according to the age, limitations and needs of each child7, being fundamental for those with mental disorders.

Among the various adaptations due to the pandemic that the hospital service introduced, one of the repercussions caused was the closure of the recreation room. Thus, these spaces could not be used, requiring institutions to plan strategies to ensure recreational and therapeutic activities in the child's room and/or bed. With this, it was encouraged the use of exclusive and non-transferable materials for painting, reading, as well as games and toys that could be discarded at the child's hospital discharge18.

The implementation of social distancing strategies, in the inpatient unit, as another measure to prevent the spread of COVID-19, in addition to limiting children from playing and interacting with each other, modified the role of nurses in their care practices.

The children had more difficulty because they could not interact with other children [...]. (N1)

Many are extremely emotional and we cannot hug, cannot touch, cannot share objects (toys), I think this is a barrier. (N4)

Social distancing promoted the rupture and/or weakening of affective, social and health care bonds, which are important for human development. The suspension of physical contact, as well as meetings and playtime, has made it difficult to offer closer care, as they are essential elements in the treatment. A simple touch or a smile became tools for embracement and building a bond between children and nurses.

With social distancing, it was necessary to rethink nursing care, since this profession is historically linked to physical presence and therapeutic touch8. These factors are capable of influencing the length of stay of hospitalized children, aggravating their health status, as they directly interfere with the establishment of emotional and affective bonds.

The look, words and gestures used by health care professionals became alternative substitutes for physical contact and became essential in this period, strengthening the humanization (which physical barriers removed) in care and (re)connecting family members, patients and team8.

Added to this, there are other ways that can mitigate the stress caused, one of them is to provide opportunities and encourage even more the active participation of the family member or caregiver who accompanies the treatment, since they are the child's reference for care and affective bonds, which can contribute to well-being during hospitalization13.

In the studied scenario, the child was encouraged to strengthen relationships with his/her family member during hospitalization, as the imitation of visits to the pediatric unit was another change introduced by social distancing strategies, which promoted a decrease in the number of people through the hospital. This change had repercussions on the care for children with mental disorders, perceived by the nurses.

We faced difficulties during this pandemic period due to not being able to have visitors, there was only one companion. (N5)

Visits were cut off, before two people (one companion and one visitor) could stay in the rooms until 10 pm, now they cannot. (N12)

In pediatric care, the inclusion of the family is a common practice and is encouraged by the team and health institutions, as it contributes to a better understanding of the situation, in decision-making and in the provision of child support. Because of the pandemic, the presence of the companion remained, but no visits were allowed, to avoid infection by the virus by people outside the hospital environment, affecting the care and bonds of affection of the hospitalized child.

Limiting visits was a necessary measure, promoting greater physical distance between patients and other family members. In this situation, families showed symptoms of anxiety, and feelings of worry and uncertainty, reporting a greater need for information from health professionals17.

Thus, with the implementation of restrictions on visits to health services, nurses had to adapt the provision of care to compensate the negative effects on the rehabilitation process of these hospitalized children. In order to follow the care model centered on the patient and family, it was reinforced the need to keep a communication channel with the other family members. These meetings were held through virtual devices, so that there was understanding on the health status of the hospitalized child17, and thus protecting everyone, reducing the circulation in the hospital environment.

In the hospital environment, through the declaration of the Ministry of Health, there was a need for the use of PPE by all people, including patients and companions. In this context, devices such as masks and face shields were essential in routines and had an impact on health care.

There was the use of the mask that hides us and we end up not seeing the other, not seeing the face of the other, so, remove the image and the proximity. (N3)

A child with schizophrenia [...] they usually see images, hear voices. The person comes with a mask and they can get scared. (N4)

For example, a child with speech difficulties, autistic, well, they need to see us talking. So, for children who have some developmental delay, this is worse [...]. (N9)

The nurses expressed that these devices interfered with the approach (both physical and emotional) of the professional to the hospitalized child, especially those diagnosed with schizophrenia or autism, because, besides these devices constituting an element that generates a physical barrier, the protective gear frightened many children.

Among the rules established in the health services, hand washing, the use of hand sanitizer and the use of PPE were essential for those who needed to remain in the hospital context. In this scenario, the mandatory use of PPE is intended to prevent the spread of the COVID-19 virus. However, the vestments made it difficult for the child to see, hear and feel the touch of the person who was providing care, impacting on the attitudes of proximity and affection between professional and patient8.

Still, regarding the use of PPE, there was a fear of hospitalized children towards professionals using masks. The use of these devices hides the facial expressions of the team members, and the child is unable to visualize the face of the worker caring for, which can generate fear and anxiety10^,11, increasing discomfort during the hospitalization period.

Some institutions used creativity during this period, by making badges with larger photos and smiling faces, so that the child could identify and see the face of the professional behind all the PPE. This action sought to humanize care, increasing the worker’s bond with the patient19⁾ during the period of their stay in the hospital.

Another issue that had repercussions on care, according to the perception of the interviewed participants, was the discharge process and the counter-referral to primary care. Assuming that care in hospital care is highly complex, it is recommended that it be of limited duration as early as possible, sending the patient home and continuing the follow-up in the territorial devices, according with the premises of the Psychosocial Care Network (Rede de Atenção Psicossocial - RAPS)20.

Nurses play a fundamental role in this practice called counter-referral. However, this procedure was disrupted as the services that were usually involved to provide continuing care had their operations restricted and/or suspended.

What will this return home be like, how will we return? And if we need to talk to the social worker, the health center, the school, how are we going to do it? [...] we would need to get in touch with the basic network, with the extended family, with the closed school, with the health center. (N3)

I see that the care was very impaired, because when this child leaves the hospital, he/she is usually already referred to his CRAS, to some special school or some school that provides this care, and the pandemic interfered a lot in this issue of contacts, it made it very difficult communication between the hospital and the health unit, because the programs had to be restructured. (N4)

In view of this, the nurses reported that contact with the network in the territory had changes due to the restructuring of services due to the pandemic, which has an impact on the follow-up of care when the child and family return home, resulting in prolonged hospitalization period or greater likelihood of future readmissions.

The restriction of professionals in some territorial-based services, to avoid COVID-19 contamination, was one of the reasons why the counter-referral did not work as expected, due to the decrease in attendances. Thus, the high demand for health institutions, which was already a latent reality, was even more repressed by the pandemic, since to adhere to safety and social isolation protocols it was necessary to keep them closed.

At the Social Assistance Reference Center (Centro de Referência de Assistência Social - CRAS) and the Specialized Social Assistance Reference Centers (Centro de Referência Especializado de Assistência Social - CREAS), professionals took turns on duty shifts, conducting scheduled appointments14, which hindered the flow of communication between the hospital and these health care services.

This communication flow needs to be aligned after hospital discharge, in which the patient is counter-referred to the Psychosocial Care Center (CAPS) in the area of their territory, which will continue the case14. In this way, the child whose condition was stabilized and was discharged from the hospital should return home and maintain follow-up in the RAPS territorial devices.

In this way, the referral and counter-referral are effective methods of following the flow of the user in the health system for the continuity of care. When these methods do not work properly, this may cause problems, as the patient is left without proper guidance, hindering the comprehensive and longitudinal monitoring of their health condition.

Study limitations

It is important to highlight that the present study has some limitations, such as the choice of a specific pediatric unit of only one hospital, as it may be that, in other similar units, care has had different implications caused by the pandemic. Furthermore, considering health care in hospital care, it is relevant to include other professionals in the multidisciplinary team, and other members such as children and their families for an even deeper understanding of the repercussions of the pandemic on mental health care. Therefore, new studies are suggested that promote the perspectives of these groups.

FINAL CONSIDERATIONS

Considering the situation experienced worldwide during the data collection of this research, this study provided an opportunity to analyze the perceptions of nurses about the repercussions in the care for children with mental disorders in a pediatric inpatient unit amidst the COVID-19 pandemic.

The implications for care caused in this health context were related to the restriction on the use of recreation, the limitation of family visits and the need for social distancing to reduce the possibility of contagion, both through toys and through people. The mandatory use of PPE, in the view of the professionals, also caused a distancing due to the physical barrier, and it caused fear in some children. Moreover, the impact of the pandemic on counter-referred care caused a difficulty in communication between services that compose the mental health network, generating insecurity at the time of hospital discharge.

In the study setting there was discussion and reflection on the subject, since the research offered space for the theme, sometimes, little debated. The results presented have the potential to provide institutional managers with tools for articulating and implementing new practices, thus meeting the demands of mental health care for children with mental disorders, especially in non-specialized psychiatric units. It is important for the hospitalized child to be recognized in their entirety, respecting their autonomy within the premises of psychosocial care.

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Edited by

Associate editor:

Helena Becker Issi

Editor-in-chief:

João Lucas Campos de Oliveira

Publication Dates

• Publication in this collection
  01 Sept 2023
• Date of issue
  2023

History

• Received
  03 Oct 2022
• Accepted
  23 Jan 2023