INTRODUCTION

Bonding consists in the formation of an affective relationship between the newborn and its bonding Figure, in most situations, the mother and/or father. John Bowlby, English psychiatrist and psychoanalyst developed the Attachment Theory, having stated that bonding is a basic mechanism of human beings and that behaviors are biologically programmed, with the newborn's relationship with the parents being a relationship established by a set of innate signs ¹. Basing his theory on research by Lorenz Konrad and Harry Harlow, from the field of ethology, Bowlby argued that the connection between the baby and its mother, would go beyond the satisfaction of its basic needs such as hunger, thirst or pain, but also the promotion of comfort, affection and learning ^2,3.

The formation of a strong affective bond with at least one caregiver is the key for the child to have an adequate physical, cognitive, emotional and psychological development, since this first relationship will affect the style of bonding relationships throughout its life ⁴. Bowlby believed that the attachment relationship was monotropic, not excluding the possibility of other attachment relationships, but he admitted that these would have less binding value for the child, declaring that the monotropic relationship was established between the newborn and the mother ⁵.

Later, Mary Ainsworth contributed to develop the theory initiated by psychoanalyst Bowlby when investigating the relationship between mothers and children in Uganda, and mainly by developing an experimental procedure to assess the quality of the relationship between the infant and his primary caregiver. This experimental procedure, which she called the Experimental Method of the Strange Situation, allowed us to observe and classify which pattern of bond was established between the infant and his or her attachment Figure. The attachment pattern could be classified as secure or insecure, according to the behavior demonstrated by the infant in the absence of their attachment Figure ⁶.

In his theory, Ainsworth concluded that all human beings are born endowed with a bonding system that allows them to seek proximity to a reference Figure that offers them protection and security, so that they can have the curiosity and willingness to explore the world that surrounds ⁶.

The bonding of parents to the child begins in the prenatal period with the desire for pregnancy and idealization of the imaginary child, with the planning, acceptance and awareness of the fetus, its movements and the perception of the fetus as an individual person ⁷. Experiencing the various stages of the pregnancy process allows future parents the beginning of the emotional bond with the child they idealize and through labor and birth, there is the personification of the couple as mother and father, and their responsibility towards the child, as a being in need of care, protection and security. It is after birth and with the possibility of seeing the newborn, touching and caring for it that the acceptance of the child as an individual belonging to that family is promoted and the bond of the mother-father-newborn triad is established ⁸.

In the period right after the birth of the newborn, there are several hormonal and physiological mechanisms that interfere in the bonding process, these mechanisms being triggered by the physical proximity between the triad. This physical proximity in the early postnatal period allows the establishment of a strong affective bond due to the experiences required by the new role of caregivers and the possibility that they manifest parental behaviors, such as the affectionate touch to the newborn, contemplation and the expression of affection by the new family member ⁹.

When the child is born prematurely, or has a pathology that necessarily implies hospitalization in a neonatal unit, there is a disruption in the bonding process, which inevitably jeopardizes the establishment of the triad bond in the early postnatal period. The hospitalization of a child, especially when it is preterm, is a situation that generates stress and has consequences in the transition to parenthood, germinating feelings in parents such as impotence, guilt and incapacity ¹⁰. Whenever there is a need for the newborn to be hospitalized, even with an adequate early postnatal course, there is a change in the transition and adaptation to this new phase. The establishment of a bond can be hampered by the newborn's health-disease situation and further aggravated by the physical barriers that exist in hospital units, preventing parents from contacting their child and performing their parental role as they desired¹⁰.

Parents, in these cases, need to maintain a balance between two opposing feelings: anguish and attachment to the newborn. In order to be able to deal with these feelings in a balanced way, parents need to acquire knowledge about the physiological needs of the newborn and recognize subtle signs that lead to the development of skills that allow them to know what specific care they should provide to the child and cumulatively re-establish the relationship that was interrupted ¹¹.

Given the importance of a good quality and safe bond for the child's development, the nurse's intervention in promoting the bond of the triad is extremely important, further emphasizing the impact of said intervention when the triad suffers a physical withdrawal due to the child's hospitalization ¹².

The motivation for carrying out this scoping review is linked to the need to map the existing knowledge in the literature to determine which nursing interventions promote the formation of a bond between parents and the child when the child is hospitalized and the triad is disrupted in its affective process.

After conducting an exploratory search in the databases PubMed, Medical Literature Analysis and Retrieval System (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO, it was possible to conclude that there is no scoping review or systematic review of the literature that systematizes the topic of interest proposed by this protocol.

In conclusion, and given the importance of the theme for the healthy emotional development of newborns and their families, this scoping review was carried out with the aim of mapping knowledge about nursing interventions that promote the attachment of newborns in need of admission to their parents, or caregivers.

METHOD

This literature review complied with the standards stipulated by the Joanna Briggs Institute (JBI) Reviewer's Manual method. Initially, a scoping review protocol was developed, predefining the review objectives and methods, as well as the review question “Which nursing interventions promote attachment in newborns with need for hospitalization?”.

Search Strategy

Thus, the inclusion criteria were established according to the components of the research question for the population, concept and context (PCC).

Population - All studies that include newborns up to twenty-eight days of life, whether term or preterm newborns, regardless of their pathology, and their family, with a focus on the mother and/or or father.

Concept - All studies related to the promotion of bonding between newborns and parents were included and analyzed.

Context - All studies that include nursing interventions to the family in the context of hospitalization of the newborn were included and evaluated.

The studies included were quantitative and qualitative, published in international and Portuguese databases. There was no limitation on the date of publication. Studies in English and/or Portuguese were included.

As for the exclusion criteria, all studies that did not comply with the PCC methodology described above were excluded.

The strategy for conducting the research was comprehensive and took place in three distinct phases. In the first phase, which took place in April 2020, and which corresponded to an initial search in the PubMed, CINAHL databases via EBSCO and MEDLINE. This initial research resulted in an analysis of the indexed keywords and terms, and the Boolean descriptors and operators were selected to be included in the next research phase.

The second phase of the research was carried out in the PubMed, Medical Literature Analysis and Retrieval System (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases via EBSCO, LILACS, Cochrane Library, including the Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL) and Academic Search Complete, in the period between May and June 2020. The last phase of research included the search for additional studies through bibliographic references of the studies selected in the previous phases. The selection of studies included in the review was performed by two independent reviewers.

The search descriptors and related words were used for the research with the articulation of the respective Boolean operators, as presented through the search equation: (Newborn OR neonatal OR infant) AND (Bonding OR attachment OR closeness) AND (Neonatal intensive care unit OR hospitalization OR hospital stay) AND (Nursing care OR nursing interventions OR nursing role).

Data extraction

After the search, all duplicated studies were removed. The resulting studies were evaluated and selected respecting the inclusion criteria, initially through the information provided by their title and abstract. Afterwards, the selected articles were subject to a full reading. The results of the research and selection of the studies in question are presented through the flowChart of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-ScR), shown in Figure 1.

Figure 1.  Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowChart adapted for scoping review by Joanna Briggs Institute (JBI) Reviewer's Manual 

RESULTS AND DISCUSSION

Fifty-three studies were included, and are shown in Table 1, according to the title, study design and purpose of each study.

Table 1.  

The main nursing interventions that promote bonding in newborns when they are hospitalized are divided into two groups: in promoting the interaction of parents and the newborn and in the interaction between parents and the nursing team, as shown in Figure 2. In this sense, the analysis of the articles included in this scoping review is structured by chapters.

Figure 2.  Nursing interventions that promote attachment to the hospitalized newborn 

Interaction between parents and the hospitalized newborn

With the hospitalization of the newborn, parents experience negative feelings such as emotional shock, fear, anxiety, depression, post-traumatic stress ^{(E1, E2)}, with the feeling of failure and helplessness being more evident in mothers, feeling disconnected and not involved in newborn care ^{(E3, E4)}.

The first interactions with the child occur in an atypical, unknown and intimidating environment, which prevents easy contact with the child ^{(E1, E3-E6)}. Regardless of the reason for hospitalization, the disruption of the relationship during hospitalization, together with the absence of touch and interaction with the newborn, can negatively affect the newborn's attachment and representations ^(E7).

Nurses have a crucial role in reestablishing proximity and early bonding, and it is important that this is established in the first hours of life ^{(E2, E8-E14)}. Attachment is beneficial, regardless of the newborn's survival ^(E5).

The quality of parents creating a physical and emotional bond with the child cannot be replaced and nurses, by promoting the bonding process, are able to consolidate parental skills, social and psychological development, as well as establish the bond ^{(E5, E15)}.

Physical proximity

The normal bonding process is initiated through proximity, contact, touch, heat, odor, skin and voice ^{(E5, E16)}. Physical proximity has several benefits for the newborn's development, such as hemodynamic stability, weight gain, temperature stabilization, reduced hospital stay, neurodevelopment and pain ^{(E5, E13, E14, E17-E20)}. For parents, there is a decrease in anguish ^(E21) and the encouragement of physical contact has positive emotional effects ^(E22) being significantly more present in the unit ^(E23), improving performance in breastfeeding and parental training ^{(E24, E25)}.

Touch has a sequential progression, starting at the extremities and evolving to the rest of the body and plays a key role in the parents' experiences ^{(E6, E13, E19, E26, E27)} increasing parental self-confidence and parent-newborn bonding was effective ^(E28).

Skin-to-skin contact, or the Kangaroo Mother Care, is considered the key to breaking down barriers between the triad and linking parents to the newborn ^{(E5, E10, E13, E19, E29-E32)}. Parents feel less worried and less anxious, increasing their commitment to the child ^(E33), assuming more control over the situation. They describe the moment of skin-to-skin contact as moving and emotional and promotes that newborn's feeling of belonging ^{(E1, E10, E14, E24, E29, E34-E37)}.

Massage is also considered an intervention that facilitates bonding, especially between the father and the child, resulting in a reduction in paternal stress ^{(E14, E28)}.

The use of web cameras is considered a good strategy to promote bonding ^(E38), however it does not replace the physical presence of parents ^(E39). This is a strategy that allows parents to feel closer to the newborn when they cannot be present at the hospital, increasing the feeling of closeness, reducing stress and anxiety ^(E39).

Breast-feeding

With regard to breastfeeding, it contributes to the reestablishment of the bond, increases the interaction between the mother and the newborn, making it possible to the mother to experience the role of caregiver ^(E40), feeling emotionally connected to the child ^(E41).

Mothers should be encouraged to touch and hold the newborn ^(E7), as the bonding time between mother and newborn increases the breastfeeding rate ^(E42) and consequently, these mothers have levels of lower cortisol ^(E43).

With the hospitalization of the newborn, most of the times breastfeeding does not normally take place essentially due to the health condition of the newborn. In these situations, the extraction of breast milk is the strategy used, but it does not correspond to what the mothers imagined, becoming a difficult and tiring challenge ^(E37). Encouraging mothers to express milk with the newborn promotes the development of a greater connection between them, consequently increasing the amount of milk extracted ^(E11). The father's support in promoting breastfeeding allows for the promotion of the newborn's health and consequently increases the interaction of the triad ^(E44).

The early contact between the newborn and the mother increases the effectiveness of breastfeeding, stimulating the secretion of hormones, namely oxytocin, which promotes bonding, and prolactin, which promotes lactation ^(E25).

Participation in routine care

Parents who experience separation from their newborn feel consequently excluded from care, which undermines the bond ^(E25).

The bond between parents and the newborn is facilitated by the development of parental skills and involvement in care ^{(E2, E9, E11, E46)} thus allowing the establishment of a connection between them through interaction ^{(E7, E11, E47)}.

Parents who are motivated by the team to stay longer and take care of the newborn feel more involved and connected to the child ^{(E7, E9, E47)}, making them more sensitive to the newborns' development and its progress during hospitalization ^(E9) and leads to awareness of the child's care needs ^(E48).

Planning the care together with the parents makes them feel included, facilitates the feelings of participation, they feel actively listened to ^{(E40, E45)} and proud to provide “normal” care (changing, dressing, bathing) to the newborn ^(E41).

Promoting the involvement of parents with the newborn from birth, allowing them to be monitored and observed, influencing the growing commitment and bond with the newborn ^{(E21, E41, E48, E49)}. Thus, they assume the role of the main caregivers ^(E40).

Interaction between parents and the nursing team

Admission to an intensive care unit is traumatic for parents ^(E50). The professional who presents for the first time the unit where the newborn is hospitalized, as well as showing the newborn, greatly influences the reestablishment of the bonding process because it presents a newborn who already belonged to that family, which is deprived of this due to the newborn's health condition ^(E3).

Encouragement from health professionals positively influences parents' feelings, making them more confident in the interaction with the newborn ^{(E5, E33)}. This is a process facilitated by giving information to parents, however it often has a slightly forced beginning, so that parents are able to overcome conflicts and feelings and realize that their care is safe for the newborn ^(E5).

Teaching and support is often directed at mothers, however it is essential to include the father at all times, from pregnancy and in the involvement after birth ^(E14).

Communication

The relationships between parents and professionals must be based on positive interactions, capable of creating a partnership and facilitated communication between them ^{(E6, E47, E50, E51)}.

Communication allows parents to become partners in care and decision-making, while nurses enable them to fulfill their parental role, increasing parents' self-confidence, generating a sense of control and a feeling of bond with the newborn ^{(E6, E49, E51)}.

It is important that all information related to the newborn is provided, in the different stages of hospitalization ^{(E7, E12, E41)}. Information, support and guidance promotes the parents' trust in the team, being the key to supporting worries and anxiety, enforcing the feeling that the newborn is safe and well cared for ^{(E1, E2, E11, E12, E36, E41, E45, E52, E48, E50)}.

Improving communication and collaboration skills to increase the presence of parents in care is essential to improve the bond with the newborn and the parents' psychological well-being ^{(E45, E49, E50)}.

Emotional Support

Regarding emotional support, it is essential that the nursing team support the family, not restricting themselves to the questions asked, as parents often do not know what to ask, as they are unaware of the seriousness of the situation, the existing equipment and the duration hospitalization ^{(E2, E7)}.

Parents must be accompanied on the first visit to the newborn and receive as much information as possible, as the first visit is impactful and influences the family bonding process ^(E7).

Creating opportunities to listen to parents' needs can reduce anxiety caused by uncertainty ^{(E2, E46)}. Parents who receive emotional support from nurses tend to improve the bond with the newborn, considering they are emotional support, informed and more confident ^(E49).

Good communication, listening skills, not making judgments, defending the newborn-parents relationship, empathy for the situation, good nursing skills, providing information proved to be important for the emotional support of parents ^(E46) and including the family's religious beliefs allows them to express their feelings ^(E7).

The relationship that parents create with the nursing team increases the commitment and responsibility on the part of parents ^{(E47, E53)}.

CONCLUSION

With this scoping review, it was possible to map the scientific evidence regarding interventions that promote attachment to the newborn in need of hospitalization. Due to the complexity of the health-disease situation that motivates the hospitalization of the newborn, the bonding process is corrupted and the reestablishment of the bond is more effective the earlier it is encouraged after separation from the family.

Nurses play a fundamental role in reestablishing the bonding process between the hospitalized newborn and the parents, promoting an effective bond. Consequently, during hospitalization they should take every opportunity to encourage, educate and enable parents to be involved with the newborn. The nursing interventions identified in the literature through the scoping review, namely physical proximity, breastfeeding promotion, inclusion of parents in newborn care, communication and emotional support are essential for parents to reestablish the bond with the child and are able to transition from a role in which they are mere spectators to becoming the newborn's primary caregivers, empowered and connected.

The increase in nurses' knowledge about the newborn's attachment to the parents, the impact that the disruption of this bond has on the triad's life course, as well as the interventions that promote an effective early attachment, result in an improvement in the performance of the nurses that will have an impact on the family's bonding path during and after hospitalization.