Exclusive Breastfeeding : Guidance in the Process of Communication between Nursing Staff and Recent Mothers

Conclusions: By using the techniques of communication, nursing professionals have demonstrated to be in tune with recent mothers when promoting their participation in the breastfeeding process, instructing them and offering encouragement. However, the social and emotional aspects that permeate the practice of breastfeeding were not mentioned by the nursing staff. Exclusive Breastfeeding: Guidance in the Process of Communication between Nursing Staff and Recent Mothers


Introduction
The puerperium is defined as the period of the gravid-puerperal cycle in which the modifications caused by pregnancy and delivery in the body of the woman return to its pre-pregnancy status.It starts with placental delivery and has unexpected end, insofar as it relates to the process of breastfeeding [1,2].
During the puerperium, mother and newborn should receive every necessary assistance care.The newborn with good vitality, shortly after birth, can stay with the mother until hospital discharge in a system called rooming-in care.This system encourages breastfeeding on free demand, strengthens the bond between mother and son and contributes to the promotion of health, since the health care professional can provide guidance to recent mothers about breastfeeding and newborn care [3].
Breastfeeding has different meanings and representations to the feminine universe.However, it is common for professionals to emphasize a practice geared primarily to the needs of the child and the idea of obligation to breastfeed, which can contribute to the inefficiency of the practice of breastfeeding [4].
The benefits of this practice are not restricted only to both mother and child, but also to society, because a child properly nourished generates repercussions in decreasing the incidence of neonatal and infant morbidity and mortality, impacting on reducing hospitalizations and hospital costs [5].
The World Health Organization [6] and the Ministry of Health of Brazil [7] recommend exclusive breastfeeding up to 6 months of age and guide its continuity as supplemented form up to 2 years old or more.In addition, the same bodies advocate the initiation of breastfeeding within the first hour of life and, from there, on free demand [8].
The practice of breastfeeding is highlighted in studies, being evidenced as essential for raising the quality of life of the trinomial (mother-child and fa-mily).However, despite the efforts and the development of incentive policies, the rates achieved are still considered unsatisfactory, with early weaning levels and low rates of exclusive breastfeeding remaining high [17].
Health education is a fundamental tool for a good quality nursing care.The nurse, as caretaker and educator, is responsible for performing the appropriate guidelines to who has recently given birth and to the family, so that all elements involved in the educational process can participate actively in the construction of knowledge and in combating early weaning [9,10].
The incentive to exclusive breastfeeding is linked to the establishment of effective communication between the subjects in the care relationship, as well as in respect to each other, to their knowledge and to their condition of participant in the communication process.The subject hears the message and translates it according to her sociocultural framework.So, the style and the choice of words make a difference in the quality of communication and it is important in the negotiation process of care along with the subject, since the professionals who provide the most effective care are precisely those which achieve a more effective communication with customers [4].
Given the importance of communication in the work of the nursing staff and the need for guidelines for effective exclusive breastfeeding practice, it is aimed to identify which guidelines on the exclusive breastfeeding are offered and which communication techniques are being employed in the process of interaction between nursing staff and postpartum women admitted to rooming-in care.

Method
Descriptive and exploratory study, with a qualitative approach, developed in the rooming-in care of a reference hospital in Fortaleza -Ceará, Brazil.The subjects were eleven nursing professionals who work in that sector and data collection occurred during the months of March to June 2012.
It is known that in the routine of rooming-in care professionals the orientation activities and assistance to mothers must be present in regard to the implementation and maintenance of breastfeeding, corroborating the due educational nature of the sector.Therefore, the professionals who worked in that place during the completion of study and who reported promoting guidance activities regarding breastfeeding were included in the study.The exclusion criteria adopted was not carrying out this type of activity.So, the excluded professionals stated that they did not perform any activity related to the practice of exclusive breastfeeding.
The technique of direct observation not participant of interactions between professionals and mothers was used, following a predefined script.In addition, semi-structured interview was carried out containing identification and professional history data, as well as issues related to the guidelines given and communication techniques used.The nonverbal expressions and impressions of the researcher were recorded in field journal.
This study was approved by the Research Ethics Committee of the Federal University of Ceará under protocol number 357 and the standards have been met regarding the 466/12 Resolution, which outlines the paradigms for research involving human beings.For professionals who have agreed to participate in the study, the Terms of Consent (TFCC) was offered.

Results
The study subjects were 11 nursing professionals operating in rooming-in care, being 3 nurses, 4 technicians and 4 nursing assistants.The sampling process is described in Figure 1.
The professionals age average was 41.45 (± 13.9) years, ranging from 23 to 65 years.The average in nursing practice time was 14 years, ranging from 7 months to 30 years.In obstetric area, the average time of performance was of 7 years, varying between 4 months and 17 years.In relation to graduate, among the nurses, two of them held the title of obstetrician nurse.It was observed that 100% of the study participants were female.
Participants were asked about the main techniques used and their respective contents in order to stimulate the practice of exclusive breastfeeding.Against this objective, Table 1 presents the main guidelines and communication techniques used by nursing professionals along with recent mothers.The study population N = 24 It was observed that the guidelines given fell predominantly about the benefits of breastfeeding (81.8%) and the correct technique (72.7%), as the words transcribed below illustrates: Breastfeeding is good for the child's development.You will see how she will develop fast, only with breast milk.It's like a vaccine, so it's good for the child, as it is good for you.Breast milk is ready and at the ideal temperature.You will not have to do the job, you will not have to buy it.

Professional 2.
Mother's milk is also digestive, the baby eats, pees and poops.The artificial milk makes the baby having difficulty to poop.

The baby has to take all the dark part of the breast, if he takes only the nipple it will hurt.
Professional 3. Regarding the communication techniques, the most used were: valuation techniques of expression, remain silent and listen reflectively 11 (100%); te-chniques that highlight the clarification, verbalizing questions and asking the customer to give the meaning of the terms used 11 (100%), asking questions and keeping the customer on the same subject 10 (90.9%).As a technique that characterizes the validation of what was said during professional-recent mother interaction, the summarization of what was said in the orientation were prevalent in 10 (90.9%) of them.

Discussion
Rooming-in care is an enabling environment for the guidance of recent mothers about the importance of breastfeeding, reinforcing the guidance received during the prenatal period.It is the role of the multidisciplinary team to encourage these women to offer the breast to the newborn in the first few hours after birth, stimulating more rapid decline in the milk, in addition to observing the positioning and the correct grasp of the areola of the child [12].Study in a referral hospital in Recife/PE evaluated the breastfeeding technique in 44 lactating gilts and their babies, and found that only 43.2% presented the correct technique, including position and picks [13].
The fact of finding 13 (n 1 ) professionals said not carrying out guidance on breastfeeding is of utmost concern, since the establishment of breastfeeding is not always an easy task for the binomial and is often fraught with fears and taboos that require professional intervention to not impede success of this process.The main difficulty for the realization of this study was the limited availability of nursing professionals to guide recent mothers, making it impossible, for several times, the completion of data collection.Future studies can find the reasons why the professionals dispense this careful, even in the face of educational character that permeates the guidelines for creation of rooming-in care.
Recent mothers of Iapu/MG, when questioned about the issue addressed during orientation activities they received from professionals, 50% said they learned about the importance of breastfeeding and the correct technique.When questioned about the knowledge acquired, 75% replied that they knew what breastfeeding meant and knew some of the benefits that it would bring for mothers and their babies [14].Such a situation does not differ from that found in our study, when the correct technique and the benefits of breastfeeding also showed itself as the most addressed issues by professionals.By using different communication techniques during guidance on breastfeeding, practitioners demonstrated to be in line with the puerperal, promoting the participation of them in the breastfeeding process, instructing and offering them encouragement.The nursing staff, in the process of therapeutic communication, should adopt an accessible language, compatible to the intellectual level of the recent mother.Listening should be attentive with the touching setting to provide support and comfort, and attitudes that increase self-esteem and confidence of the patient [15].
Therefore, the observation of non-verbal language becomes necessary in the communication of nursing professionals for the assistance provided to the client as they allow the perception of expressions, signs, gestures and movements issued by the patient [16].Given this, we highlight the importance of the establishment of empathy between client and nursing professional through communication techniques that value being in its essence, with their doubts, beliefs and taboos.
Even with the increase in the number of male professionals in recent years, nursing remains a predominantly female profession.Still, with regard to maternal and child care services, these are much less sought after by male professionals.The entirety of women found in our study was ratified in a survey conducted in Londrina/PR on the profile of nursing professionals providing care to parturient women and recent mothers.In the health institutions surveyed, it was found that 100% of the professionals were female [11].We believe that this can best be explored in future studies, with a view to identifying the experience of these professionals with breastfeeding and the possible interference of their prior experience in the management of this theme.

Conclusion
In their care practice, most nursing professionals focused their guidance on the importance of the practice of maintaining the exclusive breastfeeding until the first six months of the child's life, highlighting the benefits of it for the baby to the mother and family, and also in the clinical management of breastfeeding.It should be noted that it is of fundamental importance to evaluate the biological and clinical aspects of breastfeeding, including social and emotional aspects of recent mothers for breastfeeding success.
It is not enough for nursing professionals to have knowledge and skills about breastfeeding.They must also be able to communicate with efficiency in order to discuss with recent mothers about how they breastfeed, what they think about this activity and how they feel about themselves.For this, one can invest in group strategies that contribute to the exchange of knowledge, for the discussion of questions and the true understanding of what is being reported, adding quality to the care practice.

Table 1 .
Number and percentage distribution of nursing professionals according to the main offered guidance and communication techniques.Referral Hospital.Mar/Jun, Fortaleza-CE, 2012.