MEMORY BOX: A TECHNOLOGY FOR NEWBORN AND PEDIATRIC CARE

This was a descriptive, exploratory, quantitative, crossectional-type study, which aimed to analyze how the Memory Box can be used, with a view of the nursing team, as a technology for pediatric and neonatal care. The population consisted of 143 nursing professionals at a pediatric hospital in Santa Catarina. Data collection was conducted from August to October of 2013 using an instrument. Data were analyzed using simple and exploratory statistics, and the non-parametric test adopting a significance level of p = 0.05. It was observed that 86% of professionals consider the Memory Box an interesting tool to use in pediatric and neonatal units, and 88.1% believe it is a way to provide specific and differentiated care. Thus, the creation of the Memory Box promotes communication and bonding, as well as support in fighting hospitalization and/or death.


INTRODUCTION
The pediatric and neonatal technological advances made over the years have been of paramount importance to achieving quality in the care provided. 1The eighteenth century marked the beginning of a systematic concern about the care-child relationship.In the nineteenth century the technological developments related to the creation of equipments that have provided and continue to provide better survival conditions began, both for neonates and children in critical health situations. 1,2he increasingly use of technologies in the pediatric and neonatal area transformed the form of care expanding the view of professionals and no longer focusing only on the disease but viewing the individual as a whole, encompassing the care of psychological, social, cultural, and physical aspects. 3hus, the actions of professionals should increasingly relate to attitudes that are based on scientific principles in order to strengthen the quality and safety of care, promote family bonding with the team, allow interaction between parents, establish support groups, and provide clear and precise information. 4n the neonatal and pediatric context, the role of the nursing team must be focused on the needs of the child/newborn and their families, providing a playful environment, encouraging bonding, informing and advising on norms, routines, disease and care, and supporting the coping process for problems arising during hospitalization. 5,6eonates or children should receive all the technological support available during the hospital stay, which allows the best quality of care.However, even the technology and advances in health care, are sometimes not sufficient to achieve a cure.Therefore, the possibility of death is a reality to be considered. 7n this perspective, the team must work with parents about the importance of bonding, constructing and organizing memories that can benefit both the hospitalization process and those that may result in loss and grief. 6ne way to provide the creation and organization of memories is the Memory Box.American nurses noticed that the creation of a box of memories could be a positive way for professionals to help parents go through difficult times.Its use helps positively to cope with hospitalization and/or with immediate pain or death. 8 qualitative study of 15 mothers who experienced hospitalization of their children revealed that only one received the photo of the child in the hospital, and 12 mothers received footprints of their children on sheets of paper when leaving the hospital.Most mothers expressed that they would have welcomed more memories of their children. 9Thus, the Memory Box would serve as a resource for other memories to be added and provided to mothers.
Therefore, the Memory Box is in a way to store memories, provide comfort and consolation, and promote communica-tion with the family, creating bonds and a network of support. 8he contents deposited in the box will vary according to the characteristics of each family and their needs. 10he Memory Box can be used in various situations involving hospitalization, death, and mourning.In times of hospitalization, it helps to create bonds between the staff, children, and their families helping them to overcome this period.In cases of loss of children or perinatal deaths and stillbirths, the box can be assembled immediately after the death, and may contain pregnancy memories and moments lived with the child in addition to feet and hands' prints, electrocardiograms. 11t should be noted that the studies published on the Memory Box are of international origin, predominantly Americans and none was found in the Brazilian research literature.Thus, we emphasize the necessity and importance of further studies on the Memory Box, primarily as a technology for care in the Brazilian context.
The aim of this study was to analyze how the Memory Box can be used with a view of the nursing team, as a technology to neonatal and pediatric care.

METHODOLOGY
This was a descriptive, exploratory, quantitative, crossectional-type study conducted with nursing professionals at a pediatric hospital in Santa Catarina/Brazil, in the period from August to November of 2013.
The study was conducted in nine of the hospital inpatient units, encompassing medical, surgical, and oncology clinics, and neonatal, general, and semi-intensive ICUs.The units were selected taking into account the following criteria: being inpatient units with the average of hospitalization time of children and neonates of a week or more, and with the consent of the nursing leadership in each unit.
The sample was intentional, non-probabilistic, following the criteria of inclusion and exclusion from the study.Namely: inclusion criteria -professionals of the nursing team working in the selected units and available to provide the explanation about the Memory Box and answer the questionnaire in the period of data collection; exclusion criteria -professional nursing staff who were on vacation or on leave for any reason at the time of data collection; or having declined to consent participation in the study.
Regardless of the intentional non-probabilistic sample, the sample size calculation was performed to obtain the minimum required number of participants.The calculation was carried out by estimating the percentage in SESTATNET®, with a 99% confidence interval, precision of 50 (± 5%) and without sample loss, resulting in a sample of 143 professionals.
Data collection was performed in three specific steps.The first consisted of the design and pre-test of the data collection assistants.In the neonatal units.The use of the Memory Box was supported by 124 professionals who agreed or strongly agreed, 24 (85.7%)nurses, 88 (87.1%) nursing technicians, and 12 (92.4%)assistants.
Most professionals -126 (88.1%) -believe that the Memory Box is a way to provide individualized and differentiated care to the families and children.It is worth mentioning that a statistically significant difference was observed between nurses and technicians in relation to agreeing and/or totally agreeing with that concept.Similarly, the analysis of the responses between different time since graduation, except zero to five years, all tended to agree (including totally agreeing) to the detriment of others.However, although not statistically significant, the time since graduation 'zero to five years' agreed in 100% of responses (Table 2).
When asked about the need for training in the use of the Memory Box, 108 (75.5%) professionals agreed or strongly agreed.Moreover, when asked about their interest in receiving training, 122 (85.3%) professionals reported being interested regardless of their time since graduation.instrument.This was carried out with three nursing professionals from the pediatric and neonatal areas.
The instrument was evaluated and improved, composed of 43 questions divided into five blocks: characterization of subjects with 10 items; understanding and applicability of the Memory Box with 16 items; facing hospitalization with three items; facing death with seven items; and awakened feelings with eight items.
The second step included the presentation of the study to the units.The presentation was held through a Power Point® presentation in each unit in the morning, afternoon, and evening shifts.In addition, a assembled box simulating the Memory Box was presented.
The third step consisted of applying the data collection instrument and signing the Voluntary Informed Consent Form (VICF).After signing the informed consent, the instruments were given to subjects and, after being filled, they were deposited in brown paper envelopes to prevent conflict of interest or participant identification.
Data were evaluated by simple exploratory statistical analysis and the non-parametric test adopting a significance level of p = 0.05.The chi-square test was used to examine statistical differences between the questionnaire variables according to the professional characteristics of individuals.Analyses were performed in the R 3.0. 1 program.
This study was submitted to the Research Ethics Committee of the participant Hospital and original institution from the Brazil Platform, being approved under protocol CAAE 15296413.1.0000.0121.All standards and regulatory guidelines for research involving human subjects as defined in Resolution 466 of December 12, 2012, of the National Council of Health and Ministry of Health were respected.Therefore, confidentiality and anonymity of participants were assured; all participants signed the informed consent form.

RESULTS
The study included 143 nursing professionals, active in nine units of the selected hospital.The data revealed that more than half of participants were nursing technicians -101 (71%) -, predominantly females, with 130 (90.9%) professionals.The day and night shifts have virtually the same number of professionals, highlighting that 34 (24%) of these graduated between 15 and 20 years before.As for the time at work, 49 (34%) had less than five years in the profession (Table 1).
When asked if the Memory Box would be an interesting tool to be used in the pediatric and neonatal units, it was found that 123 (86%) professionals agreed or strongly agreed with the use in the pediatric units, of which, 25 (89.6%) were nurses, 87 (87%) were nursing technicians, and 11 (84.7%) were > 25 years 13 (9)  Regarding the use of the Memory Box, 121 (84.6%) professionals stated that they would use it or assist in the implementation of the box.And they stressed that those professionals who should be included and responsible for its implementation should be mainly nurses, with 125 (18%), followed by 104 nursing technicians (15%), and 57 psychologists (15%).Note that participants indicated more than one option in this question (Table 3).
Concerning how to present the Memory Box to families, 74 (37%) professionals reported that the best way would be showing a model; 66 (33%) thought that the best way would be explaining what the Memory Box is theoretically; and 53 (27%) of professionals preferred to recount the experiences of using the Memory Box with families as a way to present the box.It was also asked what time the professionals would present the box to families, and 50% said it would be at the time of hospitalization.
As for the arguments that they would use to offer this technology to families during hospitalization, they emphasized mainly the memory, with 120 (56%) answers, followed by bonding with 61 (29%), and aiding in coping with grief with 28 (13%) answers; this question could be answered with more than one alternative.
It was also observed that when asked to which family member they would present the Memory Box, the professional's answers was especially 'mothers' with 132 (32%) responses, and parents with 118 (29%) responses; this question could be answered with more than one alternative (Table 3).
Regarding the items that can be used to build the Memory Box, photos stood out with 123 (21%) answers; followed by personal items with 113 (20%) answers; toys with 100 (17%) answers; and locks of hair with 97 (17%) answers; this question could be answered with more than one alternative (Table 3).
Concerning facing hospitalization and death, the results were equivalent.When asked if the participants have used some technology similar to the Memory Box to work the hospitalization period with families and children, 108 (75.5%) professionals answered "no".Moreover, when asked about death, 119 (84%) answered "no".
When asked about the Memory Box contribution in the process of establishing communication between professionals and families, the majority agreed with this, with 119 (82.2%) agreeing, and with significance in all positions.The same hap-  Grandfathers 42 (10)   Brothers 44 (11)   Others 27 (7)  is no assurance of how these options are used, or how to discuss them with family members in order to bring more opportunities to elaborate on their feelings.Hence, the great challenge posed by the Memory Box is reinforcing the importance of training and capacity building in the nursing team. 13egarding the implementation of the Memory Box, the results emphasize that most of the participants agree that it would assist in this process.Thus, there is a significant interest in going beyond the merely technological arsenal promoted by equipment.It is known that the technology in hospital units becomes increasingly present, transforming the caring activity in units full of equipment and apparatuses, which often inspire coldness, detachment, and suffering.However, this environment is likely to become a cozy one providing positive thoughts to families such as with the use of decorations, wall paintings, or artifacts such as the Memory Box.
Another significant aspect of the study that deserves further deepening and discussion is related to those involved in the construction of the Memory Box.The fact that 61% of respondents claim that they would present it to parents emerges equally, the nuclear family as the protagonist in inpatient units and in the process of building the Memory Box.
Moreover, it is noteworthy that 50% of participants would present a Memory Box to families at the time of admission, making the construction a routine and not just an isolated event, and therefore, contributing to the creation of a daily bond between the team, families, and neonate/child.Thus, the Memory Box must be assembled with the family and, if possible, with the participation of children in the context of Pediatrics so they can share hopes and dreams and feel in a safe environment, and strengthen family bonds. 10In the neonatal ICUs environments, according to the conduct of the professional with the family, values, hopes, and dreams, feelings of family members can be redeemed, often representing the story that led them there.pened in relation to the time since graduation, there was no difference between the range of years since training: 114 (79.7%) opted for agreeing (including totally agreeing) (Table 4).

DISCUSSION
Given the results, most participants accepted the use of the Memory Box, both in the context of hospitalization and death.This statement was observed in 86% of participants who had positive responses for the use in pediatric units and neonatal units, with 86.7%.In addition, 88. 1% believe it is a way to provide individualized and differentiated care to families and children.
These results demonstrate that Nursing is concerned in providing care that is close to the reality experienced by neonates, children, and their families recognizing the benefits of a care focused on this pair, as well as the importance of the full presence of the family in the hospital environment promoting better adaptation and acceptance to treatments, minimizing stressing effects to neonates and children. 12n addition, the nursing staff recognizes that the Memory Box helps families facing hospitalization and its consequences, and it is one way to create memories and provide care promoting approachment and bonding.Regarding the need for training in the use of the Memory Box, the nursing staff members recognize that they need to be trained to care for families of newborns in a adequate form. 9Similarly, the importance of the permanent and continuing education in health institutions is highlighted to promote care that is increasingly qualified and safe.
Therefore, one of the ways to provide this care could be through the construction and organization of memories that show the bond with the neonate, child with his family, and with the time lived by them during hospitalization.The practice of offering, organizing, and storing memories is certainly challenging for the care providing team, especially when there es and confirms the need to carry out studies and implement projects that meet the needs of families, neonates, and children.Thus, we present the Memory Box in the Brazilian context as a tool for the process of hospitalization and/or death, which benefits all those involved in this process: the neonate, child, family, and nursing staff because it represents the possibility of establishing bonds and a way of remembering moments and precious memories in a healthy manner in order to overcome the concerns brought by hospitalization or even death of loved ones.Therefore, this study is the starting point for the deployment of technologies that strengthen the process of communication and bonding between the health care staff and families.
In addition, the empathy of the staff and the care provided to neonates, children, and families determine a significant impact in their memories about the difficult period in the hospital environment. 8Accordingly, when the nursing professional is able to engage in a positive way establishing a sensible relationship to the suffering of others, providing adequate care to the psychological and spiritual needs of families becomes possible. 14ne can also point out that 75.5% of professionals said they never used a technology similar to the Memory Box to work the hospitalization, and 84% have never used this technology to work with death.This finding confirms the necessity of conducting research and implementing projects such as this in Brazil to enhance and improve the care given to neonates, children, and their families in the situation of hospitalization and death.
It was also observed that the Memory Box contributes to the process of communication between the team and families.Professionals view the Memory Box as a way of approaching families during the hospitalization process, strengthening their bonds. 14o establish a bond, the team must show interest, empathy, and concern respecting the family's knowledge, guiding them, and strengthening the importance of their presence. 15The strengthening of the bond between neonate-child-family-team did not need many technological equipments, it can happen with gestures such as a receptive look, tone of voice, touch and dialogue, and creating and strengthening the bond between them. 16ith the acceptance of nursing professionals, it is considered that the Memory Box is an innovative technology and an important tool that can be used by the care team contributing positively to the challenges that arise during hospitalization.More studies need to be conducted on this theme involving other actors in the process of construction and implementation of a Memory Box.

FINAL CONSIDER ATIONS
The periods of childhood and birth are of great significance for the formation of the individual and hospitalization at this stage becomes a milestone in his history.Thus, the hospitalization experience will mark the entire trajectory of the neonate/children and their families along with the experiences lived in this environment characterized as good or bad.
To devote attention during assistance to neonates/children and their families, provide interaction between them, and encourage the maintenance of bonding, including family care, daily habits as far as possible, and guidance in organizing memories becomes not only a possibility in this process but also a necessity.
The data analysis show the importance given by nursing professionals to the use of the Memory Box.This aspect reinforc-

Table 2 -
The Memory Box is a form of specific and differentiated care to families and children, Florianópolis, Santa Catarina, 2013 Chi-square test.The abbreviations used for options for responses correspond to: DT: strongly disagree; D: I disagree; I: indifferent; C: I agree; CT: I totally agree. *

Table 3 -
Professionals involved in the application, materials used for the construction, and family members for who would be presented with the Memory Box.Florianópolis, Santa Catarina, 2013

Table 4 -
The Memory Box as a facilitator in the communication process between professionals and families.Florianópolis, Santa Catarina, 2013 *Chi-square test.The abbreviations used for options for responses correspond to: DT: strongly disagree; D: I disagree; I: indifferent; C: I agree; CT: I totally agree.