Public humanization policies: integrative literature review

The study aimed to investigate the scientific literature on Public Humanization Policies, available in online periodicals, from 2009 to 2012, in the health field. This is an integrative literature review conducted in the Virtual Health Library databases: Latin-America and Caribbean Health Sciences (Lilacs) and the Scientific Electronic Library Online (SciELO) and Portal Capes. Data were collected in July 2013. To this end, the following Health Sciences Descriptors (DeCS) were used: “Humanization of Care,” “Public Policies”, “National Humanization Policy”. The sample consisted of 27 articles about the investigated theme. From the publications selected for the research, three categories emerged according to their respective approaches: National Humanization Policy: history and processes involved in its implementation; National Humanization Policy: health professionals contribution; Humanization and in the care process. The study showed that the National Humanization Policy is an important benchmark in the development of health practices. For this reason, there is a pressing multiplication of related reflections on ways to promote humanization in health services.


introduction
For several decades, the humanization of practices and health care has been discussed worldwide. In recent years, it has become a constant theme in the national scientific literature, notably in the publications arising from the collective health.
The concept of humanization is polysemic, encompasses numerous statements and is permeated by inaccuracies. However, the ways to perceive or understand humanization are not dissociated from its practices. Humanization can be understood as a bond between professionals and users, based on actions guided by the understanding and appreciation of subjects, reflecting the ethical and human behavior 1 . In another sense, humanization is associated with quality of care, which includes the enhancement of workers and the recognition of users' rights. Some academic productions understand that the humanization of the Unified Health System (SUS) covers: working conditions, care model, continuing education of professionals, users' rights and work process evaluation 1 .
From another point of view, a huge challenge concerning the humanization of SUS is to ensure an ethical exercise, which is done by a triple inclusion method: the subjects, the collective and the social analyzers. It is sought an ethic that is not processed away from the world we live, in order to remove the humanization from the field of a morality that must choose between good and evil, to deepen the subjectivity production processes. From this perspective, the links between subjects are not carried out away from the plan of care practices and management processes 2 .
As challenges to the SUS humanization processes, there is also its construction as public policy, i.e., it cannot be restricted to a government policy that suffers the effects of discontinuity, due to the rotation of rulers 3 . In this approach, the National Humanization Policy (PNH) of the Unified Health System, introduced in Brazil in 2003 with the objective of disseminating humanized health practices for users, workers and managers, is not understood as a program, but as a policy that crosses the different actions and management levels of SUS, for believing in the inseparability between modes of producing health and of managing work processes, care and management, clinical and policy, healthcare production and production of subjectivity.
The construction of a possible meaning for the expression Humanization of Health is enunciated in PNH as a new positioning, according to which an ordinary man, a human being in their concrete existence, in their normative diversity and changes that experiences in collective movements 1 . For PNH formulators, humanization is not restricted to humanitarian actions, nor is performed by humans imbued of a superhuman kindness in performing ideal services. The new humanization is a result of new practices in order to do the health work, taking into account teamwork added to an exchange of knowledge, including users and professionals 4 .
Considering the relevance of the theme about the public humanization policies, it is undeniable the contribution of studies that seek to disseminate the publications, in particular in health care, so that people can understand much more this theme, in order to support and encourage the realization of new research, through secondary data, and to promote visibility to the scientific production on the said topic.
Based on the foregoing, authors felt motivated to develop this study, which had the following question as a guide: what is the characterization of scientific literature on Public Humanization Policy, available in online journals from 2009 to 2012, focusing on the approaches addressed?
To answer the proposed question, this study aims to characterize the scientific literature on Public Humanization Policies, available in online journals from 2009 to 2012, highlighting the approaches discussed.

Methodology
This study is an integrative literature review on the knowledge production on public humanization policies. Such an approach enables the analysis of scientific research in a systematic and comprehensive way, favors the characterization and dissemination of the knowledge produced 5 , and also enables the synthesis of the state of knowledge of a given subject, enabling the identification of knowledge gaps that need to be filled with new research 6 . This method allows the synthesis of several studies published and provides general conclusions about a particular field of study 7 .
This type of research is guided by a methodological approach consisted of six distinct phases, namely: establishment of the review issue (elaboration of guiding question, establishment of descriptors and of criteria for inclusion/exclusion of articles); sampling (selection of articles); categorization of studies; definition of information to be extracted from the reviewed studies, analysis and discussion on the technologies used/ developed and synthesis of knowledge evidenced in the analyzed articles or presentation of integrative review 7 .
Initially, in order to accomplish the integrative review, it was identified the topic of interest, and the research was conducted from the following guiding question: what is the characterization of disseminated publications in online journals, from 2009 to 2012, about the public humanization policies? To identify the publications that composed the integrative review of this study, it was conducted an online search in the Virtual Health Library databases: Latin American and Caribbean Health Sciences (Lilacs), Scientific Electronic Library Online -SciELO and Portal Capes, in July 2013. For this purpose, the following Health Sciences Descriptors (DeCS) were used: Humanization of Care, Public Policies, National Humanization Policy.
The total study universe consisted of 30 publications relevant to the topic investigated, available in online journals, of which 27 articles constituted the sample, considering the following inclusion criteria previously established: articles published in Portuguese, available in full in the period from 2009 to 2012, in the scientific paper modality. As for the exclusion criteria, authors considered: duplicate articles, articles published in foreign languages or that were not in the determined period, and those that did not directly address the proposed theme.
As regards the criteria used to classify the articles in the modality "reflection", it was considered those that were focused on the relevance of the theme. The modality "debate" refers to studies that showed a discussion among authors about any idea related to the theme; while the "review" is a research carried out based on previously analyzed material. It should be noted that the "original" publication is that presenting conclusive results.
In order to facilitate data collection, an instrument was elaborated with the following information: title, year of publication, type, area of expertise of the researchers and study approach. Then, the data were grouped and presented in charts to better visualize the studies inserted in the integrative review.

results and discussion
This study comprised the characterization and categorization of 27 publications on public hu-manization policies. As for the years of publication, it was revealed that in 2009 there was a higher number of published studies on the topic investigated, with nine (33%) articles, followed by the year 2011, with seven (26%), 2012, with six (22%), and 2010 with the smaller number of publications, five (19%).
As for the design modality of studies inserted in the investigation, there is highlight for the reflection articles, which accounted for the majority, with 11 (40%) publications, original, review and debate articles, with eight (30%), seven (26%) and one (4%) publication, respectively. Therefore, the selected studies consist mainly of reflection articles, which stimulate, above all, debate in order to encourage a deeper understanding and knowledge of literature regarding the investigated theme.
Regarding the field of knowledge and training of the authors, it stood out the areas of psychology, with 11 (40%) publications, and nursing, with nine (33%); following, there was medicine, social work, speech therapy and dentistry, with three (11%), two (8%), one (4%) and one (4%) publication, respectively. These data refer mainly to increased interest of researchers from psychology and nursing to produce new knowledge on the subject under study.
With regard to the approach of publications on public humanization policies, three thematic categories emerged, as shown in Charts 1, 2 and 3.
Category I consisted of twelve articles that address the issue of public humanization policies, focusing on its history and processes involved in its implementation. The Universal Declaration of Human Rights (1948) is the primary source of the principles of humanization, since it is based on the notion of dignity and equality of all human beings. This conception is linked to ideas of humanism and human rights and relates, for example, to the autonomy of users decide on the procedures they wish to be submitted.
The theme of humanization was born as a Ministry of Health program, focused on hospital care in 2001, with the aim of enhancing the service to users and health workers. That need has emerged from the disbelief with the Unified Health System (SUS) by the population, together with the various problems involving the execution and implementation of health policies 8 .
In 2003, humanization was no longer a program and became a national policy focused on the search for the realization of the principles and guidelines of the Organic Law of Health 8 .

To describe the formation of networking as a strategy created by the Humanization Working Group (GTH) for the implementation of other provisions of the National Humanization Policy in the Hospital de Clinicas de Porto Alegre
To report the experience of a training course of the National Humanization Policy aimed at managers and workers of primary care in a municipality in the state of Rio de Janeiro

To expand and increase network talks about the SUS constitution processes reactivating its constituent power and asserting its strength as an open work in facing the challenges today
To discuss the construction process of the seminar "SUS Humanization under Discussion" and to demonstrate its connection with current SUS challenges and the propositions of the National Humanization Policy (PNH) To bring the contribution of psychosomatic medicine, through its theoretical concepts, for discussion and therapeutic performance in the relationship between professionals and users in the health system

Category i -National Humanization Policy: history and processes related to its implementation
it continues Humanization has won a new inflection, since it is no longer limited to programs that include several major projects, such as the Humanized Birth and the Humanization of Hospital Care. The National Humanization Policy (PNH) brought the proposal of being a policy running through the different sectors and programs of the Ministry of Health (MOH), in order to draw a common and cross-sectional plan through the enhancement of the human dimension of the health practices 1 . It emerges as a policy developed to face and overcome the challenges set out by Brazilian society as to the quality and dignity in health care.
This policy sprang in the Executive Secretariat of the Ministry of Health (MOH) with the task of promoting transversality, and was born within the State machinery, gestated as a government policy; however, it has always been desired as a public policy, a policy of collective. Thus, the path taken was to motivate the collective, seeking to spread the PNH principles, guidelines and devices 1 .
Following its project to become stable as health policy, the PNH has been practicing institutional support as health work method that focuses on co-management, making connection to the power of collective in health services practices 9 . In this perspective, institutional support appears as a crucial element in the practical realization of the PNH as public policy. As such, therefore procedural, the PNH is constructed from everyday experience, from the ongoing work processes in healthcare institutions, asserting itself in the concrete practices of workers, users and managers that make up the SUS in our country. It should be noted that it has privileged institu- To raise self-esteem and motivation of staff of the institution, triggering the integration among professionals and to awaken the teams to a new attitude toward users

To establish an interpretive reflection on the SUS principles and show their interface with the hospital class proposal
To bring an institutional support experience in primary care network of a city in the state of Rio de Janeiro, based on the guidelines of the National Humanization Policy of the Ministry of Health Category i -National Humanization Policy: history and processes related to its implementation tional support as an important tool in the task of promoting public political exercise in the SUS 10 .
In another approach, the research emphasizes the use of networking as a strategy to implement the PNH devices in a hospital. The networks are a device recommended by the Ministry of Health for the realization of the National Humanization Policy. Through this strategy, an awareness-raising work was started within these sectors, seek-ing to promote actions convergent with the PNH proposals. It was observed that humanizing actions occurred in the various areas involved. This shows that the network device is a precious tool, since it provides indicators for PNH and favors interrelationships between the different players that seek to go beyond the difficulties of everyday hospital activity, aiming to promote other means of healthcare practices 11 . The PNH articulates its actions based on three central axes 12 : right to health, creative and valued work and production and dissemination of knowledge. As a strategy to implement the Axis 3 of the PNH, a survey highlighted the promotion of Specialization Course in Humanization of Care and SUS Management as a way to increase the provision of training processes and knowledge on the National Humanization Policy, in order to form multipliers in shared management of care and institutional supporters for change processes. The study showed that the invention of a function -pedagogical supportin the context of PNH training encouraged the

To find the role and action of SUS Humanization Policy (PNH), verifying the strategic reasons for its formulation and its importance in the construction of SUS as an inclusive and resolute policy
Category iii -Humanization in the care process reinvention of the own place of the Academy and its social commitment in the production of knowledge 13 .
In this same line of thought, a study reported the experience of a training course in the National Humanization Policy aimed at managers and workers of primary care in a municipality in the state of Rio de Janeiro. The course aimed to form institutional supporters able to motivate the network in the Unified Health System (SUS), to promote changes and to consolidate modes of care and management services. The research brought to light that, in the formation of supporters/multipliers of PNH, the way of making this policy is reaffirmed, based on a method that believes in training practices connected to the work process and that act as intervention devices in health production practices 14 .
A study aimed at establishing the National Humanization Policy in a hospital with the primary goal of improving the relationship between professionals and between them and the service users served daily at the institution. That experience tried to respond to changes recommended by the PNH, which has been making available to health professionals tools and technologies to materialize the principles and guidelines envisaged in the Organic Law of Health (Law 8080, LOS). It demonstrated that socialization of knowledge and exchange of experience, allowed by listening to the opinions and to daily experiences of each member, enables reflections that turn into new attitudes towards co-workers and users, showing that with willpower, commitment and dedication, it can become practical examples of a SUS that works 8 .
Along the way, the PNH has stimulated the emergence of actions that are intended to mitigate the negative effects -physical, emotional and social -of hospitalization and to ensure respect and citizenship of individuals. In this approach, the study suggests the creation of environments for the educational and pedagogical service, enabling the continuity of cognitive and educational development of patients during hospitalization. It emphasizes that the pedagogical action, held in the hospital, is a joint effort of education and health areas that widens schooling opportunity, that appears as a form of humanized and comprehensive care to children's health and that is independent of health status in that the individual is found 15 .
The PNH presented unquestionable advances in its history. It is a relevant benchmark for the development of health practices that promote respect for citizens, embracing their values, aspirations and needs. However, many challenges remain to be considered. Its actual constitution, as SUS Humanization Policy, cannot be achieved without the mobilization of social forces that act beyond the State.
In this context, it is necessary that the PNH serve as a social mobilization strategy, expanding its actions to beyond complaint and claim of rights. This is a way to build alternatives to face challenges of the health field and considers the differences and singularities. These actions put individuals in touch to affect each other, to produce agreements that transform us every day in a more just and fraternal society 16 .
Articles that compose the category II focus on the contribution of health professionals with regard to general humanization policies. By exercising a role of great importance in PNH, health workers emerge as protagonists of actions related to humanization. Also called HumanizaSUS, the PNH arises from the convergence of three main objectives: to face challenges set out by the Brazilian society, regarding the quality and dignity in health care; to redesign and to articulate SUS humanization initiatives and to tackle problems in the field of organization and work management that have produced adverse consequences, both in the health production and in the workers' lives 17 .
Regarding the third objective of the PNH, it is revealed the concern of its creators with health professionals. The health production process is performed by humans with their needs and weaknesses that are reflected in subject-user and subject-professional spheres. From this perspective, unfavorable working conditions, devaluation of the wishes of employees, which exalt the technicality and bureaucracy, disqualify the care and thus the humanization of practices. It is found, in this context, a fragile professional with limited potential to humanize their care actions 18 .
Confirming the emphasis given to health professionals, the PNH favors the discussion and presentation of proposals by all actors involved in the actions -workers, managers and users -which effectively must be considered for decision making, management and implementation of actions in health services. The demands, aspirations and perceptions of everyone involved in health care routine are valued 19 . Management and care are actions that complement each other. The caregiver takes care and, concomitantly, generates their work process, while the manager is not far from the care task. The management is re-shaped and loses that traditionally associated with authoritarianism, hierarchy and imposition of rules, aimed at the pre-standardization of work processes, in line with hierarchy and domination practices 1 .
The transversality is an inherent characteristic of PNH, that indicates the value given to the inseparability between management and care. The effectively transversal management overcomes the organization of the field based on codes of communication and exchanges in the current axes of verticality and horizontality. A vertical axis is responsible for the hierarchy of managers, workers and users and a horizontal axis, for promote communications that do not intersect with each other 19 . Believing that care and management are inseparable means proposing the tranversalization of these domains, often considered unable to merge 1 .
The valuation of health workers is an important issue in the institution of PNH, for daily working under unsatisfactory conditions accelerates a mismatch process between the human and the inhuman 18 . Research aimed to identify the perception of nurses about the importance of work and professional motivation, through the parameters for the humanization of work contained in the National Humanization Policy: respect, recognition, satisfaction and professional fulfillment. It was observed that nurses experience a conflict with the values and commitments of their work, which leads to job dissatisfaction. This is why the entire work process must be urgently humanized, enabling the service to meet human needs in its everyday 20 .
Health professionals are important elements in the humanization policy, essential to promote health. Study rethinks strategies and co-responsibility commitments of nursing professionals in health promotion and stresses that the participation of nurses in the dynamics of care humanization policies has shown developments in the demonstrations of embracement and links between professionals and users of health services. It emphasizes that sensitive listening, modalities of dialogue and the method of interview-conversation are technologies of relationships and mean the acquisition of the humanization policy expertise to the development of care in health promotion 21 .
In this perspective, another study claims that the psychologist can be inserted in the public health policies, acting as co-responsible for public health, as the protagonist of coordination and interaction between the different actors of the health system and in the field of management. Thus, psychology and psychologists can contribute in a rather significant way to the discussion of social and institutional practices, and to create strategies, to motivate actions to promote inclusion, to develop spaces for encounter and dialogue and to create ways of doing/knowing, among other relevant actions in the context of PNH 22 .
Another research reveals the importance of integrating social workers in the work processes of personnel management in public health, and of the choice for professional and ethical-political project aimed at development and amplification of coherent activities with the National Humanization Policy, which strives to effectuate the principles of the Unified Health System in the sphere of care and health management 23 .
The appreciation of daily life as an element for the formulation of public policies is an innovative aspect of the PNH, for health policies originate, in general, from the bureaucratic apparatus of the State, so accustomed to standardization and prescription 16 . In this approach, a study indicates that investments are needed in training and institutional and care management, so that the humanization policy is effectively implemented in an Intensive Care Unit. It was observed that actions such as open visit, ambience, hospitality, interaction with the multidisciplinary team, workshops and working groups, which are primary conditions for good humanization practices, still lack implementation 24 .
As for publications placed in category III, evidenced in Chart 3, this research shows that the humanization policy has become, in recent years, a recurring theme in investigations, reflection and discussion in health care. However, with such a discussion, social, institutional, professional and, above all, ethical and legal dilemmas emerge.
It is noteworthy that the National Humanization Policy, as well as the principles and guidelines of the Unified Health System (SUS), commits to enable comprehensive care to the population and to propose strategies through which the rights and citizenship conditions for population groups could be expanded -these groups include children, teenagers, woman, man, elderly and terminally ill patients. Thus, when considering the hospital setting, one must understand that humanization needs to be aimed at both inpatients and their families, and for health care team itself, since it is through the effective and affective interrelation existing between them that care that develops in a more humane, ethical and solidarity manner 25 .
With regard to the operationalization of the National Humanization Policy during childbirth, the study findings suggest two important perspectives: the organizational structure and the ideal attendance at delivery, which focuses on the aspects related to structural and functional components of the work; and the relational structure of the workplace and ideal attendance at delivery, which addresses the elements relating to relations in the triad parturient-family-worker. However, it should be noted that aspects recommended by the Ministry of Health in the humanization policy of the delivery, such as the prevention of maternal and neonatal mortality, the encouragement of early contact between mother and child, breastfeeding in the first hour of life, the concept of women's autonomy and control over their body and their reproductive process were not remembered by professionals of the study 26 .
Research 27 asserts that during the implementation of humanized practices in childbirth care in Brazil, the neoliberal government invested in qualified human resources that used low-complexity technologies. Although the neo-liberal policy and globalization have favored the inclusion of obstetric nurses in the humanized delivery care, the management model currently applied to health services, especially at the municipal and state levels, through privatizations, may appear as a negative factor for nurses, considering that their obstetric practice is exercised only at the municipal level, which may result in the loss of space.
Another study 28 , points out that, in order to assess the knowledge of a multidisciplinary team on the Elderly Statute, the authors interviewed 35 professionals of a geriatric hospital in São Paulo. They observed several changes in the team, in care, in institutions and in attitudes of older people and their families themselves. The most eye-catching changes were the increase in humanization and respect in care of the elderly and a greater participation of elderly in making decisions about their treatment, which gave them more autonomy. Thus, the authors 29 refer that the humanization in care for the elderly requires a priority service in its entirety and individuality, and respect for their autonomy and maintenance of their independence.
In a study 25 conducted with nursing professionals in an ICU setting, it could be seen that the concept of humanization, in these professionals' view, is extremely rooted to the most relational issues of the human being, as well as to those involving sensitivity, respect, empathy and the responsibility in/for caring. However, it is urgent to point out and discuss the fact that the humanization policy outreaches beyond those aspects of humanism, since it considers the need not only to improve access, the embracement and the care provided, but also the way to manage and administer health practices in order to qualify the services.
In addition, based on the speeches of the participants of the said study, it appears that the existing factors that may hinder the humanization process are related to three issues: the way of caring, still grounded in Cartesian model of care; the interpersonal relationships between members of the healthcare team; and the rules and routines established by the health services.
Given the explicit aspects, it is considered that, despite the intense preoccupation with people's welfare, as evidenced by the range of policies, laws and programs that ensure the rights in various aspects that affect their needs, especially in healthcare, encompassing both the physical and the emotional aspect, there are many obstacles that prevent these policies from being actually accomplished. This also prevents the fulfillment of fairness, integrity and universality, which are guiding directives of the SUS. Therefore, the strategic role of the Humanization Policy is to maintain vivid in SUS and in each of its policies, solidary spirit and actions, the construction of the common good and the uncompromising struggle against the cooptation of this sense by the State, in general, by any institution, in particular, or any singular group 30 .

Final considerations
Considering the analysis of the selected articles, it can be said that, in Brazil, public humanization policies found a path from the drafting of the National Humanization Policy of the Unified Health System, which aroused as policy built to face and overcome the challenges faced by Brazilian society as to the quality and dignity in health care.
The first thematic category emphasized the National Humanization Policy, its history and the processes related to in its implementation. The second addressed the health professionals' contributions regarding the National Humanization Policy, emerging as protagonists of actions related to humanization. The third category analyzed the humanization in the care process, high-Collaborations MADM Moreira and AM Lustosa collaborated in the development and supervision of the project, in the data collection and analysis, in the preparation and final review of the article. F Dutra collaborated in the preparation and supervision of the design, drafting and critical revision of the article. EO Barros and MCS Duarte collaborated in data collection and analysis, in the drafting and final review of the article. JBV Batista collaborated in analyzing the data, in the writing and critical review of the article.
lighting the humanization of childbirth, care for the elderly and patients under intensive care.
The theme Public Humanization Policies, with emphasis on Brazilian reality, requires great debates about the effectuation of the National Humanization Policy, which is a relevant benchmark for the development of health practices that promote respect for citizens, considering their values, aspirations and needs. It is necessary, therefore, to do further research, since it will pro-mote a broad strengthening the opinions and in the criticism on the theme in question.
Based on the foregoing, it is expected that this study will serve to support further discussions about public humanization policies, multiplying reflections related to ways to produce humanization in health services, as well as concrete actions that allow the real implementation of the National Humanization Policy according to the exquisite way it was designed.