Humanization of physical therapy in an Intensive Care Unit for adults : a cross-sectional study

294 Humanization of physical therapy in an Intensive Care Unit for adults: a cross-sectional study Humanização da fisioterapia em Unidade de Terapia Intensiva Adulto: estudo transversal Humanización de la fisioterapia en la unidad de cuidados intensivos adulta: estudio transversal Aléxia Gabrielly Mondadori1, Emanuelly de Moraes Zeni1, Alani de Oliveira1, Cristiane Cosmo da Silva1, Vaneza Lira Waldow Wolf1, Marcelo Taglietti1,2

involving the care they provide, in order to be viewed as reliable by patients and to be aware of their needs.
The aim of this study was to verify whether the physical therapy care in an intensive care unit is conducted in a humanized way.This is a cross-sectional cohort study that used patient interviews via evaluation questionnaires and included 60 subjects over 18 years of age which had been discharged from the adult ICU.The interviewed patients approved the procedures carried out by the physical therapists and stressed their concern while conducting these procedures in way to keep their patients from experiencing discomfort.They were also satisfied with the treatment dimensions, with dignity, communication, reliability, interpersonal aspects, and receptivity reaching 100% of positive answers; assurance reaching 98.3%; empathy, 96.7%; and autonomy and effectiveness aspects, 95% of answers favoring humanization.The patients were shown to be satisfied, in the various aspects analyzed, with the care provided by the physical therapists, who must strive to carry out humanized professional practices.

INTRODUCTION
We know that, over the last few years, health in Brazil has reached significant scientific and technological developments, mainly in regards to intensive care unit treatments, in which patients with severe illnesses require special care¹.At these places, where qualified and specialized care is provided, it is possible to improve the chances of recovery and survival of patients in critical conditions.However, the environment becomes aggressive, tense, and traumatizing due to the number of procedures patients are submitted to².
The devices adopted in ICUs enable an effective recovery to critical patients³.However, these same devices that support healing are also seen in a negative way, as some of them are invasive and may greatly inconvenience patients, which are exposed to lack of privacy, extreme discomfort due to noise, lights, and cold temperatures, besides the discomfort that is caused by required interventions 4 .Thus, the organization of this environment is greatly important to provide patients and medical teams with the maximum comfort and safety as possible, in a way to include these aspects in the humanization practice 5 .
Humanization has been occupying a significant space in health care institutions.It is a kind inclination to promote happiness to others, and to be generous, delicate, courteous, and pleasant 3 .Costa et al., 2 state that humanization policies must be considered as collectively constructed from the identification of potentials, needs, interests, and desires of people involved, whether they are patients, family members, or health care professionals.
During the time they spend in intensive care units, patients, who are already vulnerable, start becoming afraid, stressed, uncomfortable, and lonely, and are submitted to other factors that jeopardize their recovery 6 .Thus, aiming at minimizing the problems that may be caused by hospitalization, the caregivers of these patients must strive to provide them humanized care and bring feelings such as compassion and respect towards other people to the hospital environment 3 , clarify the misconceptions associated with this environment 7 , and involve family members in treatments 8,10 .
Physical therapists have been increasingly present in ICUs, where their treatment techniques are greatly important for an effective recovery and to preserve functional abilities of patients 11,18 .Physical therapy does not depend only on technical quality, but also on the quality of relationships, as patients in intense care units are submitted to both psychological issues and physical pathologies 19 .Considering this, in order to minimize the damage and negative effects caused by hospitalization, one must value humanized care [20][21] and provide quality treatments to hospitalized patients 22 .This article intends to identify the perception of patients regarding the physical therapy procedures that are included in their recovery process, and to investigate whether the physical therapy treatments provided in the adult intensive care unit are humanized.

METHODOLOGY
This cross-sectional study was conducted from February to June 2015 with patients who were discharged from São Lucas FAG's Teaching Hospital's adult ICU, which is destined to adult, critical, clinical, and surgical patients of physicians of all specialties.The study used convenience sampling and included 60 subjects over 18 years of age who met the inclusion criteria, which were: having a history of being an inpatient in the unit for 24 hours or longer; receiving physical therapy treatments; being sound of mind and capable of speaking and/or writing; having been admitted to other units in the same hospital at the time the data were collected; agreeing to take part in the study.
The project was analyzed and approved by the Ethics Committee of State University of Western Paraná (UNIOESTE) -under official opinion no.898,614, and authorized by São Lucas FAG Teaching Hospital.The patients were assured that their data would remain secret and that their identities would not be disclosed.
The researchers received daily information on ICU discharges, and the study was conducted as personal interviews in the patients' rooms, after they were made aware of the procedures and signed informed consent forms (termo de consentimento livre e esclarecido).The questionnaire we used had been standardized, structured, and developed by Lopes and Brito 19 , and it had closed questions that included sociodemographic data, an analysis of the physical therapist-patient relationship, and an analysis of the procedures adopted by the physical therapists, which were considered either humanized (positive) or dehumanized (negative).Treatments were characterized as humanized when represented by five or more positive answers in the evaluation of the physical therapist-patient relationship, and dehumanized when represented by five or more negative answers in the evaluation of the physical therapist-patient relationship.
As soon as the data were collected they were transported, organized, and analyzed by SPSS ® software, version 20.0, which provided their frequency distributions, and these were presented as frequencies and percentages.

RESULTS
Table 1 shows the data regarding the sociodemographic characteristics, and in it we may observe that 53.7% of the patients were men in the 18 to 59-year age range (61.7%), who were married (60%), finished high school (31.7%) and earn from zero to three minimum monthly wages (65%).Among the main reasons why the patients were admitted to the intensive care unit studied, neurological diseases are the main ones in the clinical treatment group, account for 16.7% of the total, followed by cardiovascular diseases (13.3%), and respiratory diseases (11.7%).Furthermore, 8.3% of the patients were admitted due to multiple trauma, 6.7% of them for other reasons, 5% were admitted for endocrinous and kidney reasons, and, finally, 1.7% of the subjects were admitted due to nonrespiratory sepsis and following cardiac arrest.
Cardiovascular surgery leads the surgical treatment group (15%), and it is followed by abdominal surgery (13.3%), and head and neck surgery (6.7%).Among the subjects who took part in this study, 58.3% remained hospitalized in the related unit for up to three days, and 53.3% of them did not need mechanical ventilation.
In the evaluation of the physical therapist-patient relationship, we observed positive results in regards to the physical therapy treatment in the intensive care unit; the patients were shown to be highly satisfied with the various aspects analyzed concerning the care provided by the physical therapists (Table 2).

DISCUSSION
After we collected and analyzed the data, we observed that, in a general way, the patients interviewed pointed the physical therapy treatment they received as humanized, and reported being satisfied with the services provided by the physical therapy professionals in the adult intensive care unit.
The physical therapists are the professionals who are directly in contact with the patients admitted to intensive care units, whose early mobilization is fundamental in their recovery 5 .In order to improve physical therapy care, it is important to include humanization in the everyday lives of professionals and patients admitted to ICUs 19 .
Humanization only exists when there is a stance of respect, cordiality, and attention to individual patient needs, in order to establish good communication with them 1 .Physical therapists must be aware of the needs of users and their family members, in order to have a good relationship with both.Besides this, these professionals must conduct their tasks responsibly, in order to shorten the hospitalization times of these patients 5 .Physical therapists must treat their patients courteously, convey reliability, conduct their methods carefully and cordially, with the wellness of these patients in mind.These therapists must explain to their patients how and why their procedures will be conducted before carrying them out, keep an open dialog with patients and family members, and be in line with the whole team 3 .
The opinion of patients regarding the professional behavior of their physical therapists is essential in order to improve the quality of the services provided in ICUs 19 .This study obtained excellent results concerning the physical therapy treatments, which were defined as humanized by the patients, who were satisfied in regards to the aspects that comprise physical therapy care according to the physical therapist-patient relationship.The result from the evaluation of the procedures carried out by the physical therapists was extremely positive, and all subjects who took part in the study reported that the professionals executed all their procedures in humanized ways.
Positive evaluations were observed in topics dignity, communication, reliability, interpersonal aspects, and receptivity, with these being approved by all patients.The subjects interviewed also pointed out the importance of being introduced to the physical therapist who would treat them; of receiving information about which procedures would be executed and why they were important; of therapists informing their family members about the health status of these patients; of the evolution of treatments, of clearing doubts and providing guidance; and of mutual respect.
In health care, humanization is seen as attention to the way care is provided, by ensuring the rights of patients and treating them with dignity.The patients, the medical team, the patients' families, and the institutions must be involved in the humanization process, with the professionals working and a way that is sensitive to the life of the human being that is vulnerable as a result of his/her pathology 23 .
Topics autonomy, assurance, empathy, and effectiveness received some negative answers.Patients become vulnerable during their hospitalization time, and many of them are already tired after being submitted to a great deal of interventions.Physical therapy professionals take an active part in the recovery of critical patients; due to the high number of procedures conducted, these are considered to be stress-inducing to patients, as many are invasive and painful 24 .
For the contact between a physical therapist and a patient to be considered good, it must include empathy, reciprocity, trust, and affection 25 .Both the patients and their family members expect the health care professionals to create circumstances in which quick and efficient relief from discomfort is achieved, using practices that show good professional performance and result in the wellness and quality of life of inpatients 26 .
Subtil et al 25 stress the importance of patients taking active part in their healing process.Nonetheless, the critical patients who are provided care in intensive care units often do not have the possibility of discussing and deciding the types of treatment they would our would not like to receive; this lack of autonomy in ICU is inevitable in some cases -this takes place due to the necessary restrictions of patients to their beds, due to intubation procedures that make speaking difficult 27 , due to sedation situations, and also due to the need for taking immediate decisions and conducting immediate procedures, in order to provide essential care targeting patient recovery 28 .
Being a science that focus on understanding human functional ability 3 physical therapy has a fundamental role in the recovery process of intensive care unit inpatients, where professionals work in order to rehabilitate patients admitted, by supporting their healing process 29 .We know about the importance of physical therapy interventions to intensive care unit inpatients, and that there are several benefits, which include preventing and reducing harmful effects from hospital beds, psychic wellness of patients, improving their respiratory and cardiovascular abilities, promoting functional independence, providing and accelerating a quality recovery, and shortening these patients' hospitalization periods 30 .
The procedures conducted by physical therapists are often invasive and cause discomfort and stress in patients.Considering this, physical therapy professionals who work in intensive care units must carry out humanized practices and consider the emotional healing of patients rather than just their physical healing, by working ethically for human dignity 22 .The subjects interviewed approved the procedures carried out by the physical therapists and stressed their concern while conducting these procedures in way to keep their patients from experiencing discomfort.
The Ministry of Health 31 , along with HUMANIZA SUS program 32 , understand humanization as the valuing of individuals connected to the health process, whether they are patients or professionals; fostering individuals to take a leading role in their recovery; establishing bonds in a collective way and multidisciplinary work; defending a Unified Health Care System (SUS -Sistema Único de Saúde) that knows Brazilians, by providing good health care to all; adapting management models to user needs; multidisciplinary work targeting the promotion of health in a benevolent way, so it can be more efficient; improving working conditions and patient relations; and striving to build a more humane SUS, in order to improve the services provided, and providing comprehensive health care to all.
Care may become humanized through very simple gestures, such as calling patients by their names, previously explaining to them the procedures that will be conducted, being aware to non-verbal signs from patients, preserving the privacy and trust of patients, being concerned with pain and discomfort, making it easy for patients to be with their families, enabling patients to take part in their healing processes, looking patients in the eye, being kind, respectful, and ethical while working 1 .
Any professional who works in an intensive physical therapy unit must know and employ humanized practices in their everyday life, and must be able to recognize human beings in their entirety and singularity.Such professional must be aware of his/her role to those that seek them 22 .

CONCLUSION
According to the results obtained in this study, it was possible to observe that the behavior adopted by the physical therapists who worked in the intensive care unit is humanized; we also found that the patients who needed physical therapy care reported being satisfied.

Table 2 .
Physical therapist-patient relationship