Percepção da humanização dos trabalhadores de enfermagem em terapia intensiva Perception of nursing workers humanization under intensive therapy

Objective: understand the perception of nursing workers working in the Intensive Care Unit (ICU) regarding humanization in the work environment. Method: we used the reference of phenomenology, structure of the phenomenon. Participated 25 nursing professionals working in an adult ICU of a university hospital, through focused interviews, answering the guiding question: What do you understand by humanization of the working conditions of the nursing team working in the ICU? Results: the analysis revealed the themes: humanization in the ICU; working condition in the ICU; management of people in the ICU and management process in the ICU. Final considerations: humanization is necessary through the change of the work environment and the managerial process, privileging the participatory management model as a way to transform theory into practice and value the worker. Descriptors: Humanization of Care; Intensive Care Unit; Health Personnel; Qualitative Research; Participative Management. RESUMEN Objetivo: comprender la percepción de los trabajadores de enfermería que actúan en la Unidad de Terapia Intensiva (UTI) respecto a la humanización en el ambiente de trabajo. Método: se utilizó el referencial de la fenomenología, estructura del fenómeno situado. Participaron 25 profesionales de enfermería actuantes en una UTI adulto de un hospital universitario, a través de entrevistas focalizadas, respondiendo la cuestión orientadora: ¿Qué entiende usted por humanización de las condiciones de trabajo del equipo de enfermería que actúa en la UTI? Resultados: El análisis reveló los temas: Humanización en la UTI; condición de trabajo en la UTI; gestión de personas en la UTI y proceso gerencial en la UTI. Consideraciones fi nales: la humanización se hace necesaria por medio del cambio del ambiente de trabajo y del proceso gerencial privilegiando el modelo de gestión participativa como un camino para transformar la teoría en práctica y valorizar al trabajador. Descriptores: Humanización de la Asistencia; Unidad de Terapia Intensiva; Personal de la Salud; Investigación Cualitativa; Gestión Participativa. Percepção da humanização dos trabalhadores de enfermagem em terapia intensiva Perception of nursing workers humanization under intensive therapy Percepción de la humanización de los trabajadores de enfermería en la terapia intensiva Vanessa Cecilia de Azevedo Michelan E-mail: vcpazevedo@gmail.com AUTOR CORRESPONDENTE


INTRODUCTION
The socioeconomic, political and technological transformations that occurred in the 20th century changed people's way of life and, consequently, the demographic and epidemiological profile of the population, which began to live longer, fell ill and died from chronic-degenerative diseases and traumatic causes which demand a high complexity care.Moreover, such advancement has made people more aware of their rights and consequently demanding quality of care.As in the health area the user is not always clear about the meaning of this quality, the humanization in care and the development of a critical awareness of the professionals in the search to implement quality care are relevant aspects for the population's awareness.
The National Humanization Policy (NHP), through collective forums, has been constructing opinions contrary to the fragmentation and disarticulation of actions, intervening in order to increase the degree of openness of communication between the different groups and segments (1) .In this sense, when proposing support with relational technologies and sharing of practices, it aims to improve and foster changes in management models, discussing the work situation of the Unified Health System (SUS) worker.Therefore, support is to produce other ways of working to promote the expansion of the power to act of these protagonists, such as: valorization in the work and the collaborator (1)(2) .
For the context of building the SUS, the NHP, created in 2003, can be considered as the central axis of the proposal, since it includes in its concerns, guidelines and priorities of all actors involved in the health production process (2) .
Humanization is understood, therefore: The valuation of the different subjects involved in the process of health production: users, workers and managers.The values that guide are: the autonomy and protagonism of the actors, the co-responsibility between them, the establishment of a solidarity bond and the collective participation in the management process (3) .
In this context, humanization, in the light of politics, has a comprehensive focus ranging from the provision of care and management services and technologies, to the creation of work environments that can result in comfort, safety and wellbeing for the user and their families (4)(5) .
The nursing work process, based on the science and practice of care, is a condition of law, because this work implies respecting the other, in the treatment, that is, in ethics, in order to promote health (6) .
In this sense, for a better understanding of the nursing work process, as a social practice and destined to an object to be transformed into a product, instruments are used to achieve a specific purpose (7) .
Nursing makes up a network of work subprocesses, which may (or may not) be performed concomitantly.They are: the subprocess work watch; the work subprocess management; the work subprocess teach; the subprocess of job search, and the subprocess of labor participate politically.In this way, a network of division of labor is formed, which refers to the work object, means and instruments, establishing priorities and goals, and evaluating the results achieved (7) .
It is worth mentioning that the nursing work in the various Intensive Care Units throughout the world goes through stressful processes, considering that they are crucial environments in hospitals to treat increasingly severe and senile populations (8) .
These nursing professionals, in their work process, are exposed to all loads, being the psychic wear more intense than the physical, reflecting dissatisfaction with the work activity and the physical health of the workers (7) .
Considering the peculiar characteristics that permeate the context of Intensive Care Units (ICUs) and because this is a sector in which specific and complex care is carried out, it is important not to dominate the knowledge with the high technology existing in them, it is necessary to deter attention to the integrality of care.For this, professionals must be active, apply their knowledge and skills, exercising their capacity, as well as technical, political and social (9) .
In this sense, we ask: What is the perception of ICU workers about humanization in their work?
The purpose of this research will be the construction of a proposal and intervention strategies for a humanized environment with a view to nursing care with impact to users, workers and health managers.
Thus, the objective of this study was to understand the perception of nursing workers working in the ICU regarding humanization in the work environment.

METHOD Ethical aspects
The study was approved by the Research Ethics Committee of the Faculdade de Medicina de Marília (FAMEMA).After approval, the principal investigator discussed the design and objectives of the study with the participants, obtaining the voluntary consent and ensuring confidentiality and data protection, as proposed in the resolution of the National Health Council (NHC) No. 466/2012 (10) .

Theoretical, Methodological Frame of Reference
Type of study It is a qualitative research, through the phenomenological method.According to the Merleau-Ponty philosopher, Phenomenology is the study of essences, and of all problems, according to it, it is summed up in defining the essence of perception and consciousness (11) .Because it is a philosophical reference, it is important to implement it as a method.
The structure of the phenomenon situated (12) is a proposal that comprises three moments: description, reduction and understanding.The description involves the selection of participants who best share the essence of their lived experience with respect to the phenomenon of interest.The reduction consists in identifying the essence of the participants according to the units of meaning extracted from the statements and the understanding includes the interpretations of the researchers with the units of meaning and the revelation of the themes.
Perception of nursing workers humanization under intensive therapy Michelan VCA, Spiri WC.

Methodological procedures
The research was conducted in one of the Adult Intensive Care Units of a Teaching Hospital.This institution has four health care units, which operate in different buildings, maintain unique organizational structures and complement each other in the different therapeutic and diagnostic sectors.In addition, it has the Undergraduate Course in Medicine and Nursing and Medical Residency Program in several specialties.Due to these resources, this institution serves as a point of reference for the entire region, and is currently maintained by the state public power.
The referred hospital has two ICUs, "A" and "B", in a total of twenty four beds, with twelve beds each.The average occupancy is 100%, the cases are clinical and surgical, for acute and / or severe situations of adults, and polytrauma and cardiac disorders are the predominant morbidities.The research scenario was the Intensive Care Unit Unit B, due to the author being a member of the Intensive Care Unit A.
It was a convenience sample, since the nurses (nurses, nursing technicians and auxiliaries) of the ICU B were invited to participate in the study and 25 participated in order to understand the humanization in the work, from the perspective of the team of nursing.
The data were collected between March and August 2010, using the semi-structured non-directive interview and audiotaped, performed by the principal investigator, in a private place, according to the convenience of the participants.The interviews lasted an average of 30 minutes, with the following guiding question: What do you mean by humanization of the working conditions of the nursing team that works in the ICU?
The interviews were transcribed and independently coded by the authors.The steps for analysis were those proposed by the phenomenological method of the structure of the phenomenon located (13) .Study participants validated the themes revealed.

RESULTS
Of the 25 participants in the study, 22 were female and three were male, aged 21 to 56 years and with an average of 13.5 years worked.
After the individual (idiographic) analysis of the statements, a global (nomothetic) analysis was carried out to structure the phenomena.
The subjects revealed were: humanization in the ICU; working condition in the ICU; management of people in the ICU and management process in the ICU.Diagram 1 represents the themes emanating from the statements: In the topic of humanization in the ICU, it was revealed the need of the worker to be assisted in a holistic way, repercussions on the recovery of the patient, since they indicate that the dialogue and listening are comparable with a drug treatment.They also explain that the relationship between the team, focus on the patient, reception and material and immaterial conditions are fundamental aspects.The speeches express: The theme, working conditions in the ICU, revealed that the ICU nursing workers view weaknesses and strengths regarding working conditions.Thus, they mention the importance of being informed about the diagnoses of hospitalized patients, as well as the meetings proposed and performed.They also mention the structural development of the physical space of the critical unit, use of uniforms, material resources, human resources and the technological evolution of the equipment.[...] The work condition is good, it could be a bit better in a sense, that we had more information, sometimes some diagnosis, because maybe it was a little of us to be curious to be informed, to be asking the conditions I believe it is good that the Institution proposes, "I" think it meets the needs.(DII, 3) In the subject, people management, it is observed that, in portraying management, workers feel the need to be close, to participate, to be heard and also stimulated, since they believe that there is a lack of support on the part of the managers, especially in the UTI, consequently a dictatorial management, reflecting on the need for approximation, inclusion and motivation, thus expressed in the lines: [...] First approach of the managers, according to the participation of the employees, third stimulus to the employees to evolve professionally do not have this stimulus, does not have support from the managers too, then this is missing ... (XV, 5) [...] The hospital itself as a whole is missing a lot more precisely within the ICU, I think that the managers themselves make this difficult, especially with regard to the nursing worker who wants to study, to have an opportunity to study ... the management does not release time for the study, the acceptance of the opinion of the people that there in closer contact of the patient, it is more dictatorial the regime the Management of the Intensive Therapy, then this hinders our work quite, perhaps if it were different ... (XV, 3) [...] we get on duty with four or five employees and the manager does not want to know, and you have to deal with the message, so this is not humanized care, because we wear out, we do not give that assistance that we would like to give to the client, and at the same time you are charged, then you are charged for something that does not have and that hampers your work maybe and if it had would be better ... (XV, 6) [...] I realize the difficulty is very great, to have humanization inside the team, because we are working in less employees ... lack of the nurse in the unit, sometimes the nurse has to cover two sectors also harms in the assistance , even because they end up delegating to us duties that are not ours sometimes, sometimes I can say that it is dehumanizing until the assistance, even because we are tired of the reality that we face today, so at the moment I have great difficulty ... (XVI, 1) The theme, management process in the ICU, reveals a vertically centralized and hierarchical management, lack of dialogue, lack of contact with the superior hierarchy, lack of professional appreciation.This is what the speeches reveal:

DISCUSSION
The results of the study show that humanization in the ICU involves the holistic care of the patient, relating it to the family and social context and that the work of the workers extends beyond the technological and pharmacological interventions focused on the patient (4)(5)13) .
The worker must rethink his actions, in order to guarantee the dignity of the human being not only in caring and watching, but in other aspects that go beyond the technique, as well as work environment, in its subjectivity and in the cultural aspects (14)(15) .
With a view to the recovery of the hospitalized patient in the ICUs, in order to direct the care to the physical comfort associated with the provision of care that aims to ameliorate pain and suffering, these attitudes must be established by the worker, through the commitment applied by the practice with a view to promotion of health (13) .
On the other hand, the ICU scenario alone represents a source of stress for hospitalized patients.In this environment there may be feelings of anguish and insecurity.The complexity of the intensive routine also contributes to the lack of basic actions such as listening, touching the other, and technological domination predominates in individual actions, making the process of rehabilitation and humanization more difficult (5,(13)(14)(15)(16)(17) .
In this sense, humanization in the ICU also means the understanding of the human being as a complex, singular being capable of (re) organizing itself depending on the conditions and / or environment in which it is found and the relationships in which it is constituted (9,15,18) .Lack of information is also a problem to be identified by nursing workers about risk agents peculiar to the work environment (1) .In this way, strategies that favor the safe transfer of information in shifts of shifts and patient management among the units are also necessary, for a better working condition as well as patient safety (18) .
Therefore, when a space is opened to express feelings and reflection on their practice in a situation of welcome and safety, health workers reflect on the care taken, as well as having a space for their own care (5) .
The nursing team that works in the ICU, because it requires professional knowledge, fast reasoning for decision making, due to the dynamics of the unit, says that, first, it has to guarantee enough human resources to perform the existing activities (18) .
The precarious working conditions in the public service cause suffering due to impotence regarding the quality of patient care, resulting in job dissatisfaction and disruption in the work process (16,(18)(19)(20)(21)(22) .
Another negative reflex when we mention the working conditions is the physical and emotional exhaustion, the low remuneration, resulting in the poor quality of care provided to the patient, as well as the abandonment of the profession (5)(6) .
The management of people in the nursing area, in hospital institutions, is extremely important to guarantee sufficient and competent human resources to maintain the quality of care and development of nursing work activities, and it is essential that nursing managers participate actively avoiding work overload, thus increasing patient safety (6,9,16,19,(21)(22) .
You can say that people management represents organizations and people, because organizations are people and depend on them to achieve their goals and fulfill their mission.When people are mentioned, organizations are the means by which they can achieve their personal goals with minimal time, effort, and conflict.In this way, without organizations and without people, there would be no people management (23) .
On the other hand, health institutions, as service organizations, represent psychosocial systems that are very different from other organizations, because hospitals are organizations that coexist directly with health problems, suffering, pain and death (24) .
Health institutions, because they provide direct service to people, need a differentiated and complex dynamic, because their raw material is human, their product is human, their work is done mainly by human hands and their goal is the well-being of human beings (24) .
Consequently, the workers are affected, since the fact of dealing with a differentiated and complex routine promotes the involvement and the thinking, making it possible to make decisions that are desirable or undesirable from the point of view of the organizational routine.Therefore, every manager must be aware of the role of his workers in the various administrative and productive processes and their importance (24)(25)(26) .
The worker must express himself and participate in the process in a committed way, guided by horizontality, constructing dialogic-reflexive spaces with possibilities for changes in managers and professionals, which can be part of the goals of organization and management of people, resulting in environments more welcoming and with recognition of the worker as subject, through a greater approximation with the institutional direction (25,27) .
Therefore, with the transformation of health management, it begins to develop in these services, a service with the central focus on the investment of human capital to attend patients in order to have a significant impact on the quality of the service provided and, in this way, transforming into a competitive resource (26,28) .
The tendency of the institution is to reorganize the form of management, focusing on human resources, given that the nurse worker exercises management with commitment and ethics, which he currently seeks to make his work environment more humane, guaranteeing the integrity of the people and their way of relating in the work seeking the dimension of being (28) .
In order to manage the work / care, the nurse worker within the ICU needs to create possibilities for a different job, which can be shared with co-responsibility and decentralization (27)(28)(29)(30) .
The possibilities for innovation and change in the conceptions and practices within organizations depend on the rupture with the alienation of work, the rescue of the possibility of producing knowledge from the practices, the development of strategic resources that contribute to teamwork and democratization management of health work processes (26)(27)(28)(29) .
Thus, the nurse worker must understand the reality of their organization and exercise a management process focused on the expectations of patients, as well as nursing workers, including nurses, as these professionals experience situations of lack of motivation due to the high workload, which hinder the development of the work process and compromise the quality of care (24)(25)(26)29) .
Another factor of the managerial process is the discussions and reflections about the decision making process and the decision making in the hospital environment that need to reach the training institutions so that the nurse professional can be better prepared about the decision process (25) .
In this sense, rigidly hierarchical working relationships are considered real when certain nurses adopt a centralizing and authoritarian attitude towards the team.However, this stereotype must be constructed (de) to build new working relationships in health and nursing (25,27,30) .
Participatory management and decision-making together strengthen and value teamwork, enable the participation of professionals in care planning and actions, stimulate commitment to the democratization of labor relations, create and facilitate spaces for exchange and production of the knowledge in the collective and broaden the dialogue between the health team (25,27,30) .
The care / attending, when performed in a comprehensive way, promotes professional autonomy, valorization, technical competence and team building, broadening and strengthening actions to face, solve and meet the needs of patients in the ICU (30) .

Study limitations
The limitation of the study is related to the circumscribed context of the participants, which does not make possible the generalization of the results found in the research.

Contributions for the Nursing field
The qualitative approach adopted allows a deepening of the nursing workers' experience in this context and the proposition of strategies that can contribute to the strengthening of the humanization actions in the studied ICU.

FINAL CONSIDERATIONS
The essence of the phenomenon of the situation experienced by nursing workers revealed convergences, divergences and idiosyncrasies that made it possible to understand and perceive the essence of "me" of "other", of the environment organization, institution, experiencing the participants' subjective world of study under optics in relation to the phenomenon.
The implementation of the Humanization Policy is necessary in order to modify the work environment, through listening, democratic management and a humanistic culture, and it must be a way to transform theory into practice, in order to value the worker and the relationship with the managers that represent the institution, reflected in the humanization at work.
The working conditions in the ICU, according to these nursing workers, present weaknesses and strengths.They consider information about patients' diagnoses as extremely important, as well as meetings, physical structure, use of uniforms, material resources, and human evolution of equipment.However, the lack of information can be a problem in this environment, as well as possible shortages of human resources for the performance of work activities, lack of physical space for own care and also the need for physical space between the beds, which should be higher, for better execution of tasks.
It can be said that such individuals feel a lack of participatory management, that is, in which they can be heard and stimulated.In their speeches, the institution's management of people remains centralized and dictatorial.
They also mention work overload and stress, thus generating dehumanized care for the patient, as well as problems with one's health, already precarious, due to the lack of care and the lack of care received by the institution.
As for the managerial process, they explain a centralized, vertical and hierarchical management, resulting in a lack of dialogue and professional appreciation.
In this sense, the discourses refer us to think of a participatory management as a solution in the construction in the work process.
Therefore, the scope of the phenomenon and its different perspectives may offer other approaches to be considered, thus broadening the phenomenon of the experience of nursing workers in the ICU in a humanized environment, for the patient as well as for the nursing worker.
[...] humanizing ... is the way to work not only the emotional ... not only a behavior of the employee, but to watch the employee as being biopsychosocial.(DI, 1) [...] The humanization there [ICU] is very important even for the recovery of the patient, as well as medications, good treatments, conversations the dialogue for those who are aware "I" think important, if we have this time available to them, their treatment ends up being faster and faster recovery.(DXXIV, 5) [...] I understand that ... we employees have to have a good relationship and a good relationship between employees so that our work, our performance is focused on one goal, giving the best that we can to the client.(DII, 1) [...] When one speaks of humanization one understands itself as "reception".(DXI, 1) [...] Humanization for me is all the care that already requires the patient.(DXII, 1) [...] I understand humanization as the material conditions of work, care by the managers, more humane service, respect and employee participation.(DXV, 1)

WFigure 1 -
Figure 1 -Unveiled themes: Humanization in the Intensive Care Unit [...] In my view I had more meetings, so that we could open up more and not so when the problem appeared.(DII, 4) [...] I think, the condition of ICU work has improved a lot in relation to the old ICU, because it was a poorly arranged room.Currently she is more modern has better appliances.(DXIV, 1) [...] Working conditions used to be bad, we worked with our own clothes, today have uniforms to work in, materials and employees, "I" I think you have improved enough you have a respirator and a good monitor, "I "I think that in this part the Institution has evolved [...].(DXIV, 5) [...] In relation to the management, the managers hear more the employees come closer, to work closer ... (XV, 2) [...] This proximity to us makes the employee feel more secure and open ... (DI, 8) Levando em consideração ao que foi dito anteriormente as condições de Humanização são mínimas.(DVIII,4) [...] We are in an Institution with a vertical administration, hierarchical and authoritarian, we have little contact with administrative directors, only sporadic meetings with the management.(DVIII, 5) [...] The hierarchy does not propose [humanization], I think not, and lack of dialogue mainly in the boss the top down, lack dialogue ... (XVII, 4) [...] I have never seen anything [humanization], they propose for the patient and for us too, I think with respect to other institutions I think that here is to be desired ... (XVIII, 3) [..