Implementation of the Humanitude Care Methodology: contribution to the quality of health care*

ABSTRACT Objective: to evaluate the contribution of the implementation of the Humanitude Care Methodology to the quality of health care in a Continuing Care Unit. Method: an action-research study with a non-probability convenience sampling, involving 34 health professionals from one unit in Portugal. Data was collected through a questionnaire and an observation worksheet for the Structured Sequence of Humanitude Care Procedures. We used data content analysis with the Statistical Package for Social Science, version 17.0. Results: health professionals demonstrated difficulties to provide care for people who are agitated, confused, disoriented, aggressive and who refuse care, and to communicate with patients who do not communicate verbally. The professionals valued the accomplishment of the stages of the observation worksheet. There were discrepancies between the perception of accomplishment and the actual practice. Throughout the implementation of the methodology, there was an increase in the practical application of the procedures, with positive repercussion for the patients and for the professionals. Conclusion: the results allowed to perceive the contribution of the process of implementation of the methodology, through the positive transformations in health care delivery.

. The reunion is the final moment of the relationship, in which commitment to future care is affirmed. At this stage, farewells are said, and a new meeting is scheduled, preventing the feeling of abandonment (2,6) .
In 2006, the National Network for Integrated Continuous Care (RNCCI) was created in Portugal for "people who are in a situation of dependency and need continuous health care and social support" (2) . Due to the diversity of patients, caregivers have been gradually recognizing the need to find innovative strategies to deliver quality care, appropriate to emerging needs (7) .
In this context, caregivers of the RNCCI have been receiving training for the application of the HCM (2) , which has demonstrated effectiveness for approaching people with dementia or in situations of dependency, avoiding agitation and resistiveness to care (8) .
The implementation of HCM (2,6)  training, directed to the 'support group', the strategic management team responsible for monitoring and following the implementation of the HCM (2) . This Care Methodology (2) promotes care based on rules such as: never abandoning care, never surprising the person with the approach and respecting the household of the patient, following the SEPCH (2). The present study was carried out with the objective of evaluating the contribution of the implementation of the Humanitude Care Methodology for the quality of care in a Continuing Care Unit in Portugal. To that end, the situation was evaluated to verify if there were differences between the importance attributed to each SEPCH step, to assess the perception of accomplishment and to observe the actual practice of health professionals. Afterwards, the transformations in the care provided throughout the implementation process were monitored.

Method
This is a longitudinal action research study using a model with sequential, interdependent and interrelated stages (2) . A non-probability convenience sampling was used, with the participation of 34 health professionals from the Continuous Care Unit (CCU) who provided direct care for older adults. The sample included 18 professionals who had already completed the training in Humanitude and 16 professionals who had not completed the training and were learning by observing the practice of colleagues. The Unit was chosen because it was in the initial phase of the implementation of the HCM (2) . None of the professionals refused to participate and there were no dropouts during the study. The Henriques LVL, Dourado MARF, Melo RCCP, Tanaka LH.
participants were made aware that the objective of the study was to follow the implementation process of the HCM (2) (2) , was used to verify the importance attributed After identifying the Humanitude care procedures which were less consistent and required improvements, some strategies began to be implemented: training in action, flyers, placement of labels and autoscopy of the care for later analysis and reflection with the professionals, in order to raise awareness (9)(10) . The objective of these strategies was to improve the use of HCM (2)

Results
Among the 34 professionals, most were females and the mean age was 36 years. Participants came from nine distinct professional areas, and the most representative were medical assistants (11) and nurses (11). The sample also included 1 sociocultural animator,  and four responded that they had difficulty in providing hygiene care.
Of the 34 participants in the study, 18 had undergone training in HCM (2) . Of these, 100% considered that Humanitude care procedures contributed to reduce difficulties and facilitate care delivery.       Table 2 we can observe the data obtained in the four moments of observation. The four observations demonstrated that the items of the SEPCH with lower values were: item "7. Introduce themselves to the patient (e.g.: I am…)", item "3. If there is no answer (expressed or implied), enters the room quietly and knocks on the bed bar" and item "26.
Tells the patients about the pleasant experience of being with them (e.g.: I enjoyed knowing you, being with you)." These items require more investment in training. The items with higher values were item "6.
Call the patients by the name that they prefer", item "9. Uses a calm, melodic and soft tone of voice", item   Table 3 we can see the means and standard deviations of the SEPCH stages in the 4 observations of the study.

Discussion
The participants of the study had different professional backgrounds, but all of them directly related to the direct provision of health care. In addition to being a young team, more than half of the participants had been working in the current area and function for between half a year and a year and a half, meaning that most professionals were still beginners and required follow-up, training, reflection on practices and studying (12) .
Despite the variations in time providing direct care to older adults, patients with dementia or with sequelae of stroke and people with aggressive emotional states/ agitation behaviors, all the professionals participating in the study had already provided care to people with these clinical conditions. The difficulties most reported when compared to the importance attributed. Similar results were obtained in a study (2) in which the total score of the importance attributed to the items was higher than the overall perception of accomplishment of SEPCH stages. In this study, nurses attributed great importance to the Humanitude care procedures and had a high perception of their application in practice.
However, there was a discrepancy between the perception of accomplishment and the actual practice, during observations. The first observation allowed us to perceive that there is a difference between the perception of accomplishment and the practice carried out in all the SEPCH stages. In this first observation the professionals demonstrated difficulty in complying with SEPCH procedures. A study conducted with nurses from UCC also presented similar results (2) , with differences between the importance attributed by professionals and the actual practice.
Despite the gradual increases in actual practice throughout the observations, after the implementation of several strategies to facilitate the use of the HCM (2) , it was verified that emotional consolidation was the stage where the professionals presented greater difficulties for implementing the care procedures. Another study (2) also identified difficulties to value the encounter with positive words and tender gestures, producing a positive priming in the emotional memory of the person.
There was a positive evolution between the first and fourth observations in all dimensions of the SEPCH.
This may be related to the interventions carried out during the HCM implementation process (2) , during which the professionals integrated the cares in their practice.
The stage that showed the greatest positive evolution verified that the application of this care methodology is a valuable tool for the control of agitation in older adults with dementia (8) , for the reduction in medication use (8) and consequently, the reduction of risks associated.