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Acta Paulista de Enfermagem

Print version ISSN 0103-2100

Acta paul. enferm. vol.24 no.3 São Paulo  2011 



Humanized care: the act with respect to design improving student nursing*


Cuidado humanizado: el actuar con respeto en la concepción de capacitados de enfermería



Emília Cristina PeresI; Ingrid de Almeida BarbosaII; Maria Júlia Paes da SilvaIII

ICardiac Nurse Specialist from the Heart Institute of Faculty of Medicine of University of São Paulo. Registered Nurse at the University Hospital of University of São Paulo - USP - São Paulo (SP), Brazil
IIClinical and Surgical Nurse Specialist from Escola Paulista of Medicine- Federal University of São Paulo - UNIFESP - São Paulo (SP), Brazil. Registered Nurse at Oswaldo Cruz German Hospital
IIISenior Professor of Nursing at the Nursing School of University of São Paulo - USP - São Paulo (SP), Brazil

Correspoding Author




OBJECTIVES: To investigate aspects of the hospital routine, recognizing bioethical principles (PB) impacting the delivery of nursing; verify that improving this situation requires that the concept of respect is rooted in this routine, with the patients; and, assess whether differences exist in the concept of respect among nurses working in a teaching hospital and those who graduated recently from a Program for Improvement of Personnel.
METHODS: This was an exploratory, qualitative approach, performed in a large hospital involving, as participants in the study, 20 recent graduates.
RESULTS: It was found that graduated student realizes that the PB helped in their routine; that the concept of respect applies in all situations with patients; and that the workload makes it difficult to anchor this concept in practice.
CONCLUSION: Recently graduated students had more difficulty than more experienced nurses in overcoming the routine of work and identifying ways of anchoring this concept.

Keywords: Humanization of assistance; Bioethics; Nursing care; Professional training


OBJETIVOS: Verificar aspectos de la rutina hospitalaria, en los cuales el que está siendo perfeccionado en enfermería percibe los principios bioéticos (PB) en la atención; verificar en qué situaciones ese capacitado percibe que el concepto de respeto está anclado en su rutina, con el paciente; y, evaluar si existen diferencias en la concepción de respeto entre los enfermeros que actúan en un hospital Escuela y aquellos formados hace poco tiempo, ingresados en un Programa de Perfeccionamiento de Personal.
MÉTODOS: Se trata de una investigación exploratoria, con abordaje cualitativo, realizada en un hospital de gran porte que involucró, como sujetos del estudio a 20 que se estaban perfeccionando.
RESULTADOS: Se verificó que los capacitados perciben que los PB los auxilian en su rutina; que el concepto de respeto se aplica en todas las situaciones con el paciente; que la sobrecarga de trabajo dificulta el anclaje de ese concepto.
CONCLUSÍON: Los que están siendo perfeccionados en enfermería presentaron más dificultad que los enfermeros con mayor experiencia profesional para superar la rutina de trabajo e identificar formas de establecimiento de ese concepto.

Descriptores: Humanización de la atención; Bioética; Atención de Enfermería; Capacitación profesional




In the hospital setting, the concept of humanization has become necessary in healthcare since some factors, such as the advances of medical technology, hospital routines and, to a certain extent, the team paternalism tend to limit healthcare to the application of technical procedures with mechanical aims, resulting disadvantageous to patient autonomy.

The many dimensions which constitute a human being, i.e., the biological, psychical, social and spiritual aspects and all their peculiarities, are relevant and must be taken into consideration in health care. Therefore, healthcare practices solely scientific can be reductionist as they do not contemplate the holistic care in which the human being is seen as a dynamic whole being(1).

Some of the premises of the humanized healthcare are the perception of the human being as a biopsychosocial and spiritual being and his essence and individuality should be respected. The respect towards the patient and the Principialist Bioethics principles, autonomy, beneficence, nonmaleficence, and justice ground the search for hospital humanization(2).

The principle of autonomy can be expressed by the respect any person should be treated with, as well as being regarded free to make decisions and take actions. On this account, responsibility comprises the choices one makes. The person's own will, moral values and beliefs should be respected. Based on the democratic principle that will and free consent must be regarded as preponderant factors, since these elements are directly associated with the principle of human dignity(3). Autonomy can be defined as the human ability to create laws, self govern, make choices, share, and assess, without internal or external constraints"(4).

To respect one's autonomy is to value his opinions and choices, avoiding any impediment to his actions. To show lack of respect towards an autonomous agent is to disregard his judgements, deny freedom of action based on his judgments; and omit necessary information for decision making when there are no justifiably reasons for doing that(5). On assisting a patient, expressions such as "you have to", "you have to take this medicine", "you have to bathe", "you have to eat", may induce the subject to act according to personal criteria, resulting in interference in the person's right to decide on his own life.

A research carried out in a University hospital has approached the patient's possibilities to manifest autonomy and concluded that the issue of autonomy should be developed, mainly as regards the aspect of the freedom to participate in the decision making process on his own treatment. This implies political and cultural changes and, for this reason, poses many difficulties. However, if patient's autonomy is made real, it can enable relevant advances in the improvement of health assistance(6).

The principle of beneficence indicates the need to seek the patient's well being; complementarily, the principle of nonmaleficence share the same characteristics of beneficence as it points to "no intending or doing harm"(3).

The principle of justice presumes that all patients are entitled just, equal and universal access to health care, taking into consideration their clinical and social status. This implies that their needs should be understood in order to be properly met(7).

A user-centered practice premises the responsibility of the nursing team towards the patients' needs not only to supply them with health care but also to regard them as authentic beings with all the transcendental dimensions which define human beings(8). To fulfill this commitment, the interpersonal relations must be regarded as the essence of the nursing role, what makes communication a major component in the nursing assistance. As the notion of respect involves the way we act, the manner nurses communicate is undoubtedly crucial when respect is under analysis.

Communication can be defined as the process which allows people to exchange information, consisting of the following elements: the sender, the recipient, the message itself , the signs involved and the setting in which the interaction takes place. It is noteworthy to point that this process is formed of verbal and non-verbal spheres(9).

Verbal communication is characterized by words expressed through written or spoken language and it aims expression, clarification or validation of something. In order to effectively use it, the nurses must be aware and apply techniques of communication, such as to verbalize his interest towards the patient's discourse, remain in silence and not interrupt the patient , listen, clarify and validate the messages received(9).

Non-verbal communication implies all sorts of information generated from people's interaction through gestures, postures, facial expressions, body language, natural or artificial idiosyncrasies, spatial organization of objects, and the distance between the subjects(9). An analogy between human communication and an iceberg can be made, where the verbal element of communication constitutes the top part of the latter. An efficient communicator is able to recognize that "under" the words uttered, there is a large number of symbols and human signs(9).

Based on these reflections and on the understanding that respect is expressed through communication, a recent study carried out at a University hospital assessed whether the nurses perceived that bioethical principles should rule their practices, and, also, whether the manner these nurses communicated, acted and performed procedures demonstrated respect towards their patients. The authors of this study concluded that the nurses believed that bioethical principles helped their routine, although the grounding of these principles can be made difficult due to hospital norms and routines. They also concluded that, even in simpler situations, nurses noticed the interference of bioethics in their routine, revealing awareness of the necessity to reevaluate their practice in more complex situations(10).

We consider that professional qualification should provide a holistic and dialectical view of the health problems of the community as well as cultivate ethical values. Moreover, there is an increasing need to improve team qualification in order to keep up on the new advances of technologies introduced in the medical realm. This work aimed at understanding how newly graduated nurses deal with the bioethical principles in their practice. Also, as we find relevant, to raise the questions: How do these nurses perceive the bioethical principles in their actions? Are they aware that the manner employed in their actions and in the communication with their patients in hospital routine indicates respect or lack of respect towards the ill in their totality?



We aim to assess the different aspects of hospital routine from where the newly graduated nurses perceive the bioethical principles applied in assistance, as well as to verify which situations respect can be perceived in the interaction with patients. Furthermore, we aim to assess if there are differences as regards the concept of respect between the registered nurses and the newly graduated nurses working at a university hospital and taking part in a Performance Improvement Program.



This was a qualitative descriptive exploratory research carried out in a high complexity terciary hospital located in São Paulo, São Paulo. The subjects of this study are 20 newly graduated nurses enrolled in 2007 in the Performance Improvement Program (PIP) with a total of 44 students. The Performance Improvement Program is a Scholarship Program of the State of São Paulo, created on September 11, 1979, by the decree no. 13.919 for graduated health professionals.

By the Secretary of Health of the State of São Paulo, PIP was conceived to stimulate post-graduation qualification of human resources responsible for direct health assistance of the population. The Administrative Development Foundation manages the Program and has been in charge of internship grants since its creation.

The PIP aims to complement the formation of recently graduated health professionals, excepting for medical professionals, through training, and its chief objectives are: capacitate professionals for a qualified and differentiated practice in an object area of PIP, enhance professional performance through access of new theoretical knowledge with emphasis on specific practices; stimulate the development of a wide and critical of the Brazilian Unified Health System (SUS) aiming to contribute to an improvement in the health service offered to SUS users; improve the process of professional formation based on the SUS guidelines and principles to develop wide and integrated comprehension of the different actions and work processes of the participating institution.

Among the criteria for the inclusion of the participants of this study are: ingression in the program in 2007 and interest in participating in it as well as having signed a Free Consent Form. Following the approval of the Research Ethics Committee of the Nursing School of the University of São Paulo, the students were contacted, had their signatures for the Consent Forms collected and their interviews were audio-recorded. The questions they answered were: How do you think the bioethical principles of autonomy, justice, beneficence and nonmaleficence can help you offer more appropriate care? In your opinion, what daily situations we can respect or disrespect the client? What does it mean to you to render care in a humanized way? How can you apply "humanization" in your everyday life? The interviews were booked and carried out individually according to the time availability of the participants.

The audio recording and speech transcriptions will remain safe under the first author's care and subsequently erased after the data publication.

Data were analyzed based on a content analysis plan(11), which suggests three phases for the analysis of discourse: pre-analysis, with an analytical description and inferential interpretation. In order to accomplish the third objective, the data were analyzed and compared with the answers obtained from the previous work carried out with more professionally experienced nurses(10).



Of the 20 nurses interviewed, 85% had graduated less than a year before, and 10% between one and five years before. As regards the job market, 35% of them already had some professional experience in activities related to home care, high school education, trainings, nursing auxiliary personnel; and only one had worked in a hospital for less than a year.

Following the analysis of discourse, four categories were created which were divided into subcategories, as shown in Table 1.

The category A: Interference of bioethical principles in nursing practice, demonstrates through the interviews that awareness of the bioethical principles interfere in nursing care. It guides the practice of the nurses and improve the quality of care, as well as increasing the respect towards the patients who is seen as a biopsychosocial being.

This category is subdivided into three; the first guides the professional acting, pointing that the nurse's conduct, under influence, is guided by bioethics and its principles, resulting in better care and no harm to patient.

"This is what guides your conduct at all moments. Because if you do not understand these concepts, this can harm the patients under your care." (E9)

"They guide healthcare. You rely on bioethical principles... with a parameter it is easy to judge if you are acting appropriately or not." (E19)

The second subcategory - How to respect the patient - seeks to demonstrate that bioethical principles remind the nurses that the patients have rights, desires and opinions which should be respected. It also discusses how the interviewed subjects can perceive that the principles of justice, beneficence, nonmaleficence and autonomy can help render respect to patient.

" If he doesn't agree with a procedure, he has autonomy to refuse it, and I have to accept it" (E17)

" when I elaborate a plan of care to my patient , besides inserting what I believe will do him good , I have to see what he thinks it will be good for him. (E3)

"He is the one who will undergo the procedure, so he has to give his opinion over what he wants and which way it should be performed." (E9)

The third subcategory - Help provide full care - demonstrates through the interviews that the bioethical principles can contribute to foster the nurse's perception of the patient as a biopsychosocial being and render care based on this perspective.

" It is to fully respect him, respect his religion, his beliefs." (E10)

"It is to see the person as a biopsichosocial being and, in this way, to try to apply it practically." (E11)

"To take care of the patient as a whole, knowing that, for us, he may be one more, but for him, it may be an experience he had never had before." (E17)

The second category - How to respect the patient - discusses what ways and types of actions performed by the nurses that can express respect. It is divided into two subcategories. The first subcategory, Access to information, based on the interviews, demonstrates that to provide information on the patient's sickness, treatment, procedure and prognosis is a form to respect him.

"You have to show, clarify, give all necessary information, so that he has the right to accept it or not. If you explain, you offer him the option to choose." (E11)

"Every patient has the right to know what will happen to him." (E10)

"At the moment of any procedure, any care, the patient has the right to know what it is. When he has questions about something, you must clarify it; and if you don't clarify it and let it be, this is disrespect." (E2)

The second subcategory - Having empathy, being polite and establishing good relationships -seeks to show the importance of building rapport and empathy, and always with good manners, are forms to respect the client.

" I try to put myself in his shoe. I wonder how I'd feel if I couldn't sleep because of the light on, how would I be? The best way to give care is through empathy. Would I like to be treated by me one day? (E3).

"It's it to offer care that meets the patient and his family's needs. It is to look at the patient and figure out what they need besides technical care." (E7)

"You can talk to the patient. "Hello, good morning, what's your name? Tell him my name, ask him how he spent the night." (E12)

The Category 3 - Hospital routine interference in the nursing care - discusses the perception of the study subjects with regard to how routine can interfere in humanized care. This category is divided into two subcategories; the first: Work overload hinders the respect for the patient, approaches how hospital routine with work overload can represent an obstacle as for respecting the patient and his rights.

"Many times, a family member does not know what is happening and neither does the patient due to the haste, to the tight schedule; so, sometimes, some of the principles are not respected." (E14)

"Sometimes, we find ourselves in a hurry, just following protocols and what is imposed by time." (E11)

"Many times, we are not humane to fulfill the many aspects you are demanded. You don't know what to do first, so you keep trying to do everything, and have to do everything. So, sometimes you give a rude answer to a patient, family member or care-giver. Then keep wondering you could have been more attentive, have offered better care." (E1)

Overcoming the work overload in order to maintain adequate communication is a subcategory constituted by some of the nurses' replies. They perceive that work overload represents an obstacle to be fought in order to maintain adequate communication when rendering care; and, therefore, succeed in accomplishing humanized practice.

"Just think... a family member arrives at the ICU and sees all those pipes, bombsLike this: 'No, you can touch him, he is asleep but will enjoy it'. Sometimes we are overburdened with routine, as there are so many things to do and, sometimes, it's not the patient (who needs), it is the family member." (E3)

"Despite the daily hectic rhythm here, I try to apply humanization donating time to the patient. If I have 5 minutes, It'll be 5 minutes with him, wondering what he needs, trying to find out what he and his family needs." (E7)

The Category 4 - How to provide care with humanization - reveals some of the aspects which help the subjects apply and ground the discourse of humanization in rendering care. The first subcategory is Communicating adequately. It demonstrates that in order to achieve appropriate communication, both verbal and non-verbal linguistic codes must be taken into consideration and can be regarded as manners to apply the humanization theory.

"You should address the patient by his name, look at him, look at the client, mainly." (E8)

"Even if the patient is intubated , I tell him my name, I explain what I'm going to do, no matter if he is or not listening to me at that moment." (E9)

"Treat him as a human being is look at him eye-to-eye and say "Good morning". If he allows, touch him..." (E18)

The subcategory, Rendering care with Love, reveals that to establish friendly and loving relations and demonstrate concern and esteem to the patient is a means to practice humanization.

"You have to do it looking at your patient. Despite the haste, you have to do it kindly." (E1)

"Showing zeal, respect, with a comforting word." (E17)

"holding the patient's hand during a test, if he is scared." (E18)

The third subcategory, Providing full care, points that the perception of the human being as a biopsychosocial and spiritual agent leads to humanized healthcare.

"Sometimes I try to talk and understand what is happening to that patient, and what I can do to help him, not materially, but to try to listen, talk to him." (E3)

"To Humanize is to see a person as a whole, with everything that is important for him, for his life." (E19)



When applied with respect , the bioethical principles autonomy, beneficence, non-maleficence and justice ensure consistency to hospital humanization(2). Considering Bioethics a multidisciplinarian field which includes the area of health, it can be implied that nursing professionals' practice should make use of that ethical reference to guideline their actions.

As well as the nurses working at a University hospital(10), the newly graduated nurses, the subjects of this study, also notice the impact of the bioethical principles on their professional practice, resulting in more humanization. Having those principles in mind, the professional can understand, more easily, that the care embedded with ethics represents respect both for the patient's and for the professional's values, ideals and motivation(12). Under the same category, it was observed that the principles helped raising the respect for the patient, as concluded in a previous research(10).

As referred before, to ground justice involves acting based on equality, considering that each patient has particular necessities. To individualize is to recognize each human being as a unique being with social, spiritual and biological peculiarities(6). The principles of beneficence/non-maleficence complete one of the concepts of the word "respect", which is "not to cause any harm". Each patient has the right to be respected as a citizen, and this implies their participation in the decision making process on their care and treatment, this way expressing their autonomy.

As mentioned before; to understand the human being as a spiritual and biopsychosocial agent, to consider the essence of their Being, and to respect their individuality are assumptions to accomplish the humanized care(2), and the principles help the rendering of the holistic care, according to the verified subcategory.

Fortunately, the interviewed nurses have noticed the access to information is a way to respect the patient and provide means to the practice of autonomy. Each patient has the right to receive care with clear information on their diagnosis and treatment, expressed in an intelligible language; the right to refuse the treatment and be informed about the consequences of this decision; and also the right to complain about what they disagree with, without any decreasing in the service quality. Access to information is a citizen's right, it is an available means to the individual to acquire knowledge and to support a decision related to the situation they are going through. Without information, citizens are not able to claim and/or fight for their rights, they have no conditions or arguments to questioning, what makes the practice of autonomy difficult.

Another way of expressing the respect for the patient, according to the interviewed nurses' opinion, is to establish a good relationship with them, expressing empathy and being polite. The human relationship is a fundamental tool to Nursery, and it is made possible due to the adequate communication between patient and nurse, so that the nurse can understand the patient's situation adopting a holistic view over the health-illness care process(8-9).

Some of the interviewed, besides giving examples of suitable interpersonal relationships, have identified inadequate attitudes of the caretaker. "We, as students, end up paying attention to people, and observing many things. We say: we would never do that" (E6). Many things can be inferred about the reasons of this difference of care, but another research can certainly provide the answers for this question.

The third category, Hospital routine interference in the nursing practice, shows that the hospital routines interfere in the nursing care. The same result can be observed from the work performed by enrolled nurses at a university hospital(10). In a study with more experienced nurses at a university hospital, most nurses have noticed that the necessity to follow hospital routine rules and norms affected the quality of care. In this study, only a small group of newly graduated nurses of a tertiary hospital did not show the same perception; most of them considered work overload an obstacle to respect patients, their individuality, and their rights.

A subcategory demonstrated that the routine may negatively affect the respect for patients because of work overload. Likewise, one of the interviewed noticed that the physical structure of the hospital also interfered in rendering respectful care to customer, and another pointed the lack of material and human resources is a way of manifesting disrespect.

"Sometimes you are assisting a patient, and another one is calling you. In the surgical ward, there are some beds in the reception area for anesthesia recovery. Some patients, who are entering the center get in contact with the ones who are leaving, therefore the ones who are waiting for a surgery can see the ones leaving in anguish. The patients who are still under anesthesia have no privacy as the beds for men and women are all lined together". (E12)

To overcome work overload to render adequate communication was a subcategory found in the category : Hospital routine interference in nursing care. Similarly to what was found by the study conducted at a university hospital(10) where nurses pointed that a break in hospital routines was a way to humanize care, in this study, newly graduated nurses expressed the need to find alternatives to the lack of time and the routine overload in order to maintain adequate communication with patients, and therefore, accomplish care humanization.

The fourth category, How to provide care with humanization, demonstrates that, according to the newly graduated nurses, if you act according to the bioethical principles, you apply the humanization theory; this category expressed interest in the approaches to accomplish humanization.

As demonstrated in another study(10), communication is regarded as the most important factor in rendering humanization. If nurses communicate adequately, they ought to act in a humanized way. Indeed, interpersonal relations are the essence of the nurse's function, what makes communication the fundamental component in the nursing care(8-9). In addition, some of the interviewed nurses have observed that adequate communication among the team members is important in the humanization process.

"Say 'Good morning' when you arrive, not only to the patient but also to the team". (E4)

" .even with the team, establish a good relationship". (E5)

To render care with love was the second subcategory pointed by the interviewed on the subject humanized care. They consider rendering care with love towards both the patient and the work itself. This interpretation is reasonable as the word care comes from the ancient Latin form coera, which was used in the context of love and friendship relations, expressing an attitude of care, zeal and concern towards the beloved one(13).

The third subcategory found - Providing full care - shows that people should be treated in all dimensions, not only their physical illnesses. This perception is absolutely necessary to make professionals act in a humanized way.



The newly graduated nurses have observed that the bioethical principles support their routine as they guide their actions, helping them respect the patient and treat them in a more complete approach. For most of them, respect is regarded as the foundation of any situation involving patients; and communication, interpersonal relationship, and the access to information are considered facilitators. Very difficult situations to be solved were not mentioned. They have pointed that work overload can affect the element respect in their routines, but no strategies to minimize the situation were suggested. That might be due to the short time experience of the interviewed and/or to the lack of "voice" within the group of registered nurses, as mentioned by one of the interns describing a certain conflict situation and disagreement with a specific institutional norm.

We can conclude from this study that the newly graduated nurses enrolled in the Performance Improvement Program have perceived that the concept of respect can be applied and extended to all care rendering. However, they encounter difficulty to envisage ways to overcome the work routine to ground respect, regardless what institutional norms they have to follow, as well as to suggest strategies to respect the patient even under strict institutional rules. Based on this, we highlight the importance of teaching this subject in undergraduate programs aiming to avoid disrespectful attitude and posture of future professionals. The disciplines Ethics/Bioethics and Communication in Health Area can discuss these issues and help nurses find ways to ground the concepts of respect, autonomy and dignity even under stressful work overload situations.



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Correspoding Author:
Emília Cristina Peres
Av. Dr. Enéas de Carvalho Aguiar, 419 - Cerqueira Cesar
São Paulo - SP - Brazil
Cep: 05403-000

Received article 18/12/2009 and accepted 13/12/2010



* Study undertaken at Hospital das Clinicas of Faculty of Medicine of São Paulo University - USP - São Paulo (SP), Brazil.

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