CONTRIBUTIONS OF HUMANITUDE CARE DURING THE PANDEMIC IN AN INSTITUTION FOR THE ELDERLY IN PORTUGAL

APORTES DE LA ATENCIÓN BASADA E LA HUMANITUDE DURANTE LA PANDEMIA EN UNA INSTITUCIÓN PARA ANCIANOS DE PORTUGAL

ABSTRACT

Objective:

to identify the contributions of the Humanitude Care Methodology in the comprehensive care provided to the elderly in a long-term care institution during the COVID-19 pandemic.

Method:

a qualitative, exploratory and descriptive research study. Data collection took place through individual online interviews in September and October 2020 with eight caregivers of elderly people from a long-term care institution for aged people in Portugal. Thematic categorization was adopted for analysis and treatment of the information.

Results:

the contributions of the Humanitude Care Methodology contemplated operationalization of the humanization of care, that is, approach, consolidation, professionalization of the relationship, and intentionality in the interaction. It also contemplated the organizational system with changes in care and opening to the outside and, finally, contributions to aged people such as acceptance of the care provided, decrease in agitation, promotion of autonomy and self-care, respect, satisfaction and promotion of verticality.

Conclusion:

the strategies related to the Humanitude Care Methodology facilitate the care practices during the COVID-19 pandemic period. Although organizational and operational matters of the care provided were altered, it was possible to maintain comprehensive care for aged people, due to the fact that the principles of Humanitude were already integrated in the institution's care practices.

DESCRIPTORS:
Coronavirus infections; Old age assistance; Elderly; Humanization of assistance; Institutionalization

RESUMEN

Objetivo:

identificar los aportes de la Metodología de Atención Basada en la Humanitude a la asistencia integral prestada a los ancianos de una institución de permanencia a largo plazo durante la pandemia de COVID-19.

Método:

investigación cualitativa, exploratoria y descriptiva. La recolección de datos tuvo lugar por medio de entrevistas individuales en línea durante septiembre y octubre de 2020 con ocho cuidadores de ancianos de una institución de permanencia a largo plazo para ancianos de Portugal. Para el análisis y tratamiento de la información se adoptó la categorización temática.

Resultados:

los aportes de la Metodología de Atención Basada en la Humanitude contemplaron la operacionalización de la humanización de la asistencia, es decir, aproximación, consolidación, profesionalización de la relación e intencionalidad en la interacción. Además, contempló el sistema organizacional con cambios en la atención prestada y en la apertura hacia el exterior y, finalmente, aportes para los adultos mayores como aceptación de la atención, reducción de la agitación, promoción de la autonomía y autocuidado, respeto, satisfacción y promoción de la verticalidad.

Conclusión:

las estrategias relacionadas con la metodología de atención basada en la Humanitude facilitaron las prácticas de asistencia durante el período de pandemia debido al COVID-19. Además de que diversas cuestiones organizacionales y operativas de la asistencia sufrieron modificaciones, fue posible mantener atención integral para los ancianos, debido a que los principios de la Humanitude ya estaban integrados en las prácticas de atención de la institución.

DESCRIPTORES:
Infecciones por coronavirus; Asistencia a los ancianos; Ancianos; Humanización de la atención; Institucionalización

RESUMO

Objetivo:

identificar as contribuições da Metodologia de Cuidado Humanitude na atenção integral aos idosos de uma instituição de longa permanência durante a pandemia da Covid-19.

Método:

pesquisa qualitativa, exploratória e descritiva. Coleta de dados ocorreu por meio de entrevistas individuais online em setembro e outubro de 2020, com oito cuidadores de idosos de uma instituição de longa permanência para pessoas idosas em Portugal. A análise e tratamento das informações adotada foi a categorização temática.

Resultados:

as contribuições da Metodologia de Cuidado Humanitude contemplaram a operacionalização da humanização da assistência, ou seja, aproximação, consolidação, profissionalização da relação e intencionalidade na interação. Ainda, contemplou o sistema organizacional com mudanças nos cuidados e na abertura para o exterior, e por fim contributos à pessoa idosa como aceitação do cuidado, redução da agitação, promoção da autonomia e autocuidado, respeito, satisfação e promoção da verticalidade.

Conclusão:

as estratégias relacionadas à Metodologia de Cuidado Humanitude facilitaram as práticas de cuidado durante o período de pandemia pelo COVID-19. Ainda que questões organizacionais e operacionais da assistência fossem modificadas, foi possível manter um cuidado integral aos idosos, devido ao fato de que os princípios da humanitude já estavam integrados nas práticas dos cuidados na instituição.

DESCRITORES:
Infecções por coronavírus; Assistência a idosos; Idoso; Humanização da assistência; Institucionalização

INTRODUCTION

Longevity is increasing worldwide and has become the most expressive phenomenon of the 21^st century. Older adults represent 12% of the world population, and this percentage is expected to double by 2050 and triple by the year 2100.1 Greater longevity is an achievement for the history of mankind.2 Therefore, it is urgent to recognize in the public policies the contribution of aged people,1 aiming to ensure the right to grow old with dignity and quality of life.3

In Portugal, individuals over 65 years old characterize 21.9% of the total population,4 with a projection of reaching 30% in 2035, which shows growth of aged people over 75 years old, with an estimate of reaching 80.9 for men and 86.7 for women.5 In comparison, in Brazil, there are more than 29 million aged individuals (60 years old or more) and it is estimated that such number could reach a quarter of the total population in 2043.6 There are also estimates that the fastest growing segment of the population worldwide is from the age of 80 years old onward. Therefore, these data raise concern because, even though aged people continue to develop a relevant social role, diverse health problems emerge, the main ones being the following: loss of cognitive function, including the ability to learn; chronic stress; dementia syndromes; and frailty due to the combination of multiple motor, chronic and degenerative dysfunctions.7

The fact is that the longevity of the world's population produces social demands that are difficult to solve, which has repercussions in the increase in the number of aged individuals living in Long-Term Care Institutions (LTCIs). Different social and economic changes result in difficulties for the aged population to continue living at their homes, causing the family to transfer care to an LTCI. These difficulties can be exemplified by the extinction of the woman's role as main caregiver and her inclusion in the labor market, by the impairment of aged people's independence and autonomy either due to the aging process itself or to health problems, and by the loneliness experienced due to death of the partner.8

The number of older adults living in LTCIs in Portugal is increasing. In 1974, for example, the number of institutions was 200, while in 2017 it already was 2,413, with installed capacity for 71,803 people.9 However, the care of institutionalized aged people has raised several challenges for caregivers, namely the person with cognitive changes and who refuses care, as well as in the current moment of the COVID-19 pandemic, due to the restrictions imposed to prevent transmission of the infection.

The Humanitude Care Methodology (HCM) was developed in France since the 1970s by Yves Gineste and Rosette Marescotti, due to the authors' concerns about the way in which care was provided to patients who were in vulnerable situations, both physically and cognitively debilitated. From this perspective, “respect for dignity, freedom and autonomy” assumes a preponderant role in this care scenario. The HCM is grounded on the relational pillar through gaze, speech and touch, and on the identity pillar, expressed by verticality. This care methodology has shown successful results in maintaining the dignity of the person cared for, promising for people in vulnerable situations, namely with behavioral changes resulting from some type of dementia, agitation, refusal of care and aggressiveness, especially aged and institutionalized individuals.10^-12^:2

The HCM is operationalized through a “Structured Sequence of Humanitude Care Procedures” (SSHCP), organized into five progressive and interrelated stages.13:54 The first stage, called “pre-preliminaries”, represents the moment when the environment and the person are prepared for the care proposed, avoiding a surprise approach; it aims at respecting the intimacy, freedom and autonomy of the person cared for. In the second stage, entitled “Preliminaries”, an approach is made to the patient through “gaze, touch and speech”. In the stage called “sensory circle, the coherence among the sensory inputs - sight, hearing and touch - is observed, providing a perception of well-being. The fourth stage is called “emotional consolidation”, in which the professional reinforces in a positive way all the cooperation, dedication and improvements achieved, showing appreciation and recognition. And finally, the “reencounter” stage, in which continuity of the assistance provided is asserted and the next meeting is scheduled, thus alleviating the sensation of abandonment or feeling of contempt. For each of the five stages to occur, relational techniques are developed and professionalized.13

It is believed that the performance of professionals with training in the HCM is crucial for the provision of dignified and humanized care to the elderly living in LTCIs. The principles and pillars that anchor this methodology must be assumed as a globalizing commitment, promoting quality in care, efficiency and respect for individuality, which favors maintenance of the aged people's autonomy. However, it should be noted that working with the elderly presents added complexity,14 especially in adverse situations such as the global pandemic caused by the Coronavirus Disease 2019 (COVID-19).15

In late 2019 the world was faced with the emergence of a new disease, Coronavirus Disease 2019 (COVID-19), which has become a serious public health problem, a global pandemic, transforming people's daily life, especially that of the aged population. Death due to COVID-19 increases with age, mainly in older adults with chronic diseases.15

In the current situation, it becomes relevant to understand the contributions of the HCM for the development of care targeted at the real needs of the elderly. Studies on this care methodology can contribute not only to the expansion of the discussion on the theme at the national level, which is restricted, but can also awaken reflections on our weaknesses in care and the need for change, which can be contemplated by training in the Humanitude Care Methodology. There is scarce literature on this theme; therefore, the need for research is urgent, in order to contribute to the Health and Nursing area in caring for aged people in pandemic times.

From this perspective, the objective of the study was to identify the contributions of the Humanitude Care Methodology in the integral care of aged people in a long-term care institution, during the COVID-19 pandemic.

METHOD

This is a qualitative, exploratory and descriptive research study conducted in a Long-Term Care Institution (LTCI) for the elderly in northern Portugal. A total of 28 aged individuals lived in this institution, with other 30 attending the Day Center.

The team is comprised by 20 professionals from various performance areas. Eight professionals participated in this study, selected from the following inclusion criteria: having HCM training and experience in caring for aged people in LTCIs during the COVID-19 pandemic. The exclusion criterion was professionals who were on holidays or leave during the data collection period. Thus, all the professionals in due conditions to participate were invited and accepted to take part in the study, without refusals or withdrawals. It was not necessary to consider data saturation.

Data collection took place through online interviews on the Zoom platform during September and October 2020 and was conducted by the main author, who had no previous relationship with the research participants. The interview script consisted of sociodemographic data and included a guiding question: “Which are the contributions of using the HCM in the comprehensive care provided to older adults living in an LTCI during the COVID-19 pandemic?” The interviews were audio-recorded and transcribed to a Microsoft Word document, totaling 14 audio hours.

Data analysis and treatment followed a categorization technique16, which is a content analysis mode that operationally consists of three stages: “pre-analysis, analysis, and treatment of the results and interpretation”16:124. In general, the content analysis process was initiated with an analysis of the material obtained, followed by exploration of the material and organization into three categories and thirteen subcategories. Coding was performed by assigning specific codes to registration units with a semantic content previously specified by the researcher, based on the principles of HCM. There was saturation of the speeches' contents in each category. Validity and reliability of the content analysis was ensured by two coders who are experts in qualitative research and validated the findings. The participants were also given the opportunity to offer feedback on the findings.

The Consolidated Criteria for Reporting Qualitative Research (COREQ) guide was applied to verify the scientific quality of the research, and the criteria of the various domains were globally met.

The ethical precepts set forth in Resolution No. 466/12 were followed, and the research was approved by the Research Ethics Committee of Universidade Federal da Fronteira Sul on July 18^th, 2020. For the interviews, an informed consent form was signed, guaranteeing the voluntary nature of their participation and ensuring their full freedom to participate or not in the research. The opportunity was also given to access both the verbatim transcription obtained from the interviews and the final study. In order to ensure anonymity, the letter “E”, standing for Interviewee (“Entrevistado” in Portuguese), was used to identify the research participants, followed by an Arabic number (E1, E2, E3, E4, E5, E6, E7, E8) in the chronological order in which the interviews took place. All the participants were informed about the scientific nature of the research and that it would be used for academic purposes.

RESULTS

The study participants were eight professionals: six females and two males. Their age varied between 30 and 50 years old, with the highest frequency for 40 years old. All participants had university degrees in the following areas: three nurses, one social worker, one psychologist, one sociologist, one occupational therapist, and one administrator. In relation to the working time in the LTCI, two professionals had worked for six years and two for twenty-three years, with the highest concentration between eight and twelve years. Three categories emerged from the analysis, namely: Operationalization of Humanization of care; Organizational system; and Contributions for older adults. A number of subcategories were identified in each category, presented in Chart 1.

Chart 1-
Categories, subcategories and registration units. Florianópolis, SC, Brazil, 2021.

Categories	Subcategories	Registration units
Operationalization of the Humanization of care	Approach and Tuning	3
	Consolidation/Proaction	3
	Professionalization of the relationship	3
	Intentionality in the interaction	3
Organizational system	Change in care organization	3
	Opening to the outside	4
Contributions for older adults	Acceptance of the care provided	2
	Decrease in agitation	2
	Promotion of autonomy	3
	Promotion of self-care	5
	Respect for individuality and intimacy	2
	Satisfaction and well-being	2
	Promotion of verticality	3

Operationalization of the Humanization of care

Four subcategories emerged in the Operationalization of the humanization of care category, namely: approach and tuning, consolidation/proaction, professionalization of the relationship, and intentionality in the interaction.

In the Approach and tuning subcategory, the professionals describe the accomplishment of the pre-preliminary stage described in the Structured Sequence of Humanitude Care Procedures;10 this is made evident in their speeches: […] I have to think about organizing the materials and the environment (E1). […] When we want to enter the room, first we knock on the door (knock-knock) so he knows that someone is coming in, we call the person by his name, and then the person introduces himself, will meet and know how to care and negotiate care (E7).

In the Consolidation/Proaction subcategory, the professionals show appreciation for the person cared for and are reciprocated, highlighting care that strengthens the bond between professionals and aged people, as elucidated by two interlocutors: […] when I finish the care for that person I always thank them very kindly, they return this love in the most different ways, from hugging to kissing, calling me, showing appreciation for me, these are several indicators that they are saying they like my work, the time I was with them (E1). [...] when we say ‘See you tomorrow!’, they say: ‘You come back tomorrow?’. Or are you coming? We have a man who always uses the same words: ‘we have you here again tomorrow?’ Basically, this union is already a family, all of us already know a little bit of each other [...] what she does that I like very much (E7).

The Professionalization of the relationship subcategory highlights the professionals' appropriation of the HCM and the certainty that its applicability favors the care practices, as emerges in the following statements: […] we already knew how important the relationship is, despite all these physical limitations, we knew that the care of the elderly needed to be done, and on this basis of affective relationship, according to the pillars and principles of Humanitude, we knew that we would be able to keep people well (E3). [...] this methodology is a path intended for the person to be cared for and for the caregiver, it takes care on both sides, gives meaning to the relationships (E5).

The Intentionality in the interaction subcategory also emerges, which comes from the awareness and appropriation of the principles and pillars of Humanitude, fundamental in the care of frail patients, namely in time of the COVID-19 pandemic, evidenced in the speeches that follow: The gaze says many things, we know if the person likes it or not, if the person is fine or not. The look in the eyes is so important! Smiling, taking care of never raising the tone of the voice, always speaking with calm and serenity! (E7). Today communication is more difficult because we have the mask, which is a barrier, but we have started to smile more with our eyes, now the hug has to be only ours because we no longer have the family here (E8).

Organizational system

Two subcategories emerged in the Organizational system category, namely: Change in care organization and Opening to the outside.

In the Change in the care organization subcategory, the extent to which care is centered on the interaction between the caregiver and the aged person and not on the task to be performed can be identified. The following report expresses this understanding: […] it is necessary to take the focus off the task and place this task within the relationship that is established between the caregiver and the person to be cared for, it is to be with the person and in that time we will have a relationship that will allow or not this task to be accomplished, where both would be in agreement (E2).

In the Opening to the outside subcategory, as a guiding principle of the Humanitude philosophy, where it is stated that institutions should preserve the humanitude ties with the outside world, namely family and community. In this subcategory, the professionals say how they are (re)organizing the daily care provided to aged people, in order to preserve the connection with family members, without their physical presence; this emerges in the following speeches: […] the home turned out to be a little closed, we were a household that received families every day, they could come in at any time. We had a culture that was very opened to family and friends, and with the COVID pandemic, we had to change that, and aged people basically had physical withdrawal from the presence of their relatives (E3). [...] The children work, but they always came here before the pandemic and that's not possible now. What we try to do is to always keep the calls, the video calls [...] this calms them and makes them feel good (E6).

Contributions for older adults

Seven subcategories emerged in the Contributions for older adults' category, namely: Acceptance of the care provided; Decrease in agitation; Promotion of autonomy; Promotion of self-care; Respect for individuality and intimacy; Satisfaction and well-being and Promotion of verticality.

Acceptance of the care provided, which, although challenged by the COVID-19 pandemic, care is negotiated by avoiding forced assistance, that is, against the patient's will, as evidenced in the following report: […] I believe that knowing what is right, the decisions and our practices have remained in what is our focus, the care of aged people in a humane way [...] a path that will never be as in the past, forced care, never again! That's a thing of the past (E4).

Decrease in agitation, being able to identify that the use of HCM exerted an impact on increasing confidence and reducing anxiety and agitation in the pandemic period, as described below: […] they don't shout, they are calmer (E7). [...] the use of this methodology has helped us to reassure, and I deeply believe it, because the fact that things are going well with us so far, we have not had any more complicated situation, in fact, we already have this kind of care, our aged people are not nervous or agitated, they trust the care we provide and we are doing well here (E5).

Promotion of autonomy, which reinforces the need to keep aged people active, reinforcing and rescuing their remaining capabilities, in order to increase their participation in the activities of daily living, verified to the extent verbalized by the professionals: […] dignity has a lot to do with the ability to decide and be free to speak our minds. If the caregiver doesn't give me that possibility, I don't feel like a person. They may say that I'm a person, but I don't feel as such. Because I'm not being respected as such (E1). [...] it is important to preserve the person's autonomy and ability to decide and have an opinion about the things that concern him (E2).

In addition, the promotion of self-care subcategory was presented, in which the need to keep aged people active is addressed, reinforcing and recovering activities that are possible to perform, as reported in the following speeches: […] some people think they will never be able to talk, walk, raise their arm, but they can do it with time, if we give them time and stimulus, we can get them to do things they didn't even think they could do (E7). We have several activities of daily living, many directed especially to those with dementia, which are the activities they can still do, that they remember, for example: separate cutlery, we have plastic and colored cutlery, and we ask to separate them by color (E6).

Respect for individuality and intimacy, by highlighting the need to consider the particularities of each aged person, respecting their differences, shown through the following statements: […] there are people here who prefer to be alone and don't even want to talk much; them we don't talk much to them, only what is essential (E7). [...] here the aged people are treated according to their differences, the way I treat Mrs. Maria is directed to the characteristics of Mrs. Maria, to be the way she likes to be cared, as for Mr. Manuel, I will treat him according to his characteristics, the way he wants to be treated, because each aged person here is unique and has their characteristics (E6).

And finally, the Satisfaction and well-being and Promotion of verticality subcategories, where Satisfaction and well-being reveal the consequences of the care dimensions, reinforcing the contributions of HCM in the integral care of aged people, satisfying their wishes and interests: […] our way of caring makes them like to be where they are, accept care better, and be other people, because they are totally different when they are with a humane caregiver (E7). [...] in our conversations new things come up that I know they like and then I try to fit in the activities I develop with them, what makes them feel good, what meets their expectations, what really makes sense to them and I see that they like and participate... We also focus on the activities that bring the group together, they like to play bingo, alphabet soup. This activates their mind (E6). […] promotion of verticality, which expresses the identity pillar of Humanitude, and one of the principles of Humanitude, which is to keep the person standing until the end of their life, according to the following speech: We can destroy a person's humanitude if we leave them bedridden, we have to make our best efforts for them to stay living and standing up with dignity (E8). [...] when we see a person who was bedridden getting up, there is satisfaction and we feel that we are not failing as professionals (E1).

DISCUSSION

The contributions of HCM in the integral care of aged people in a long-term care institution during the COVID-19 pandemic involved the direct care of elderly people and the operationalization and organization of the care system. In this way, the pillars and principles that sustain the HCM favored that, in the face of the changes resulting from the COVID-19 pandemic, care could continue to be guided by respect, sensitivity, kindness, affection and communication, even if in this new context, in a redefined way.

Considering the results obtained, it was identified that the professionals working in the Portuguese LTCI develop care based on the stages described in the SSHCP.12 Following these stages systematizes and operationalizes care and promotes professionalization in the relationship, due to the development of consecutive and dynamic care procedures as defined by this methodology.13

The high demand for care that aged people have due to the aging process requires an improvement in the reality of work and professional qualification in order to offer dignified care to this population.17 The HCM is a tool that improves care quality, evidencing invaluable gains in restoring the older adults' quality of life, especially in those with a high dependence degree and in those with dementia or other situations of frailty.13

Application of the HCM principles was identified in the reports associated with care consolidation, which contemplates the offer of a space that is a place of life where the person wishes to live and that preserves the connections to the outside, that respects the patients' uniqueness, and that values maintenance of the ability to stand up.18 Although confronted by the changes imposed by the COVID-19 pandemic, the professionals manage to preserve these principles of Humanitude, contributing to the integral care of aged people living in LTCIs, preserving their dignity as persons. The professionals confer intentionality to the relationship with the aged people, which can be identified through the reports that point to strategies to preserve intentionality in the interaction and opening to the outside. Despite the contact limitation and the inability to express smiles integrally, the Humanitude characteristics that permeate the care practices end up contributing to the confrontation of adversities.

To develop Humanitude Care, it is necessary to confer intentionality, that is, to develop the action consciously, in a purposeful way, to be attentive and involved in the care relationship. When the professionals learn to use the relational pillars of gaze, touch and speech, they are able to interact intentionally. This leads them to know how to look, when and how to speak, and where and how to touch, thus seeing the materialization of an affective and intention-oriented relationship. Finally, the professionals trained in HCM perceive the importance of this methodology and its applicability and develop greater intentionality in the relationship, which facilitates provision of care and its effectiveness and efficiency.10

As a strategy to contain transmission of the COVID-19 virus, the authorities seek to implement control measures in order to guarantee the reduction of the contamination speed, thus, the most recommended strategy was physical distancing.19 Faced with these changes, there was the need for a reorganization in the daily life inside the LTCI, in order to maintain social interaction, although preserving physical distancing. Cancellation of the family members' visits to the aged individuals was one of the necessary measures, which should be balanced with strategies to maintain bonds with the families, namely through video calls and protected visits.

During the COVID-19 pandemic, several crises are experienced by humanity, becoming an even greater challenge for the aged population, which can be severely affected by this pandemic scenario. Therefore, the need to strengthen and narrow the care practices conducted by safety and respect are pointed out as fundamental.20 These issues can be identified in the speeches that reinforce the practices of self-care promotion, performed with these aged people, who manage to maintain the relationship among themselves, preserving interaction activities that can be seen as a resource for facing the challenges experienced in the pandemic.

It is notorious to understand that social isolation had repercussions on the behavior of the population, especially older adults.19 With the strategies used through video calls, in a certain way it minimized the distancing from family members. The use of technology as a strategy to calm aged people is associated with the fact that it is capable of providing a feeling of belonging and favoring the maintenance of support networks.21 This preservation of the family bond, the possibility of offering spaces to speak and to be heard, as well as for the clarification of doubts, is pointed out as essential in the face of the limitation of physical visits to the LTCI space.22

When the professionals get to know the philosophy, the principles and the pillars that govern the HCM through on-the-job training, that is, when they are trained in the care environment, they take on the role of care protagonists in an intense and meaningful way, thus empowering themselves. This ability motivates and leads them to a commitment of loving life and the human beings that surround them. The professionals' performance, dedication and competence are beyond the pandemic, as they recognize in the HCM an instrument capable of qualifying the assistance provided, in which care performed in a forced way is definitively abandoned. They understand that effective and efficient care occurs through negotiation and understanding who the other really is. Thus, they respect the life story, the values, the precepts, the routine, and the wishes of each aged person cared for and, in this way, they interact with the LTCI residents and care is gradually accepted and approved.

The professionals' training in HCM was fundamental to conduct the care practices and can be perceived in the reports that address the way in which the professionals approach aged people, consolidate their actions and conduct relationships based on intentionality. These results are in agreement with another study conducted in Portugal which evidences that Humanitude training contributes benefits both for caregivers and for those cared for, by facilitating interaction, intentionality and professionalization of the relationship.23

On the other hand, it was observed that LTCIs point to quality care as a reference, based on humanization and with patient professionals; however, aged people still occupy the place of passive individuals, and the care practices are conducted in a fragmented manner and with impaired conversations.24 This difficulty in the care practices with aged people, and especially with institutionalized elderly people, are related to deficient and fragmented professional training processes, disconnected from the integrality of the aged individual and disarticulated from the social health demands. These arguments reinforce the importance of the Humanitude training process, which allows professionalization of the relationship to the entire team, leading to changes in the organizational culture.

It is necessary to consider that different cultures provide different realities, which is clear in a study25 developed with 38 professionals working in (an LTCI in) Brazil, which observed problems that compromise the recommended care practices, among them neglect, disrespect, understanding old age as something negative and absence of public policies.25 These issues are associated with the sociocultural understanding that permeates the aged individual, and which, in the face of the pandemic may be accentuated, thus reinforcing the need for social change and reflection on professional performance.20 When confronted by the HCM, these problems can be considered as negative aggravating factors in the assistance provided to aged people.

These differences lead to reflections on the socio-political understanding of being aged in society, and how this can influence the conduction of care practices and the organization of services. This is observed in one study,23 which points out that developing care with the acceptance and collaboration of the aged person, considering the biological, psychosocial and spiritual dimensions and based on the use of the HCM, provides reliability and expresses the perception of integrality.

By providing the people assisted greater understanding of the care practices performed and assistance based on intentionality in the relationship, it is possible to observe some improvements with regard to agitation, aggressiveness and refusal of care.13^,26 The principles of Humanitude are a compass that guides the practice, they are ethical references, rules and moral precepts that promote convergence in those involved during the care process.10^,12^-13

Among these principles, we identified that promoting the older adults' autonomy is a construct that refers to human dignity. This factor can be preserved or stimulated from practices that consider the individualization of each aged person and that are directed to self-care maintenance.27 These issues could be identified when the professionals reported respecting the characteristics of each elderly individual and conducting the care practices based on the individuality of each person.

In the same way as promotion of autonomy is essential, self-care must also be stimulated in order to provide greater functional independence and well-being. One of the indicators of the aged people's health conditions and of their frailties and vulnerabilities is their functional capacity, that is, their abilities to perform activities of daily living, such as personal hygiene, eating, toileting, walking and performing transfers. Different levels of functional capacity impairment can influence the autonomy and self-care of aged people and, thus, their quality of life.28 Therefore, the possibility of keeping aged people active most of the time and delaying situations of dependence are important features in the preservation of autonomy;27 issues that are strongly identified in the professionals’ speeches, when they mention practices that promote verticality, which are carried out without measuring efforts due to the importance they attribute to these characteristics.

Even not pointing out the use of HCM, the study29 carried out in 170 LTCIs denoted the use of individualized interventions directed to self-care activities that could stimulate the participation of institutionalized aged people in an independent way. One of the difficulties identified was to direct actions that contemplated the particularities of each elderly individual, thus respecting the level of functional capacity of each person.

As a limiting factor of this study, we point to the choice of only one institutional reality. Therefore, in other institutions and sociocultural regions, we might find different realities than the one herein presented.

CONCLUSION

Identification of the contributions of HCM in the integral care of aged people in a long-term care institution during the COVID-19 pandemic revealed that, during this pandemic period, it was possible to respect dignity, autonomy, healthy coexistence, reducing feelings of loneliness, fear, anxiety, preventing agitation and aggressiveness behaviors, which promotes well-being and quality of life in the aged people and caregivers.

The HCM is based on a wealth of elements, strategies and principles that were applied in the care of aged people in an LTCI, which enabled - as predicted by the methodology - promising results about the contributions of this applicability in the care practices provided during the COVID-19 pandemic.

The organizational and operational demands of the assistance provided have changed due to the COVID-19 pandemic, such as the use of personal protective equipment, which limits contact and viewing of the entire face, and the limitation of opening the physical space to the outside, due to measures to restrict physical contact with family members. However, alternatives for preserving the bonds were resignified and strengthened by the HCM, which was already strongly implemented in the organizational culture, reinforcing the possibilities of contribution in the care and integral attention to the aged individuals assisted. This study has important contributions for Nursing, as appropriation of the HCM, through a structured sequence of technical-relational procedures, allows for the integration of humanistic principles in a systematized and structured way, conferring intentionality to the relationship, transforming routine and depersonalized care into conscious and humanized care.

REFERENCES

• 1. Tavares RE, Jesus MCP, Machado DR, Braga VAS, Tocantins FR, Merighi MAB. Healthy aging from the perspective of the elderly: an integrative review. Rev Bras Geriatr Gerontol [Internet]. 2017 [cited 2020 Nov 9];20(6):878-89. Available from: https://doi.org/10.1590/1981-22562017020.170091
  » https://doi.org/10.1590/1981-22562017020.170091
• 2. World Health Organization. World report on ageing and health [Internet]. Geneva, (CH): WHO; 2015 [cited 2020 Nov 9]. 260 p. Available from: https://apps.who.int/iris/bitstream/handle/10665/186463/9789240694811_eng.pdf?sequence=1
  » https://apps.who.int/iris/bitstream/handle/10665/186463/9789240694811_eng.pdf?sequence=1
• 3. Silva MRF. Envelhecimento e proteção social: aproximações entre Brasil, América Latina e Portugal. Serv Soc Soc [Internet]. 2016 [cited 2020 Nov 9];126:215-34. Available from: https://doi.org/10.1590/0101-6628.066
  » https://doi.org/10.1590/0101-6628.066
• 4. Instituto Nacional de Estatística. Projeções da população residente, 2015-2080 [Internet]. Lisboa, (PT); 2018 [cited 2020 Nov 9]. Available from: https://bit.ly/2Xe4eYH
  » https://bit.ly/2Xe4eYH
• 5. Instituto Nacional de Estatística. Evolução da população portuguesa por grupos de idade: cenário central [Internet]. Lisboa, (PT); 2017 [cited 2020 Nov 9]. Available from: https://bit.ly/2zLOeET
  » https://bit.ly/2zLOeET
• 6. Instituto Brasileiro de Geografia e Estatística. Nota técnica: projeção da população do Brasil e das Unidades da Federação [Internet]. 2018 [cited 2020 Nov 10]. Available from: https://www.ibge.gov.br/apps/populacao/projecao/
  » https://www.ibge.gov.br/apps/populacao/projecao/
• 7. Minayo MCS, Firmo JOA. Longevity: bonus or onus? Ciênc Saúde Colet [Internet]. 2019 [cited 2020 Nov 9];24(1):1. Available from: https://doi.org/10.1590/1413-81232018241.31212018
  » https://doi.org/10.1590/1413-81232018241.31212018
• 8. Castro M, Amorim I. Qualidade de vida e solidão em idosos residentes em lar. Rev Port Enferm Saúde Mental [Internet]. 2016 [cited 2020 Nov 9];3:39-44. Available from: https://doi.org/10.19131/rpesm.0115
  » https://doi.org/10.19131/rpesm.0115
• 9. Daniel F, Monteiro R, Ferreira J. Cartografia da oferta pública e privada de serviços dirigidos à população idosa em Portugal. Serv Soc Soc [Internet]. 2016 [cited 2020 Nov 9];(126):235-61. Available from: https://doi.org/10.1590/0101-6628.067
  » https://doi.org/10.1590/0101-6628.067
• 10. Henriques LVL, Dourado MARF, Melo RCCP, Tanaka LH. Implementation of the Humanitude Care Methodology: contribution to the quality of health care. Rev Lat Am Enfermagem [Internet]. 2019 [cited 2019 Jul 25];27:e3123. Available from: https://doi.org/10.1590/1518-8345.2430-3123
  » https://doi.org/10.1590/1518-8345.2430-3123
• 11. Simões M, Salgueiro N, Rodrigues MA. Caring in Humanitude: study applied to a continuum of care. Rev Enf Ref [Internet]. 2012 [cited 2019 Oct 31];6:81-93. Available from: https://doi.org/10.12707/RIII1177
  » https://doi.org/10.12707/RIII1177
• 12. Melo RCCP, Costa PJ, Henriques LVL, Tanaka LH, Queirós PJP, Araújo JP. Humanitude in the humanization of elderly care: experience reports in a health service. Rev Bras Enferm [Internet]. 2019 [cited 2019 Oct 31];72(3):825-9. Available from: https://doi.org/10.1590/0034-7167-2017-0363
  » https://doi.org/10.1590/0034-7167-2017-0363
• 13. Figueiredo AMG, Melo RCCP, Ribeiro OP. Humanitude care methodology: difficulties and benefits from its implementation in clinical practice. Rev Enferm Ref [Internet]. 2018 [cited 2019 Oct 31];17:53-62. Available from: https://doi.org/10.12707/RIV17063
  » https://doi.org/10.12707/RIV17063
• 14. Fonseca C, Luz H, Melo RCCP. Aging and Humanitude Care: opportunities for the organizational system. J Aging Innov [Internet]. 2020 Aug, [cited 2019 Oct 31];9(2):33-47. Available from: https://doi.org/10.36957/jai.2182-696X.v9i2-4
  » https://doi.org/10.36957/jai.2182-696X.v9i2-4
• 15. Hammerschmidt KSA, Santana RF. Health of the older adults in time of the COVID-19. Cogitare Enferm [Internet]. 2020 [cited 2019 Nov 10];25:72849. Available from: https://doi.org/10.5380/ce.v25i0.72849
  » https://doi.org/10.5380/ce.v25i0.72849
• 16. Bardin L. Análise de conteúdo. São Paulo, SP(BR): Edições 70; 2016. 288 p.
• 17. Gil AP. Estruturas residenciais para pessoas idosas: Relação entre qualidade dos cuidados e qualidade do emprego. Cid Com Ter [Internet]. 2020 [cited 2021 Mar 8];40:67-87. Available from: https://doi.org/10.15847/cct.jun2020.040.doss.art05
  » https://doi.org/10.15847/cct.jun2020.040.doss.art05
• 18. Melo RCCP, Queirós PJP, Tanaka LH, Salgueiro NRM, Alves RE, Araújo JP, et al. State-of-the-art in the implementation of the Humanitude care methodology in Portugal. Rev Enferm Ref [Internet]. 2017 [cited 2021 Mar 18];4(13):53-62. Available from: https://doi.org/10.12707/RIV17019
  » https://doi.org/10.12707/RIV17019
• 19. Mamade Y, Mendes I, Balhana S, Pereira CS, Vasconcelos M, Moreira AP, et al. COVID-19 e doença cardiovascular: consequências indiretas e impacto na população. Med Interna [Internet] 2020 [cited 2021 Mar 8];27(4):341-5. Available from: https://doi.org/10.24950/PV/191/20/4/2020
  » https://doi.org/10.24950/PV/191/20/4/2020
• 20. Hammerschmidt KSA, Bonatelli LCS, Carvalho AA. The path of hope in relationships involving older adults: the perspective from the complexity of the covid-19 pandemic. Texto Contexto Enferm [Internet]. 2020 [cited 2021 Mar 9];29:e20190025. Available from: https://doi.org/10.1590/1980-265X-TCE-2020-0132
  » https://doi.org/10.1590/1980-265X-TCE-2020-0132
• 21. Leão LRB, Ferreira VHS, Faustino AM. O idoso e a pandemia do COVID-19: uma análise de artigos publicados em jornais. Braz J Develop [Internet]. 2020 [cited 2021 Mar 16];6(7):45123-42. Available from: https://doi.org/10.34117/bjdv6n7-218
  » https://doi.org/10.34117/bjdv6n7-218
• 22. Rossini GA, Levites MR, Janaudis MA, Ribeiro MJM. COVID-19 in long term care institutions for the elderly: thinking globally, acting locally and feeling individually. Arc Med Familiar [Internet]. 2020 [cited 2021 Mar 18];22(4):135-43. Available from: https://sobramfa.com.br/wp-content/uploads/2020/11/Covid-19-em-Instituicoes-de-Longa-Permanencia.pdf
  » https://sobramfa.com.br/wp-content/uploads/2020/11/Covid-19-em-Instituicoes-de-Longa-Permanencia.pdf
• 23. Henriques LVL, Dourado M, Melo RCCP, Araújo J, Inácio M. Methodology of care humanitude implementation at an integrated continuing care unit: benefits for the individuals receiving care. Open J Nurs [Internet]. 2020 [cited 2021 Mar 3];10(10):960-72. Available from: https://doi.org/10.4236/ojn.2020.1010067
  » https://doi.org/10.4236/ojn.2020.1010067
• 24. Damaceno DG, Chirelli MQ, Lazarini CA. The practice of care in long-term care facilities for the elderly: a challenge for the training of professionals. Rev Bras Geriatr Gerontol [Internet]. 2019 [cited 2021 Mar 3];22(1):e180197. Available from: https://doi.org/10.1590/1981-22562019022.180197
  » https://doi.org/10.1590/1981-22562019022.180197
• 25. Poltronieri BC, Souza ER, Ribeiro AP. Violence in long-term care facilities for the elderly in Rio de Janeiro, Brazil: perceptions of managers and professionals. Saúde Soc [Internet]. 2019 [cited 2021 Mar 8];28(2):215-26. Available from: https://doi.org/10.1590/S0104-12902019180202
  » https://doi.org/10.1590/S0104-12902019180202
• 26. Melo RCCP, Soares IFF, Manso MSC, Gaspar VFP. Redução da agitação nas pessoas idosas com demência durante os cuidados de higiene: contributo da metodologia de cuidar humanitude. Milleniun [Internet]. 2017 [cited 2021 Mar 9];2(2):57-63. Available from: https://doi.org/10.29352/mill0202e.04
  » https://doi.org/10.29352/mill0202e.04
• 27. Silva RS, Fedosse E, Pascotini FS, Riehs EB. Health conditions of institutionalized elderly: contributions to interdisciplinary action and health promoter. Cad Bras Ter Ocup [Internet]. 2019 [cited 2021 Mar 9];27(2):345-56. Available from: https://doi.org/10.4322/2526-8910.ctoAO1590
  » https://doi.org/10.4322/2526-8910.ctoAO1590
• 28. Aguiar VFF, Santos BSC, Gomes DCN, Tavares TCA. Assessment of the functional capacity and quality of life of Brazilian elderly people living in a community. Rev Enferm Ref [Internet]. 2019 [cited 2021 Mar 9];4(21):59-66. Available from: https://doi.org/10.12707/RIV19011
  » https://doi.org/10.12707/RIV19011
• 29. Lacerda TTB, Horta NC, Souza MCMR, Oliveira TRPR, Marcelino KGS, Ferreira QN. Caracterização das Instituições de longa permanência para idosos da região metropolitana de Belo Horizonte. Rev Bras Geriatr Gerontol [Internet]. 2017 [cited 2021 Mar 3];20(6):743-53. Available from: https://doi.org/10.1590/1981-22562017020.170014
  » https://doi.org/10.1590/1981-22562017020.170014

NOTAS

• ORIGIN OF THE ARTICLE

  Study design Post-PhD internship program – Humanitude Care Methodology: a tool that promotes care management in the comprehensive assistance provided to aged individuals in times of the COVID-19 pandemic, presented at the Graduate Program in Nursing of Universidade Federal de Santa Catarina, in association with Escola Superior de Enfermagem de Coimbra, Portugal, in 2021.

• FUNDING INFORMATION

  Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Programa de Excelência Acadêmica (PROEX) nº364/2021

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research of the Universidade Federal da Fronteira Sul, opinion No.4,161,725 and Certificate of Presentation for Ethical Appreciation No. 33882620.5.0000.5564.

Edited by

EDITORS

Associated Editors: Melissa Orlandi Honório Locks, Ana Izabel Jatobá de Souza. Editor-in-chief: Roberta Costa.

Publication Dates

• Publication in this collection
  29 June 2022
• Date of issue
  2022

History

• Received
  27 Apr 2021
• Accepted
  15 Dec 2021