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Print version ISSN 0104-1169
Rev. Latino-Am. Enfermagem vol.15 no.1 Ribeirão Preto Jan./Feb. 2007
Humanizing care through the valuation of the human being: resignification of values and principles by health professionals
Dirce Stein BackesI; Magda Santos KoerichII; Alacoque Lorenzini ErdmannIII
IDoctoral Student in Nursing, Nursing Service Manager at the Santa Casa de Misericórdia de Pelotas, RS, e-mail: email@example.com
IIDoctoral Student in Nursing, Assistant Professor, Santa Catarina Federal University, e-mail: firstname.lastname@example.org
IIIRN, PhD in Nursing Philosophy, Full Professor, Santa Catarina Federal University, CNPq researcher, e-mail: email@example.com
This qualitative study aimed to find the values and principles steering health professionals' practice, in order to reach the values guiding humanization. The study took place between October and November 2005, when 17 professionals from a multiprofessional team at a hospital in the South of Brazil were interviewed in three different samples. The methodology used for comparative data analysis and interpretation was based on Grounded Theory, resulting in the creation of a theoretical model, guided by "humanizing care through the valuation of the human being". Data demonstrated that new competencies can be developed, which are capable of provoking a resignification of values and principles guiding humanization, with a view to reaching personal/professional accomplishments through work, allying technical and human skills in professional practice and experiencing humanized care.
Descriptors: patient care team; professional-patient relations; nursing
THE HUMAN BEING GIVING CARE - WHAT HUMANIZATION DOES HE PRACTICE?
Philosophical reflections on humanization have become very important, mainly in view of the principle of scientific and social responsibility and the apparent impotence of ethics to act on technological human beings, who are capable of organizing, disorganizing and radically changing the foundations of life, that is, to create and/or destroy themselves.
The growing development of sciences and their applicability to human life lead human beings to an infinity of inquiries, perplexities and uncertainties that frequently provoke a profound value crisis, challenging professionals' ethical posture and their ability to conciliate new demands and competencies. Despite the indisputable benefits of technological progress, more specifically associated with the problem-solving capacity of therapeutic discoveries and health professionals' qualification, we need to discuss and redefine/reorient the limits that will establish how far human beings can or should go(1-2).
In this sense, a conscious and coherent philosophical reflection about the human values guiding the humanization process and the principle of social responsibility can help to problematize the actual needs, that is, the advantages and/or disadvantages progress imposes on health professionals' practice. Therefore, it should be reminded that the entire technical-scientific development related to life not only conducts human beings towards novelties associated with therapeutic hopes, but can also give rise to fears and enormous ethical dilemmas that challenge health professionals' practice. In this context, there is an urgent need to develop new competencies that are capable of provoking a resignification of the values and principles guiding humanization in the health scenario.
The development of technical-scientific progress can follow different courses and use different methods. However, it should be reminded that knowledge is a value in itself and that the decision about what knowledge society, scientists or health professionals should concentrate their efforts on implies the consolidation of moral, ethical and human values and the critical and reflexive analysis of reality. Hence, the debate between values and interests about each of the options depends on researchers' and professionals' ethical and social responsibility(3).
One important initiative in the health area, besides academic reflections, was the Brazilian Health Ministry's implantation of the National Care and Management Humanization Program in the Single Health System - Humaniza SUS. This proposal calls upon all stakeholders, managers, workers and users to commit themselves to the humanization process, as the Ministry itself identified a growing number of user complaints about lack of welcoming, access and work conditions, among others(4).
However, a policy cannot be implemented because public and/or institutional entities want to only. It requires all stakeholders to commit themselves, mainly those in daily contact with users, as well as other professionals who show, through their work and attitudes, the characteristics of health services offered to the population.
To reach a new understanding of the principles and values guiding humanization, health professionals need to articulate theoretical and technical scientific knowledge with affective, social, cultural and ethical aspects of the relations they establish through their practice, so that humanization does not remain restricted to merely technical attributions, but includes the capacity to understand and respect human beings in their different forms of being and existing(5).
In sum, an infinity of questionings, doubts and uncertainties originated from and/or persist under the technical-scientific paradigm, guided by the values of technical efficiency and scientific knowledge. In this perspective, professionals focus on disease and cure, instead of humans as weakened and vulnerable beings. This gives rise to questions like: Where is history heading and/or to what point can it advance without infringing human dignity? How can a more dignified experience be constructed? How can care relations be humanized?
The human condition as a principle of citizenship and/or principle of humanization is actually recovered through authenticity, dignity, solidarity, affect and respect for human individuality(6).
The uncertainties and destabilization of values are the visible side of a humanity immersed in a profound crisis, seeking new debates and possibilities that are capable of reconstructing/reordering knowledge based on human and ethical principles(1,7-8).
From this viewpoint, crisis is characterized by an explosion of complexity, contradictory directions in evolution and high doses of uncertainty. At the same time as available technological knowledge multiplied capacities to dominate nature, it also provoked the disorganization of knowledge, creating practices that jeopardize the human race itself.
Hence, we need a new paradigm, that is, a new view on reality, a radical change in our thinking that is capable of facing the complexity of reality, confronting the paradoxes of order and disorder, singular and general, the part and the whole(7-8).
In view of this universe of new rationalities, the paradigm of complexity intends to redefine the form of current development, guiding knowledge through human and ethical values and conquering a new systematic perception, based on a reflexive subject who is capable of articulating different kinds of knowledge. Complex thinking helps human beings/professionals to acknowledge the complexity of realities, that is, it reveals the uncertainties inherent in knowledge structures themselves and also the "black holes of uncertainty in current realities"(8).
The main challenge of humanization is to rejoin/reconnect inquiries, knowledge and, mainly, ethical, moral and social values. To redraw a new horizon, distanced from the reductionist debate oriented towards individual rights and more concerned about the recovery of broader concepts related to human dignity and to the deconstruction of particularities, with a view to constructing the humanizing knowledge ecology(9).
Technological solutions do not necessarily involve the academy, but they do include the mentors of these technologies through training or practical orientations(6). What is important in this area is not to know the origins of professionals' technological thinking, but the capacity to stimulate the critical reinsertion of human beings in reality, based on complex thinking.
Thus, humanization, in the light of the complexity paradigm, can be achieved through the revolution of "relations among humans, ranging from relations with themselves and others, relations between nations and states and relations between men and the techno-bureaucracy, between men and society, men and knowledge, men and nature"(7).
Humanization presupposes a value system, that is, a complex system of organization and civilization that respects individuals' autonomy, diversity of ideas and freedom of expression and recovers subjectivity. Hence, health professionals' challenge in view of technical-scientific progress is to construct the process of including all persons and peoples and beneficiaries of this progress(1).
In sum, humanization is a process of transforming organizational culture, which needs to acknowledge and value clients' and professionals' subjective, historical and sociocultural aspects, in order to improve work conditions and care quality by promoting actions that integrate human and scientific values.
In order to contribute to the development of new competencies that incorporate both human and technical-scientific values, that is, to include the human being in scientific processes and allow for the experience of and coping with a fragmented disciplinary logic, this study aimed to look for the values and principles directing health professionals' practice, with a view to reaching the values that guide the humanization process.
We carried out a qualitative study. This kind of study is capable of answering very singular and subjective questions, that is, of "working with the universe of meanings, motivations, aspirations, beliefs, values and attitudes, which corresponds to a more profound space in relations, processes and phenomena that cannot be reduced to the operationalization of variables"(10).
In the attempt to respond to a research, data analysis and comparative systematic interpretation method for the construction of philosophical meanings in the context of humanization, the choice of Grounded Theory (GT) was an important methodological strategy. Through induction and deduction, the method allowed for the construction of a theoretical model to explain the study phenomenon, with a view to explaining the wealth and diversity present in human experiences.
Based on Symbolic Interactionism, Grounded Theory is oriented towards knowledge about perception and/or meaning, with a view to capturing the intersubjective aspects of human beings' social experiences and, thus, adding new perspectives to reflections about the phenomenon. Hence, all GT procedures are aimed at identifying, developing and relating concepts, starting from various sample groups, that is, to generate theories on the basis of the research data, which are analyzed and compared systematically and concomitantly(11).
The constant comparison of the interviewees' data is used to elaborate and theoretically improve the categories highlighted on the basis of these same data. In comparative analysis, however, aspects like the following have to be taken into account: knowledge of the environment, data coding, category formulation, reduction of number of categories, identification of central category and modification and integration of categories(12).
The study was carried out between October and November 2005. Participants were seventeen professionals from the multiprofessional health team at a hospital in the South of Brazil, who constituted three sample groups. The study institution and one of the authors have been inserted in the Humanization Policy since June 2003, which facilitated the study development. The number of participants (17) and sample groups (3) was determined through the theoretical sampling process recommended by Grounded Theory.
Participants were informed about the objectives and proposed methodology, and the right to access the database and anonymity were guaranteed. At that moment, they were asked to sign the Free and Informed Consent Term, as recommended by Resolution CNS/MS196/96 on ethics for research involving human beings. Besides these ethical precautions, the project was submitted to and approved by the Ethics Committee for Research involving Human Beings at the same institution.
In order to guarantee participants' anonymity, the letter "e" was used and the number corresponding to the statement, identified in the text as (e1); (e2); (e3) and so on.
The first sample group consisted of six nurses who were members of the Nursing Care Systemization Group at the study institution. These nurses were actually involved in humanization and nursing care systemization.
The second group included clinicians from the hospital. Participants were randomly chosen, seeking to represent different medical specialties. However, during the first meeting, only two physicians, one pediatrician and one intensive care physician participated, requiring a second appointment, when six physicians took part: one pediatrician, one gynecologist, one oncologist, one general clinician, one cardiologist and one urologist. The latter was the hospital's technical director.
The third sample group consisted of five randomly chosen professionals who were members of the Humanization Group at the study hospital: one administrator, one administrative technician (responsible for the hospital kindergarten), one accountant, one nutritionist and one nursing technician.
Data were collected through group interviews, which were tape-recorded and took approximately one hour. Date and time were previously scheduled for the three groups. The interview technique is used to obtain in-depth information, that is, information in the respondents' own words and a detailed description of situations. Attentive listening is part of this instrument's actions(12).
The following guiding question was used to start the interviews: What are the meanings of the values and principles that guide your practice as a health professional?
After the tapes had been transcribed, data were validated by the participants and then categorized, interpreted and compared with data from the subsequent interview and so on, in a constant back-and-forth movement, as recommended by the proposed analysis method. Finally, three categories resulted: Work as personal/professional realization; Allying technical and human competence in professional practice and; Experiencing humanized care.
ANALYSIS AND COMPARATIVE SYSTEMATIC INTERPRETATION OF CATEGORIES
Work as personal and professional realization
In understanding the worker's logic as well, the humanization process points towards work as a humanizing and/or dehumanizing instrument. In this perspective, institutions occupy an important place, mainly to get to know workers' personal and professional satisfaction and/or dissatisfaction level and create concrete spaces for the expression of subjectivity and the development of human potential.
The National Health Service Humanization program - PNHSS - aims to reduce difficulties during user treatment and also attempts to focus on professionals, for them to perform their work with satisfaction/realization and social responsibility(4).
You need to like what you do. But we need to take into account professionals' private life, personal and financial problems [...] When something bothers them, this soon ends up interfering in their professional satisfaction (e1).
According to the workers, talking about humanization based on the federal government's proposal requires that managers and professionals reflect on the relational context in- and outside the organization. Thus, satisfaction and realization at work cover a set of elements that refer to the human being - professional - as the subject of the process(13).
As a complex company, hospitals should give priority to a structured organization and a dynamic and democratic management team that is able to understand the profound changes in the field of development. Hospital management should also prioritize a climate of good relationships and favorable conditions to perform activities.
It is complicated, because we can't always do as we'd like to. You need to have the conditions to deliver good patient care. I think doctors are not that valued. They lost a lot of their autonomy. I think it should be an exchange because, if qualified and satisfied in all senses, doctors will be able to deliver good care to their patients (e3).
The care process needs to occur in an interactive relation, in an actual exchange of information, knowledge and interests, based on the ethical compromise established between both. No organization can be considered humanized if it does not fully know its clients' needs, whether internal or external, or if it knows those needs but ignores them. It should be acknowledged that clients' expectations always create improvements, as a needs-oriented environment is dynamic and constantly adapting to their aspirations. That is because their needs change in the same way as their expectations of how these needs will be satisfied(5).
In this process, it is relevant to create a democratic and participative environment in order to achieve personal and organizational objectives and goals. Participatory management, with a view to realization and humanization, contains a strong social characteristic, due to the development of solidary practices in relations between professionals and clients. Health practices point towards a strong correlation between happy/realized employees and satisfied clients. Thus, employees who are satisfied with their work reflect in work quality and in a positive feedback by clients. In the last instance, humanization emerges from professional pleasure at work and, at the same time, from a favorable organizational climate and adequate work conditions. It should also be highlighted that, when people like what they do, humanized and humanizing practice flow naturally and spontaneously. A Buddhist saying concludes: "discover something you like to do and you will never have work again".
Allying technical and human competence in professional practice
The constant and continuous development of professional competences involves not only technical improvement and acquisition of new technologies, but mainly the capacity to mobilize, articulate and put in action values, knowledge and abilities needed for the efficient and effective performance of activities required by the nature of the job(14).
Respect for the patient is fundamental and that is the need for permanent recycling (e4).
Competence is, also, "a capacity to act effectively in a certain type of situation, base don but not limited to knowledge". Knowledge is considered as "complementary cognitive resources", or "representations of reality we construct and store depending on our experience and training". Human actions, "the more complex, abstract, mediatized by technologies and supported on systematic models of reality, the deeper, more advanced, organized and reliable the knowledge they require". But knowledge is not enough for competences to manifest themselves as actions, this knowledge needs to be used to "relate", that is, to "judge its pertinence to the situation and mobilize it judiciously, it is the "art of execution"(15).
Values do not come along with the degree. College brings the technique, but values are constructed in life (e5).
We may say, then, that being competent implies knowing what to do in each concrete situation and presupposes a judgment about the situation and an intentional action. It requires a set of knowledge but is not limited to this set. Professionals acting competently base their practice on cognitive, technical and communicational competences. That is, a set of characteristics that involve the acquisition of solid and updated technical knowledge, the development of humanist value, a responsible ethical posture, a permanent learning attitude, besides the capacity to act upon the unexpected and work in multiprofessional teams(16).
Respect for life, commitment and, mainly, teamwork are great values for me today. [...] in the team, each one has his own way, attitude, way of working. We need to learn how to look with the other's eyes (e8).
I believe there's a need to link the human with the technical. Technique has always been and will be fundamental in patients' cure process, but we need to understand that it's not everything (e4 and e12).
Technical competence can be allied with humanization to the extent that the development of sciences and their applicability in care for human life entail the social responsibility for a broader understanding of what is qualified and humanized professional care.
The patient has to be treated as if he were our relative. I perceive that the interns often treat the patient as an object [...]. We should establish a family relation between physician and patient. During visits, I usually lose a lot of time with the relatives. I think that orientation is fundamental for them to feel more secure. Sometimes, relatives even ask: 'doctor, what's your name?'. The relative perceives the professional's smile and sensitivity. It's not just the drug and the doctor that cure the patient (e6).
In the humanized hospital environment, the physical, technological, human and administrative structure values and respects human beings and is at their service, guaranteeing high-quality care(17-18).
The recovery of human values, that is, of humanity as the essence of human beings, does not derive from mechanic and routine work but, through work as personal/professional realization, from technical and human competence and from the experience of humanized care as an innovative practice that transforms the relations and conditions of production systems.
In my opinion, respect for the patient is a fundamental attitude and that is the need for permanent recycling [...]. Actually, responsibility and respect are the strongest values (e10).
I think that value is all about the education we get from birth. Value does not come with the degree. College brings the technique. Human values are constructed in life. Values come from good character. People who only think about technique are merely oriented towards economic interests (e8).
Hence, technical and human competence in professional practice is not limited to care as a practice that is realized from professional to patient only, in a verticalized and paternalist way. On the opposite, it considers that everybody is a subject and receiver of care in its most diverse forms and expressions. Just like patients, professionals are unique human beings and, as such, demand valuation and recognition of their needs and the attention needed to have the conditions to develop humanized care in health practices. In humanitarian management and care practices, professionals allow themselves to be human, to feel themselves in relation to an OTHER, who is also human, to manifest their sensitivity, create empathy, establish a subject/subject relation and, thus, turn care into a humanizing practice(13).
Experiencing humanized care
In the last instance, humanized care means directing the experience of being in a hospital environment to the human being as much as possible, considering values, beliefs, feelings, emotions and not just the biological aspect. Humanized care starts when the professional enters the patient's phenomenal field and is capable of detecting, feeling and interacting with him, that is, capable of establishing an empathic relation, centering care on the client and the environment in order to perceive the other person's experience and how he lives it(18).
Besides the patient, this care also includes the professionals involved in the process.
I think that the human being's value is already a value in itself [...], the value of patients and professionals as well. Humanization aroused a new attitude in people, especially in their way of getting closer to the other, of being sensitive to the other (e6).
Hence, humanized care is an experience process that permeates professionals' being and doing in different expressions, dimensions and interactions.
I have learned a lot. Respect for life, commitment and teamwork are great values for me today. I learned that, in the team, each one has his own way, attitude and way of delivering care. We need to learn how to look with the other's eyes. When I understand this process, it seems that everything around me gets better. I consider that the team has to be a whole, but the whole in all areas (e11, e15, e16).
In this perspective, understanding and experiencing humanized care does not only include technical attributions and/or a verticalized professional-patient relation, but the ability to perceive and welcome human beings in their different dimensions, interactions, and to understand how they develop their identity and construct their own life history. When delivering care, professionals should be fully present, give everything they have, value the other person's experience and knowledge. If they only face their activities as an obligation and not as a social commitment, they will neither feel encouragement nor passion about what they are doing(5).
When we modify our way of being, we end up modifying the others as well. Through the humanization work, we managed to transmit the importance of small expressions of care to the others. Humanization has made us think more. The thing is that these questions had never been addressed. You acted isolatedly, mechanically, without thinking. Humanization already existed at the hospital, it's just that everybody did it his own way and worked very separately. Humanization came as a call for greater integration (e12, e13, e14).
Starting from real and concrete experiences, research participants pointed towards the importance of the hospital humanization process as an innovative proposal that transforms work relations and conditions. Their statements demonstrated the power of positive personal/professional attitudes to influence the dynamization, mobilization and potentialization of care practices. The humanized care experience strengthens personal and collective commitment in the concretization of practices that are capable of recovering the human dimension in different spaces and expressions.
Professionals move around in organizational spaces, constructing opportunities for relations and experiencing care to the extent of their potential to delimit and use this space, that is, of dependence and interdependence, of belonging and privacy(6).
Thus, in this perspective, humanized care as the essence of life ranges from the small acts of thinking, being and doing to the configuration of a care process that involves both the person receiving care and the caregiving professional. At this moment, the meanings attributed to care do not matter. It is important for humanized care to prioritize the essence of human beings as unique, indivisible and autonomous beings who are free to choose, that is, the understanding of human beings as integral beings.
THEORETICAL MODEL CONSTRUCTION
The construction of the theoretical model to explain the study phenomenon aims to establish a relation among the categories, based on causal conditions, intervening conditions, context, action and interaction strategies and consequences contained in these categories, with a view to the identification of the central idea(11).
In trying to represent a theoretical model to explain the values and principles guiding humanization in the health scenario, we attempt to identify the dynamics and complexity of the humanization process, expressed in the following categories: Work as personal/professional realization; allying technical and human competence in professional practice and experiencing humanized care.
During data analysis and comparative systematic interpretation, from the start of coding until categorization and connection among categories, we verified the need for integrality and interactivity in professional practice. The different phases demonstrated humanization as a gradual, dynamic and systemized process, determined by the incessant search for ethical values and principles with social responsibility for human beings' dignity. In seeking professional integration and the increasing strengthening of human and relational competences, health professionals contribute to the development of new competences that incorporate both human and technical-scientific values, that is, the inclusion of the human being in scientific processes and the possibility of living and coping with a fragmented disciplinary logic.
Thus, professionals are: Humanizing care by valuing the human being, as an expression of hospital humanization. This central theme is surrounded by the categories that constitute the theoretical model represented in Figure 1.
In summary, health professionals at the study institution experience humanized care by allying technical and human competences and achieve personal and professional realization in a dynamic and continuous care process, valuing the human being. Their values and principles experienced in care relations allow them to humanize care by valuing the human being.
Most study participants associated the values guiding their professional practice in the first place with humanization. Values and principles directed at respect, dignity and actual valuation of the human being. They consider that values can receive a new meaning, that is, they can be treated and internalized to the extent that people are willing to or decide to go through a personal/professional transformation and socialization process.
Hence, humanized values represent an internal personal process, stimulated by a space of reflection, confrontation and collective mobilization, capable of understanding the parts in the whole and the whole in the parts, that is, stimulated by a participatory humanization process.
Participants also pointed towards the importance of the hospital humanization process an innovatory proposal that transforms relations and work conditions. They also demonstrated the power of positive personal/professional attitudes to influence the dynamization and mobilization of practices that transform reality. In this sense, values strengthen personal and collective commitment in the concretization of practices that are capable of recovering the human dimension in different situations.
In sum, humanization requires a process of reflection about the values and principles guiding professional practice, presupposing, besides the delivery of a dignified, solidary and welcoming treatment and care by health professionals to their main work object/subject - the sick human being/weakened being -, a new ethical posture that permeates all professional activities and institutional work processes.
This study showed that new competencies can be developed, which are capable of provoking a resignification of the values and principles guiding humanization, aiming at work with personal/professional realization, allying technical and human competence in professional practice and experiencing humanized care.
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Recebido em: 17.3.2006
Aprovado em: 10.7.2006