Humanization knowledge of undergraduate nursing students

Objective: identify the senses and practices representative of humanization in the training of undergraduate nursing students. Method: a qualitative study, supported on the national policy of humanization and the concept of social representation. An interview was conducted with 40 undergraduate nursing students from a public institution. ALCESTE software was used for lexical content analysis. Results: the sense of humanization is built on the practice and disciplines of social and human sciences. The coordination between theory and practice is representative of humanization, but does not take place in learning experiences. The professor’s participation and teamwork are elements that infl uence humanization. Conclusion: humanization should be reinforced in the training of undergraduate nursing students, using learning-teaching strategies and experiences that make sense to students, including alliances between theory and practice, learning and service, research and care.


INTRODUCTION
Humanization of healthcare has been a subject of discussion in the health area, especially in recent years, following the creation of a public policy under the Unified Health System (SUS -Sistema Único de Saúde).The National Humanization Policy (PNH -Política Nacional de Humanização), created in 2003 by the Ministry of Health (MS), shows the concept of humanization related to the right to health, deviating from the concept of charity and philanthropy linked with the practices of healthcare, including those formally seen in health services.This fact is evident in common sense, as humanization of healthcare is emphatically built on moral attributes that support interpersonal relations between professionals and patients, deviating from what is proposed by the PNH (1)(2) .
The PNH has humanization as the guiding principle of SUS attention and management practices.Its objectives are to develop strategies and an inclusive method built with the collectivity -patients, health professionals, and managers -to overcome the challenges of health practices in Brazil.One of the purposes is to achieve quality in service in understanding that subjects are autonomous and active players, with health inserted in the context of citizenship (1) .
One of the challenges to maintain and qualify the PNH as a public policy of SUS has been the training of health professionals (2) .In terms of nursing, care is its central concern in science and practice; therefore, the theme of humanization is part of the debates held in the area, especially in terms of professional training.Nursing training should promote discussions and debates about the policies and concepts involved, with emphasis on the social responsibility of nursing (3) .
To better understand the theme, it is necessary to consider the historical construct of the concept of humanization and how it has been increasingly addressed in scientific productions.In 1950, studies indicated that there were dehumanization aspects related to faults in service and labor conditions in the health area.In this sense, humanization has become a question to be discussed, once it has been recognized that situations of dehumanization occur in the daily provision of health services (4) .
In the 1950s, 1960s, and 1970s, the need to humanize health services was observed, especially in hospitals, relating the service organization in terms of investment in physical structure.The focus on workers appeared in the literature in the 1960s, 1970s, and early 1980s, highlighting some characteristics present in nurses and physicians.These characteristics are linked with a charitable feeling, such as sweetness, compassion, a spirit of charity, ability to forgive, and detachment.These feelings also emphasized a sense of being privileged and chosen by God (4) .
It should be noted that, until the 1980s, the attention devoted to curative care was provided in hospitals.After the Eighth National Health Conference held in 1986, the most important political sanitary event of the mid-20 th century, health began to be discussed as a right everyone is entitled to.In 1988, with the Brazilian Federal Constitution, the SUS was created, incorporating most proposals from the sanitary reform movement submitted by the popular amendment monitored by the participation of involved segments (5) .
Starting in the 1990s, humanization was inserted into a political health project, specifying the appreciation of the individual, and deviating from the charity feeling.Between 1999 and 2002, the Ministry of Health created other programs in addition to the National Policy of Hospital Care Humanization (PNHAH -Política Nacional de Humanização da Assistência Hospitalar), including: a letter to patients (1999); a national program of hospital service assessment (1999); a program creating collaboration centers for hospital quality and attention (2000); prenatal and birth humanization programs (2000); standard of humanized care for low birth-weight newborns (known as the kangaroo method) (2000); and a hospital accreditation program (2001), among others (5)(6) .
Studies on humanization focused on professors, students, nurses, and nursing technicians have shown that the sense of and images related to humanization still link it with moral and charity feelings, without the political, social, and economic character that involves healthcare, as proposed by the PNH (7- 9) .This result justifies investigations on learning-teaching experiences representative of humanization, aiming to better understand why the political dimension is not so evident to undergraduate nursing students.
Thus, this study aimed to analyze the humanization of healthcare in the learning-teaching experiences of undergraduate nursing students.The question of this study was: what learning-teaching experiences, in the practice of nursing students, are representative of humanization?The objectives were to identify and analyze the senses and practices representative of humanization in the context of nursing training.

METHOD
This is a qualitative, exploratory, and descriptive study, which applies the concept of social representation (SR) in the psychosociological segment.In this approach, SR expresses the common-sense knowledge of a group, which links the actions, thoughts, and language of subjects.The content comprising SR allows the subject to understand the phenomenon, ensuring communication and easy understanding of the world and the relations that occur in it (10) .This study was conducted in a federal educational institution of Rio de Janeiro.The option to analyze this institution specifically was based on its differentiated curriculum, which allows students to have contact with patients in the first period of the program.It is believed to allow the contact of students with practical healthcare experiences at the beginning and end of the program.This study selected students from the third period of the program, as they are concluding the first curricular portion that addresses healthcare to supposedly healthy people in their daily contexts (children and adolescents at school and adults at their workplaces), and students from the last period of the course, as they are near the end of the program, with varied experiences in situations of care to supposedly healthy people, ill people, and people in situations of difficult social integration.Then, this study would have a population in different training phases, characterizing it as participants chosen by convenience.
The participants were 20 students from the third period and 20 students from the eighth period of the nursing program, totaling 40 students.The inclusion criteria were: nursing students regularly enrolled and attending the disciplines in the terms selected for the study.The exclusion criteria were: nursing students who took a voluntary leave of absence or medical leave.
Data collection was performed between June and September 2012.The method of in-depth interview was adopted, using an individually applied semi-structured instrument divided into two parts.The first contained questions about the psycho-sociodemographic profile of subjects, required in SR studies, as it requires to outline the conditions of production of these representations.The second contained open-ended questions that explored the senses, practices, experiences, and expertise of undergraduate nursing students in relation to the theme of humanization.
Data collected in the interviews were inserted in ALCESTE (Analyse Lexicale par Context d'um Ensemble de Segments de Texte), software that allows to distinguish word classes that represent different forms of speech regarding a subject of interest (11) .The interviews were separated by a command line in which variables were inserted, such as: gender; term; religion; prior certified nurse technician program; and family member in the nursing team.
The corpus was comprised of initial context units (UCIs), which correspond to the interviews with students.Therefore, this corpus was comprised of 40 UCIs.After running the analysis, the software performs a text segmentation of UCIs into elementary context units (UCEs), which correspond to the discursive material that distinguished the classes to be analyzed by the investigator.For each class, ALCESTE calculates a value of association (khi²) to all reduced forms of words selected for the analysis, identifying those significantly associated with the class, which directly reflects a value of khi².
ALCESTE totaled 75% of utilization of the analyzed corpus, originating four classes.The analysis of words present in each class and its cross-matching with associated UCEs allowed for an understanding of the senses and images from the speech of nursing students about humanization.Class 4 grouped words that provided a sense of the learning experiences of students about humanization, gathering 444 UCEs, which had their content and production analyzed according to the groups of study participants.
The project was approved by the Research Ethics Committee of the studied institution.All subjects who accepted to participate as volunteers signed an informed consent term, in compliance with the requirements of Resolution nº 466 / 2012 of the National Health Council.

RESULTS
The word class focused by this study presents a statistical association with students from the eighth period (khi²=35) of the nursing program, without a family member in the nursing team (khi=24).The other variables did not present a relevant association with this class.All 444 UCEs comprising Class 4 represent 21% of the corpus, with 106 analyzable words.The reduced forms and their semantic contexts are presented in Box 1.

Box 1 -
Reduced forms with associated khi² and full forms associated with the class This class has two subclasses: A) how to do it; and B) knowledge.Subclass A expresses the differences and similarities between practice and theory, and it is influenced by academia; it is named: How to do it?(Dis)articulation between practice, theory, and teamwork.Subclass B has content that shows how academicians build knowledge based on humanization considering what is taught in the disciplines, in each term of the program, according to the professor and the content addressed.This subclass was named The Disciplines and the Professor Figure.
Each subclass will be presented with its respective UCEs, which represent the fragments of illustrative speeches of Class 4, followed by the interview indication (UCI) and the student's period in the nursing program.
Subclass A: How to do it?(Dis)articulation between practice, theory, and teamwork For academicians, humanization is learned in practice, but such learning is directly influenced by academia, due to the learning and teaching process implemented in the program.
My entire program was conducted and based on this type of thought.Then, that's why it makes me think about the practice.(uci n° 18, eighth period) Then, in the academia, which is when you have contact with the theory, and that's how it should be, and you try to implement that in practice.(uci n° 4, eighth period) I guess we have to learn in practice.That's why I think we have to leave the classroom a little and go to the training program, because that's where we will learn and have contact with workers and customers.(uci n° 26, third period) Then, it is something that concerns me, how it will be put into practice, because what we see is that it's not put into practice.And there are things like: "the students are patient because they haven't been there for 10 years in the market."(uci n° 13, eighth period) But it's like I said: in practice, it's more difficult to put it.Then, in academia, it was better for me in theory; in practice I couldn't see much, I couldn't take it.(uci n° 13, eighth period) In addition, the nursing program context has challenges that should be solved, that is, when the learning-teaching process is different from the practice, without articulation between the classroom theory and the effective practice.With the challenges imposed by the practice towards the implementation of humanization, academicians propose strategies to promote and disseminate humanization guidelines and instruments in congresses, lectures, rounds of talks, and the development of activities for permanent education to include the nursing team as well.
I guess we have to start studying this subject in high school, in schools, congresses, and it should be disseminated even through these vehicles we have for dissemination, and these issues of permanent education.(uci n° 20, eighth period)

One way is to take knowledge to people through lectures, permanent education, continued education. I guess that's how this knowledge could be disseminated to professionals. (uci n° 20, eighth period)
Proposing strategies, that could influence the sector itself, if we could, through these rounds of talks, these debates, propose solutions.It would improve a lot, not only for us, the students.(uci n° 14, eighth period) The speeches of students are in agreement with the strategies indicated by the policy, showing they have knowledge about this theme.
In all the training programs I took, I couldn't be part of the team, I passed.I felt I was part of the team in the family clinic.In basic attention, I felt part of the team, we spend more time.(uci n° 15, eighth period) Some other times, the problem is in the resistance of some team members that create barriers for the work process which, in this context in particular, includes the professional nursing training process.

They try to talk, many times they can't, due to this resistance we see during the college period; we see many people don't like having us there in the sector, they think it gets crowded, and more material is spent. (uci n° 13, eighth period)
The greatest resistance is when we go to the practical area, and it bothers the student, because, when we are in the classroom studying, we have one thousand ideas of providing care, and when it's time to do that, we can't put it into practice.(uci n° 16, eighth period) Then, the challenges of working with the nursing team with resistance can affect the performance of students who want to implement in practice what they have learned in the classroom.

Yes, I guess that what has influenced me in academia is the professors, the professionals who teach us every day, who bring something else every day, the training program which I think is essential. (uci n° 19, eighth period)
In the classroom, what influenced me was that, despite everything, the professors explain the theory to us and, when they are with the patient, most of them try to put the theory into practice; I got to learn what theory is actually.(uci n° 13, eighth period) However, some experiences show professor-student relations that do not favor humanization learning, when the communication process is not always satisfactory.

I don't see much action of the professor because the professor is not very open with students, and I didn't see many discussions about that, of the professor with the nursing team; then, we have to listen in the classroom to what they see, what is wrong, and discuss. (uci n° 18, eighth period)
Because the professor is also a professional and even so he doesn't have that feeling of talking to the student at the same level.(uci nº14, third period) The students mention that it is necessary to change the professional profile of the professor for a better preparation of students to act in the practice considering humanization, developing more practical activities than research activities.
You [the professor] are 40 years old and then you can be discarded because you are not updated.It's not like that, but today he makes changes, yes; then, there is this diverse deficit.This diversity is in young professors in the classroom, with experience, because they tend to believe.Then, from graduation, they go straight to research and straight to papers and then teaching, and it's not a good status.(uci n° 1, eighth period)

They [the professors] only understand papers; then, they believe they teach something you don't believe; it doesn't work. I guess it lacks young professors, not that they are too old and can't continue. (uci n° 1, eighth period)
As professors are much more focused on research than the reality, they end up not preparing us very well.(uci n° 29, third period) The analysis of UCEs shows the conception of indissociability among theory, practice, and research, as students are considering research as a deviation from practice, and consequently, from humanization.

DISCUSSION
Practice is recognized by students as the start of learning about humanization, as they should build and experiment new Subclass B: Knowledge: The disciplines and the professor figure This subclass covers content that represents the knowledge built in formal humanization teaching.The content of UCEs shows it is important to work on nursing training, the concept of humanization and, in particular, the PNH guidelines, scope, and instruments.Humanization is addressed during the program, in the classes, in general, and specifically in disciplines of social and human sciences, such as anthropology, sociology, and psychology.Some disciplines, for example, anthropology, sociology, psychology, that we had in the first period of the program, tend to this area of understanding others as people, as human beings.(uci n° 36, third period) Psychology is also very interesting in the program; I loved psychology for nursing, because it also shows how to see people in a different way.(uci n° 27, third period) These were the disciplines most mentioned by the students because they understood they are more related to humanization learning, once these sciences allow for an understanding of human beings as a whole, considering all their aspects, appreciating their culture, respecting their concepts and values.
In every class we learn that we have to humanize; of course humanization always, but there is no class with this theme; but every class emphasizes that.(uci n° 30, third period) I guess humanization is treated as it should be naturally, within all content; we don't need a specific content saying: "Look, today we're going to talk about humanization."(uci n° 16, third period) For the students in the third period of the program, humanization should be addressed transversally during the nursing program.However, the students from the eighth period say they learn about humanization only at the end of the program, even considering that the program ensures contact with patients early in the program when, according to students, the theme is formally learned only at the end of the program.

I guess the theory is good, I guess we have to learn about humanization from the first period; it is taught too late in the program. (uci n° 6, eighth period)
We have training programs already in the first period of the program; we start with children.I guess there's something of this humanized care in it, but we start to learn what humanization would be in the last periods.(uci n° 18, eighth period) The professor figure resulted from the speech of students as an element to promote learning about humanization by means of the teaching methodology.For instance, when a professor is with the students in the training program, a student observes how this relates to healthcare patients and realizes it is possible to put into practice what was learned the classroom.knowledge and practices with the subjects involved in healthcare processes, namely professionals and patients.It agrees with the PNH when it states that health training should imply collective actions and exchanges, based on concrete practices of intervention to allow the creation of new practices (12) .
However, some content shows that students' concerns about humanization are affected in practice, as they have already experienced challenges regarding difficult application of theory into practice, according to the PNH guidelines.
Humanization practices should promote debates in the nurse training program.Academia should promote healthcare spaces built with other professionals and patients, so that professionals are capable of performing in the challenging routine of SUS (13) .In addition, challenges are also seen in the training context, when the teaching-learning process is different from the practice, without articulation between the classroom theory and effective practice.
For humanization to be effected into practice, teamwork is required, including actors from all health scenarios.For this reason, in the nurse training process, all members should promote spaces to allow learning and teamwork to address the challenges.However, students report challenges in working with the nursing team.
The challenges indicated by the nursing students to the implementation of humanization in practice include the need to create an instrument defined by the PNH in institutional spaces where nursing teaching-learning takes place: namely workgroups of humanization (GTH).This instrument promotes meetings of people interested in discussing the work environment and relations that occur in such environments, making it a place to bring people together.It could be a contribution of the nursing training institution to healthcare services to implement the policy guidelines, discuss daily problems, raise issues, and propose solutions.As proposed by the PNH, it is not possible to work in the context of humanization without teamwork (14)(15) .
Nursing training should be understood as a process that can change the routine of health services.This way, the student should consider the main role of their teaching-learning process as that of someone who performs something in addition to the assignments, someone who manages and takes care, so that, based on these daily experiences, they can find encouraging elements in the teaching-learning process that can intervene in the reality, seeking new solutions and stimulating new forms of care (16)(17) .
In this scenario, the active participation of the professor makes a difference.Therefore, applying the methodology of teaching by example influences and drives students to perform changes in health practices, with direct impact on healthcare practices the students establish with patients.Significant learning experiences and training strategies may contribute to changes in representations (18) .Based on this idea, considering representation as social production effected in action (10) , the professor-student interaction may influence both, especially those of the students, to resignify and implement humanization.
The students find it difficult to articulate knowledge resulting from the combination of science and empirical knowledge acquired with healthcare practice, as they understand healthcare practice is superior to research, not correlating it with data obtained through investigation.This representation makes them believe that changes are required in the nursing professor profile, more aligned with practice, so that humanization can be effected and thus deviate from research.
However, it should be noted that research has brought innumerable benefits to health, contributing to the development of science and technology.Through research, it is possible to ensure safe practice, based on evidence and systematized care (19) .And it should be noted that research also promotes healthcare humanization.
Nursing students are building social representations in a context with challenges to humanization, as the content shows that the image of professor and nursing team does not favor humanization being effected in practice.This result shows that academia should promote spaces for students to learn and practice healthcare humanization, recognizing the role of nursing and the responsibility of the profession through PNH instruments in public health services.
Therefore, at the admission with risk classification, which is a PNH instrument, the nurse is responsible for screening for emergency services.Also, the nursing team should act with the patient and his/her family, informing the patient's rights, and recognizing the importance of an accompanying person and open visits.Ambience, another PNH instrument, recognizes the importance of a healthcare space beyond the physical aspect, reinforcing the environmental theory of Florence Nightingale (20)(21)(22) .

FINAL CONSIDERATIONS
The nursing program appears to nursing students as a humanization learning and teaching space, with common aspects and singularities about this theme in the representations of students from the third and eighth periods of the nursing program, presenting the SUS professional training process.The experiences representative of humanization are combined with the healthcare practice experienced during the program.However, it is not always effected, according to a critique clearly stated in the representational content from the eighth period students.
Also, according to the concept of social representations, each thought results in an action, and the students propose strategies for effectively implemented humanization, in compliance with the provisions and strategies from the PNH, which evidences the theoretical learning they had in the classroom.
Working with the team, integrated with the team, is an element representative of humanization, in particular for the eighth period students, who have already had almost all learning experiences defined in the program in practical terms.However, it is a challenge because, as students, they do not feel part of the team due to the short time for the insertion in the fields used as learning scenarios.This problem highlights the need for articulation and a better integration between education and service institutions, considering that practical experiences are essential for the development of critical reflection on what is learned in theory.
Regarding the humanization learning process, the students from the eighth period represent it at the end of the nursing program, unlike the students from the third period, who represent learning experiences in the disciplines of Anthropology, Sociology and Psychology, which are taught in the three first periods of the program.It shows that, for both groups, learning happens during the program, but in different ways.The students from the eighth period select situations linked with healthcare practice and the students from the third period are more connected to theoretical discussions.The conclusion is that the experiences representative of humanization are based on groups of belonging of subjects and close to the daily routine, their practical knowledge, in agreement with the social representations of students.
This study concludes the need to reinforce the theme of humanization across the nursing training process, with teaching-learning strategies and experiences that make sense to the students.Finally, it highlights the need for an alliance between theory and practice, between teaching and service, between research and healthcare, in a convergent process in which the professional training occurs in favor of SUS.Humanization involves many challenges in the current sociopolitical context and the graduation programs act as favorable and legitimate spaces for intense debates and collective construction of strategies to allow the implementation of PNH instruments.
practice.The words, together, that indicate humanization is learned in practice, in the scenarios of application where it is possible to experience what is debated in classrooms, in theories, with the professor.Regarding the knowledge about this theme, it refers to the disciplines comprising the program.
The words inBox1 show that the theme of humanization in nursing training involves a number of elements related to the teaching-learning process: the agent, represented by the professor, and the context of nursing teaching-training, represented by the knowledge, theory, teaching, subject, experience, Rev Bras Enferm [Internet].2016mar-apr;69(2):261-8.and They teach us one thing in the classroom and what we see in practice is very different; the reality is very different from the classroom.(ucin° 25, third period)I guess it's in humanized practice, because there's no point in learning the theory and when we get there in practice, in the question of learning, we do it in a different way.(uci n° 36, third period) I learned in theory only, it's complicated in practice, we take a training program at Hospital X, which has no resources, the building is worn down and it has no professionals, then it's kind of complicated.But we, of course, we see the potential of each professor.(uci n° 6, eighth period)