Humanization of health care in the perception of nurses and physicians of a private hospital *

Objective: Exploratory, descriptive, qualitative study aimed at checking the meaning of the term humanization for nurses and physicians at a private hospital in the city of São Paulo and identify factors that hinder and facilitate humanization in care. Method: Exploratory, descriptive, and qualitative study conducted with 19 health care professionals. After data collection, the reports were categorized according to the method proposed by Bardin and analyzed within the theoretical framework of humanization. Results: Humanization is related to respect, caring, and empathy. In professional practice, the actions aimed at humanization can be facilitated by organizational culture, but hampered by overwork. Conclusion: It is necessary to adopt management policies and actions that provide professionals to meet the expectations of patients and their families in search of humanized care.


intrODUctiOn
The term humanization is a difficult concept because it presents subjective and complex characteristics (1) and, despite its positive qualitative tone, it can take on different meanings due to cultural differences and individual values.What is humanized care for one person may not be for another.
In health care, this discourse is organized around the defense of human rights and ethics.It relates to the fight for patient rights and is based on the Universal Declaration of Human Rights, which was adopted and proclaimed by the United Nations on December 10, 1948 (2) .
In Brazil, there was a change in access to health care for the population after the approval of the Federal Constitution in 1988, which states in Chapter II that health is a social right, and it provides for the regulation of the Unified Health System (SUS) through Law 8080 of September 1990, which states in Title I that "Health is a fundamental human right, and the state should provide the necessary conditions for its full enjoyment" (3) .There is no unified code or rights statute for patients, but there are several laws and decrees that promote and protect users, including by groups of diseases, ethnicities, and age groups.
In 1995 the state of São Paulo issued a Handbook of Patient Rights prepared by the State Health Department and by the Pathologies Forum.The guidelines contained in this Handbook inspired State Law No. 10.241 of March 1999, which governs the rights of users of services and health actions in the State of São Paulo (4) .
Despite the importance of humanization, research carried out has shown that, in relation to the satisfaction of users with public health services, technological advances in health care have not been accompanied by humanized care (5) .
For the population served, the dehumanization of health care was due to problems such as: long lines; insensitivity of health care workers when dealing with people's suffering; disrespectful treatment; the isolation imposed on patients from their families and social networks during procedures and hospitalizations; and authoritarian management and degradation of the environment and labor relations.These issues expressed not only ethical and individual flaws, but also the way of organizing health services in Brazil.Because of this, the Health Ministry sought ways, together with society, to identify complaints from users in order to redeem and humanize health care (6) .Thus, in 2003, the National Policy of Humanization of Care and Management of the Unified Health System (PNH/Humaniza SUS) was launched.It was a program for change in models of care and management, and was deployed as a public health policy, understanding humanization as "the valuing of the different subjects involved in the health production process: users, workers, and managers" (7) in order to better assist users and provide better conditions for workers.
Considering the diversity in definitions of the term humanization, its importance for professional practice, and the recognition of the existence of factors that interfere with its implementation, the present study aimed to investigate the meaning of humanization for nurses and physicians in a hospital; get to know how nurses and physicians perceive humanization of care in professional practice, and identify factors that hinder or facilitate humanization of care.

MetHOD
It was an exploratory, descriptive, and qualitative study conducted in a general, private hospital that has a Catholic religious orientation.The institution has 284 beds and provides care for individual patients and those with health insurance.
The study included 19 professionals from various hospital care units, who had at least six months of work experience in the institution.The data was collected during the second half of 2011.
A two-part instrument was developed to collect the data.One part covered characterization of the participants; the other utilized the following guiding questions: "For you, what does the term hospital humanization mean?" and "What are the factors that hinder or facilitate the humanization of care in this institution?"A pretest was carried out on the instrument and the changes necessary for better understanding of the participants were made.The data obtained in the pretest was not used in the study.
The answers were categorized according to the method proposed by Bardin (8) , analyzed within the theoretical framework of humanization.
The research project was approved by the Research Ethics Committee of the Institution and of the School of Nursing at the University of São Paulo (Process No. 1057/2011).

reSUltS
Nineteen professionals participated in the study: 9 nurses and 10 physicians.Of these, 12 were female and 7 male.The time of professional experience in the institution ranged from 2 to 17 years and the daytime work shift prevailed among the subjects interviewed.As for the work location, 4 participants worked in the adult emergency room, 1 in the child emergency room, five in the adult intensive care unit, 1 on the maternity ward, 2 in clinical surgery, 2 in the oncology unit, 1 in clinical medicine, 1 in the neonatal intensive care unit, and 2 in the pediatric intensive care unit.
After analysis, the following categories emerged: "Meaning of the term hospital humanization," "Facilitating factors for the humanization of care," and "Overwork as a factor that hinders humanization of care."

Meaning of the terM hospital huManization
In this category, the participants related respect, caring, and empathy to the meaning of hospital humanization.
To define humanization, the participants used the word respect, expressing it as respect for the customs, desires, beliefs, and values of patients.They said that when admitted, patients must reconcile their habits with care routines; this requires that care teams work to make ad-aptations that can be translated into respect for people.It became evident that hospital routines are important for teams to do their work without problems, but in order to offer dignified and respectful hospital care to patients, hospital professionals must seek to adapt these routines to the needs of patients and caregivers.The subjects believe that by respecting patients, they make them feel they are being treated in a dignified manner in an environment that is not their own.Thus, besides technical care, differentiated service that considers the particularities of each person should be provided.
To express the meaning of humanization, the participants also mentioned the importance of caring, explaining that this includes receiving patients with warmth and getting to know the context in which they are inserted, and not just looking after physical aspects and their disease.They affirmed that it is necessary to dedicate time and attention to patients' anxieties and fears, and that this approach by professionals, with gestures of tenderness, protection, and concern for patients, is when humanization of the care takes place.
It was shown that humanization is also related to improving the conditions of the environment, which should be warm and comforting to minimize the suffering from being ill and hospitalized, considering that patients are away from their homes and often deprived of interaction with their families.
The professionals highlighted actions that make some of the rules of the hospital environment flexible, such as allowing visits outside the established visiting hours and the presence of a companion in intensive care units.The family's presence of families is cited as an important factor in caring for patients during hospitalization.
As for empathy, the respondents said that putting themselves in the place of patients enables them to better assist them.For some professionals, humanization is empathy for the person.It means treating the patient as if they were a member of your own family, or a loved one, and treating them as you would want to be treated.

factors that facilitate huManization of care
Among the factors that were mentioned as facilitating humanization of care were organizational culture, the multidisciplinary teams, and autonomy.
As for organizational culture, the religious identity of the sponsoring institution was mentioned, as well as the attitude of the directors toward the staff, concern for education as related to humanization, and implementation of accreditation programs.
It became evident that humanization is valued by the institution and workers and that the religious orientation is perceived as a factor that favors the careful handling of people.It was reported that treating patients and staff well is part of this culture, and that when employees are treated well, they are motivated to treat others well.It was also brought up that the promotion of periodic training, in addition to the training conducted at admission, and ongoing guidance emphasizing aspects of humanization, reinforce the humanized professional approach.Another positive aspect of the institution's culture was the implementation of care protocols related to risk management and patient safety, because they stimulate and support humanization.
It was considered that using multidisciplinary teams is a facilitating factor for humanization of care.For the participants, it is not enough to have good equipment and good doctors to provide assistance with quality and humanization.It also takes the joint efforts of doctors and professionals from the areas of nursing, physical therapy, speech therapy, psychology, social work, occupational therapy, nutrition, and even from support staff such as cleaning.According to the interviewees, multidisciplinary teams help them consider the necessary interventions with patients and caregivers, contributing information and individual perceptions for comprehensive care of patients.
With regard to autonomy, respect for professionals' autonomy by the institution and managers, which leads to respect for the autonomy of patients by professionals, was considered a facilitator of humanization by the respondents.For them, the practice of humanization is facilitated by being able to assess patients' needs and desires, decide on exceptions, and allow patients to control some aspects of their life without negative interference by the institution.The subjects understand that this exercise of professional autonomy requires attention and careful analysis of each situation.Acting with autonomy does not mean that anyone can do whatever they want, but it does mean making the best decision when problems or requests occur.

overwork as a factor that hinders huManization of care
In this category, it became evident that overwork is the component that makes humanization the most difficult.The lean staff for providing healthcare services and the large number of activities to be performed make it necessary to establish priorities for providing care, making it impossible to adequately meet the demands of patients, which creates stress for professionals.For participants, humanized care requires dedication, and that takes time and available staff.

DiScUSSiOn
Ignorance of and disrespect for the rights of patients and not legitimizing their power of choice can be considered causes of processes of dehumanized care.Furthermore, healthcare professionals need to understand that every patient is different, because failure to recognize this uniqueness can lead to provision of standardized and impersonal treatment.
It is important to point out that standardization of care does not necessarily mean it is dehumanized care, and in the same way, individualized treatment does not guarantee humanized care (9) .
In this context, increased technicality of care provoked a change in the relationship between health professionals and patients, making these workers forget the importance of caring, showing concern, and giving support and comfort during hospitalization.
It can be noticed that the concepts of humanization and caring merge.To be someone who cares means listening, and offering protection, refuge, and comfort.To be caring requires professionals to be in an emotional condition of being open to being touched by the patients' stories, their needs and desires, in order to trigger a commitment that goes beyond the technical and merges into the human side of each person, awakening the desire to solve problems and refer them on to others when necessary.
So, for caring to exist, it is important to listen and engage in dialogue.It should also be pointed out that in addition to being heard, patients want their requests to be granted (10) .Therefore, when caring does not bring resolution, it can be a source of discontentment for patients.
All forms of communication (speech, nonverbal expressions, listening, writing, and touch) should be used to minimize conflicts and benefit the relationship between patients and health professionals (11) .For the effort in humanizing to be true and comprehensive, it must include the entire universe in which care is produced.
Therefore, it cannot be disregarded that even well-meaning professionals who have the desire to assist the patient, when working in institutions with limited resources, lack of materials, and problems in work schedules, are exposed to conditions that make it difficult to provide health care and compromise the quality of care and humanization.
The respondents related humanization with empathy.It cannot be forgotten that empathy requires deep reflection, because people have spontaneous feelings of sympathy (reciprocal inclination between two people), dislike (aversion), apathy (insensitivity and indifference), and empathy in relation to others.
Difficulties in feeling empathy, due to personal reasons or limitations, may create biases in the relationship between professionals and patients, and consequently not contribute to dignified and respectful care, but actually damage it.In excessive cases, empathy can bring suffering and anguish to health professionals, making their jobs difficult to bear emotionally, or even compromising their professional attitude and precipitate attitudes that hurt patients' autonomy or benefit them at the expense of others, exacerbating injustice.
In the present study it was explained that by putting oneself in the patient's place, professionals can practice care as they would like to receive it.Interestingly, this lead to problems for humanization, because cultural differences make it impossible for all perceptions to be uniform.So, therefore, what for one professional is a positive reference of care may be perceived as inhumane or offensive by patients or their families.
Empathy should not be considered a natural gift or a strictly positive skill, but a competency to be developed.Receiving support and guidance in facing difficulties related to empathy is one of the stages of professional development.
Organizational culture, together with a religious institutional identity that values the person, facilitates humanization of care.However, it is important that humanization of care be configured as a right of everyone involved in the production of health care, and not as an expression of goodwill on the part of professionals.
Another important point to is that humanization for patients is not possible if there is no humanization for workers.Dealing with pain, death, and disease is neither easy nor pleasant.Health workers often become afflicted by the suffering of their patients and become so concerned about solving the problems of patients that they don't understand or overlook their own problems.
The principles embodied in the guidelines of the National Policy of Humanization of Care include transversality, the inseparability of care and health management, and the strengthening and the essential role of the subjects, changing ways of working and intervening in work processes in the field of health are essential for promoting the culture of humanization (12) .
The need for integration of professionals, which is viewed as articulated and continuous work in health care actions, becomes evident when we consider multiple health needs (biological, psychological, social, and cultural).
The heterogeneous composition of health care work groups nourishes the process of humanization, because it recognizes the field of subjectivities as key to better understanding of problems and searching for shared solutions (13) .
The knowledge of various professionals and the dialogue between them and patients, family members, and managers enable an expanded understanding of individuality and allows the synergy needed to meet the demands presented.
The fragmentation of the patient care activities that are not performed by a single caregiver leads to a number of operations being carried out by different workers.Because this makes up a web of different actions, they must be coordinated (14) .
Work environments that value relationships between professionals and recognize the importance of the performance of all members of teams, who provide direct or indirect care to patients, provide space for the views of various professionals and create better conditions for providing humanization of care.
The recognition of people's autonomy not only facilitates humanization, but is the central issue in both the moral and legal frameworks, since in health, legal issues are traditionally governed by the principle of beneficence and by the idea that the physician is the decision maker.
When people's autonomy is discussed, one must not make assumptions about the opinions of the parties involved, since values can be different in the relationship between professionals and patients (15) .
To foster autonomy, the people involved should be quick to listen, accept, and allow the will of the parties to be expressed.A listening attitude by professionals is possibly the first step toward humanization of health care.
Hospital settings involve many situations considered inhumane with respect to patient autonomy.Several clinical conditions diminish autonomy, and even when able to exercise some level of choice, patients are subject to the team's decision or institutional routines.
Patient autonomy is one of the main concerns of ethics, and the focus should not be just on situations to determine the health care interventions that patients will or will not receive (16) .
The planning and distribution of human resources are one of the most challenging managerial activities in the sphere of health care today.The ability to balance the number of professionals needed to improve the quality of service offered and the quality of life of the professionals with the growing need to reduce costs, increase competitiveness, and supply services is an important and essential activity to determine the financial health of institutions well as their level of services (17) .
Inadequate working conditions result in stress for professionals, and improving those conditions depends on intrinsic and extrinsic factors.Quality of life has different connotations for different people, since it is based on individual expectations and needs.This can make it difficult to deal with the stress in an institutional manner, but that does not relieve institutions of the responsibility for implementing professional assistance programs (18) .

cOnclUSiOn
The meaning of the term humanization for nurses and physicians is related to respect, caring, and empathy.Professionals realize that to enable humanization of care requires respecting patients' individuality and culture, adapting hospital activities to patient needs, investing in the quality of interpersonal relationships between patients and health care professionals, and not limiting care to just physical needs.
The factors identified as facilitating humanization are as follows: organizational culture, multidisciplinary teams, and autonomy.The institution's religious orientation, training courses given on the theme of humanization and hospitality, participation in hospital accreditation programs, and respect for the autonomy of professionals were highlighted as strengths of the institution's culture in relation to promoting humanization.