Humanization and Volunteering: a Qualitative Study in Public Hospitals

ANÁLISE DOS RESULTADOS: Cinco temas principais foram formulados: perfi l do voluntário (idade, sexo, faixa de renda); organização do trabalho voluntário (termo de compromisso, treinamento); relações voluntariado-hospital (relacionamento com a direção do hospital e com os funcionários);


INTRODUCTION
In 2000, the Brazilian Ministry of Health launched the National Program to Humanize Hospital Care (PNHAH), a aiming to change the predominance of scientifi c-technological aspects over humanistic-interracial aspects in health culture.The objectives of the PNHAH include strengthening and integrating initiatives of humanization already present, improving the quality and effi ciency of care given to users and qualifying hospital professionals for a health care concept that values human life and citizenship.
In 2003, the PNHAH was replaced by the National Humanization Policy (PNH).b The term "policy" was intentionally used instead of "program" to call attention to the fact that humanization should cross different actions and management levels, translating its principles into the ways different network personnel and equipment work.For the PNH, humanizing health care and management entails the following: access with welcoming, comprehensive health care, responsibility and bond, appreciation of workers and users, management democratization, and participatory social control.
The process of humanization is broad, slow and complex.In addition, there is resistance to it, as it involves changes in behavior, which, in its turn, cause insecurity.New patterns are not ready in decrees and in books; 12 therefore, the gradual building of possible approaches 15 to this project requires wisdom.
One of the mechanisms created by the PNHAH and maintained by the PNH to develop the process of hospital humanization was the humanization group.One of its objectives is to involve the many participants of each institution with the changes of hospital institutional culture, making it more humanized.It is known that volunteers play an important role in the hospital humanization process, although few details about such participation are known.
The volunteer activity is defi ned as "unpaid activity performed by an individual for any type of public organization or non-profi t private institution, with objectives that have a civic, cultural, educational, scientifi c, recreational or social work nature, including mutual aid." c In 2001, the United Nations (UN), by establishing the International Year of Volunteers, extended the discussion on this theme, valuing civil society's space of participation in countless social problems encountered by many nations.This initiative promoted the development of studies on volunteering.Themes such as the motivation to perform volunteer activities, 1 the relationship between volunteering and the volunteer's physical and mental well-being, 6,16,20 volunteers' psychological, occupational, and socio-demographic characteristics 5,20 and volunteer group management strategies 3,4,14 have been debated in the international literature.
In Brazil, the scientifi c literature about volunteering 8,9,13,[17][18][19] points out the importance of considering this theme in a broad perspective, avoiding negative or positive unanimities d and analyzing favorable and unfavorable aspects of the volunteer activity.
8][19] Selli & Garrafa, 17 based on bioethical principles and those involving the belief in the potential of volunteers, propose critical solidarity and organic volunteering as mechanisms of intervention and transformation of society.Critical solidarity means the ability to discern the social and political dimensions present in an action of solidarity.Organic volunteering 17,19 would be the one motivated by the exercise of critical solidarity.
Research in the fi eld of health psychology 8,9 has been dedicated to the following: the identifi cation of the volunteer's profi le, their self-perception, and the health professional's perception of volunteers; the motivations for cooperative behavior; and the stress and burnout associated with volunteering.
It is known that volunteers play an important role in hospital humanization.A study performed in public hospitals of the state of São Paulo 10 showed that volunteers were responsible for 11% of humanization actions.Nevertheless, their inclusion and daily activities provided to Brazilian health services are not quite clear yet.e The present study aimed to analyze the profile of volunteers and their work process in hospital humanization.

METHODOLOGICAL PROCEDURES
A qualitative study was performed, aiming to understand the senses and meanings given to the set of perceptions, feelings and experiences involved with the volunteer work of 26 volunteer coordinators and 26 volunteers of 25 state hospitals in the metropolitan area of São Paulo, Southeastern Brazil, in 2008 and 2009.The volunteers were invited to participate in the study based on their coordinators' recommendation.
The 52 semi-structured interviews (26 coordinators and 26 volunteers) f were developed from a basic interview guide, which addressed themes related to the experience of being a volunteer (and/or a coordinator) and aspects of the activity developed in hospitals, especially those associated with the process of hospital humanization.There was fl exibility as to the use of this guide; therefore, the direction of the interview also depended on the interviewee's participation. 11Before each interview, an occupational-socio-demographic questionnaire was g The content in parentheses corresponds to coordinator (C), volunteer (V) and number of the hospital.Thus, the initials C4 mean coordinator of hospital 4.
applied.Volunteer coordinators also answered questions about the volunteer group coordinated by them.
Interviews were recorded, transcribed and subsequently analyzed, according to thematic analysis principles. 7ata from the occupational-socio-demographic questionnaire were analyzed in terms of frequency with the SPSS software.

ANALYSIS OF RESULTS AND DISCUSSION
A total of two groups were considered to analyze the interviews: one with the coordinators and another with the volunteers.Combined analysis was made for themes that were common to both groups.g Themes were as follows: a) volunteer profi le; b) volunteer work organization; c) volunteer-hospital relationships; d) motivation and benefi ts and e) humanization and volunteer activities.

A. Volunteer profi le
With regard to age, 71% of volunteers of the hospitals surveyed (1,243 volunteers) were over 45 years of age (24% were over 66 years; 24% from 56 to 65 years; and 23% from 46 to 55 years).Volunteer coordinators highlight life experience and maturity as positive elements for the role of a volunteer, due to the fact that elderly individuals tend to reestablish their goals and priorities, giving more importance to emotionally signifi cant experiences, rather than material and fi nancial achievements. 5,20

"The elderly volunteer has more tranquility. He's calmer; he's done what he had to do." (C4)
Of all volunteers, 89% were women.The larger proportion of women could be associated with their retirement laws, as their required number of years of work is nearly 15% lower than that of men, and their life expectancy, 10% higher. 17For those women who did not previously work out of their homes, the choice for volunteer work may be attributed to their search for a meaningful activity, after their children have reached adulthood. 5Another reason could be related to the hospital demands for soft services, which focus on the comfort and emotional well-being of patients and the reduction in patient's and family's anxiety; 9 i.e., care activities, traditionally associated with women.

Suddenly, her children graduate and leave home (…)
then she wants to give more of herself (…) she wants to give that emotional support (…) and this is probably a way for her to support herself." (C17) Among the interviewed volunteers, there was a great variability in income (14% earned from one to two minimum wages; 26%, from three to fi ve; 23%, from six to ten; 23%, from 11 to 20; and 14%, more than 20) and profession (housewives, welders, secretaries, teachers, biologists, school principals and others).These data indicate that the volunteer activity is not a prerogative of individuals with a higher socioeconomic status anymore, 2,4 and that there is a broad scope of possible motivations for volunteering. 1Additionally, the fact that 66% of the interviewed volunteers take part in paid activities suggests a change in the traditionally described profi le, according to which volunteers would consider volunteering as a way to be busy.
Having a certain religious belief seems to be a constant in volunteering. 1According to data from the sociodemographic questionnaire, all coordinators and volunteers interviewed reported they had a religion.

B. Volunteer work organization
One of the instruments used to manage volunteering is the volunteer agreement, through which:

"...he [the volunteer] knows he doesn't have an employment contract and that his job is not paid. He has to wear a white coat and an identifi cation badge and he has to follow the hospital's biosecurity norms." (C16)
The training course was usually held during three months; this period of time also serves as experience, at the end of which it would be defi ned whether the volunteer continued their work in the hospital or not.
In the majority of hospitals, although volunteer activities may complement health professionals' tasks, they cannot replace them, once they require specialized skills. 4The volunteer] is not allowed to perform any technical procedures, like, checking if the IV is fl owing well, if there is a clogged tube (...) or any technical touch on the patient."(C12) Although many hospitals recommend that volunteers do not impose their religious beliefs and values, some coordinators have reported such situation, which is usually diffi cult to handle.

"You can't persuade the patient to follow your own religion. Because, sometimes, many volunteers want to work here to convert others (...) to that religion they think is the right one." (C13)
With regard to the number of hours dedicated to volunteer work, a high number of hours of work was found both in the group of coordinators (32% working from 21 to 40 weekly hours, and 12%, over 40 weekly hours) and in the volunteer group (11%, from 21 to 50 weekly hours, and 9%, over 50 weekly hours).This can compromise the well-being provided by the volunteer activity 16,20 and lead to stress and burnout symptoms as well, because the hospital activity involves being in contact with disease and suffering. 9On the other hand, the tendency of spending many hours away from home may be an indicator of diffi culties with spouses or family.
"We had a very dedicated volunteer (...)She spent all day in the hospital...But as time went by, she got very stressed (…) and started having problems with the patients."(C24)

C. Volunteer-hospital relationships
The relationship between the volunteer group and the hospital institution is not always harmonious.A frequent tense situation for the volunteer group involves management changes.

"When management changes, it's very funny: the new director sees us as ladies of leisure, he thinks that we come to the hospital to pass the time (…) [a long time must pass] until we're discovered." (V6)
With regard to volunteer coordinators, there is no uniformity regarding their inclusion in the institution.In certain hospitals, the coordinator is an employee; in others, he/she is a volunteer; yet in others, coordination is the joint work of an employee and a volunteer.Those who are both volunteer coordinator and hospital employee (11 out of the 26 participants interviewed) tend to complain about work overload.

"My diffi culty, sometimes, is that I have to give attention to them [volunteers] and, at the same time, have to fulfi ll our role as professionals..." (C18)
At times, employees have negative reactions to volunteering, 4 fearing to be replaced by volunteers.

"Ill-informed employees think that volunteers will take their jobs... At fi rst, we felt rejected by some of the employees." (V9)
The material collected from interviews indicates the necessity for hospitals to understand the importance and potential of volunteering 8 and to encourage volunteers to cooperate with the institution's goals and objectives.

D. Motivation and benefi ts
There is no consensus among different fi elds of knowledge in regard to basic questions about the behavior of helping others and that of being helped. 1,9,18The motivation for volunteering may have many nuances.
As shown in the study by Moniz & Araujo, 9 one type of motivation identifi ed was one's previous experience with a certain disease (one's own or a close person's).

"In life, you learn through love or through pain. In my case, it [being a volunteer] really was through pain and the need to fi nd somebody, because when I needed, I couldn't fi nd any. The idea is that other people don't have to go through what I did..." (V2)
The search for personal fulfi llment 1,9,18 was also pointed out as motivation for volunteering: giving meaning to one's life, developing potential abilities, feeling useful and increasing the circle of social contacts were reasons given by volunteers.

"I was doing nothing at all... I needed a goal... Now, I'm useful, I know the patient is waiting for me and that I'm going to help him..." (V26)
Some coordinators reported that the volunteers are often looking for an activity to either resolve or forget about confl icts and problems, 1 which would not be an early impediment to volunteering.However, there is the need for health care measures and training, especially the volunteer coordinator's, as a way for them to distinguish the magnitude of a problem faced by the volunteer candidate and adequately decide whether to admit this candidate or not.
With regard to the perception of volunteer work benefi ts, the interaction among three aspects mentioned by Selli et al is observed: 18 individual (the volunteer is benefi ted: learning, overcoming oneself, re-dimensioning of everyday life and fi nding one's own humanity); dual (the volunteer and the patient are benefi ted simultaneously, i.e. they provide and receive benefi ts, in a horizontal relationship); collective (the social dimension is present -one makes oneself useful to the needs of others).In regard to the subjects of this study, the collective aspect presents itself in a tenuous way.The great emotional availability found in interviewees is not always associated with critical solidarity, 17,19 which is still incipient as a motivational guide for volunteer activity; thus, there is a predominance of the care dimension. 8vertheless, there is evidence of the direction being oriented towards a volunteering model committed to current specifi c demands. 17 didn't have any problems, I was well aware [of my social role] when I came" (V7)

E. Humanization and volunteer activities
Some of the terms used by volunteers highlight the close relationship perceived between volunteer activity and humanization: "being a bridge, being a link, welcoming, smoothing".
"The volunteer provides that 'link' between patient and doctor, patient and nurse, patient and the family member who is waiting outside."(C7) One of the interviewees emphasized that volunteers can contribute and they have in fact been contributing to the transformation of hospitals before offi cial humanization policies are implemented.
"The hospital doesn't need to be a cold place, a place where people only talk about diseases, it can be a place of transformation (...) And this has always happened here, even before this humanization stuff."(C15) However, although the core of volunteer activity is closely related to hospital humanization proposals, the integration with hospital humanization groups is not the main focus; there is still a gap between this group and the volunteer group.
Volunteer activities are varied, contributing, as a whole, for hospital humanization.These activities are as follows: -fundraising: visits to companies seeking donations, charity lunches and dinners, campaigns to raise donations; -donations to patients: food, wheelchairs, clutches, -donations to the hospital: rebuilding of indoor and outdoor areas, wall painting, purchase of toys for the playroom, purchase of materials for workshops, purchase of materials and equipment (bedpans, general devices); -patient care: offering food, helping in baths and changing their position, helping with walks, making beds, helping mothers to dress their babies; -logistic support: phone calls to patients and relatives, patient follow-up in the hospital, organization of lines, exam follow-up, transport of materials to the laboratory, transport of internal documents; -emotional support: hospital welcoming, establishing bonds with patients, their relatives and others accompanying them; -specifi c care: music therapy, yoga, hydrogymnastics, pre-delivery exercises, massages; -aesthetics and beauty: setting up a small "beauty parlor", haircuts, hairdos, pedicure, manicure; -guidance and teaching: information about hospital routine (for patients and those accompanying them), guidance on breastfeeding, participation in technical guidance (in regard to specifi c diseases), help with school homework; -development of patients' abilities: handicrafts, computing, carpentry, painting; -leisure: recreational activities in bed and in playrooms, educational games, theater; -organization of commemorative events: celebrations related to special dates, such as Christmas, Mothers' Day and others.
The activities previously mentioned were classifi ed into six categories: a) typical volunteering activities (fundraising, donation to patients, donations to the hospital); b) activities related to soft services (emotional support); c) activities the hospital needs (patient care and logistic support); d) socializing activities (recreation, commemorative events); e) educational activities (guidance and teaching, development of patients' abilities) ; f) special activities (special care, aesthetics and beauty).
With regard to fundraising and donation ("a" category), some interviewees mentioned the advantages of having an association to legally act on its behalf, allocating resources and making agreements.The key point is that volunteer work does not exist to replace actions that should be the government's duty. 8However, due to limited government resources for the most essential public services, volunteering plays a compensatory role; there are so many demands that volunteers frequently feel responsible for the solution to problems that should not be their responsibility. 13th respect to activities associated with soft services ("b" category), it is relevant to inquire whether official humanization policies to improve relationships between health professionals are really being followed.Likewise, it should be questioned if the volunteers' need to be a link between professional and patient expresses the fragmentation of care between the technical aspect and the relational aspect (soft services).In terms of welcoming actions, certain activities, already performed by volunteers for a long time, have been recently adopted in offi cial health care programs.With regard to other types of care offered to patients (for instance, helping with baths and walks), it is not clear where the limit of volunteer and professional actions lies.These activities should be directly supervised, at the least.

CONCLUSIONS
The results show problematic and positive aspects of the volunteer activity in hospitals in the metropolitan area of São Paulo.
The problematic aspects are those associated with volunteers performing activities that are not their responsibility and that might pose risks to the patient, the hospital and themselves.The latter includes coordinators' work overload and volunteers with excessive weekly hours of activities.Therefore, the existence of rules, norms and limits is essential for volunteer activities.
On the other hand, volunteering was considered very useful to the hospital and very satisfactory for volunteers.Thus, it is important to offer conditions for health institutions to manage and develop volunteer activities more effi ciently.Some possibilities are as follows: promoting volunteer management courses for volunteer coordinators, providing adequate physical space for volunteer activities, and organizing specifi c events to improve volunteer work.
From the point of view of the volunteer's inclusion in the hospital humanization process, there is the need for more communication with humanization groups, so that volunteers and groups can benefi t each other and work for the transversality for the institutional humanization.
In regard to the evolution of groups aimed at organic volunteering, volunteer associations would be a privileged place to achieve such purpose, thus having a potential role in this process.
The study was performed according to the guidelines and regulations for research on human beings found inResolution 196/1996, according to the Conselho Nacional de Saúde (Brazilian Health Council).The project was approved by the Research Ethics Committee of the Instituto de Saúde da Secretaria de Estado da Saúde de São Paulo (State of São Paulo Department of Health, Institute of Health,), on September 17 th , 2007 (Process 009/07).
Therefore, although the material of the interviews points to a poor connection between volunteers and humanization groups in many aspects, the evaluation of necessities is associated with action proposals of both volunteers and the government.As a result, nowadays, activities that used to be performed by attendants are now being performed by volunteers.In several hospitals, patient food distribution and management are activities carried out by volunteers.These questions include the adequacy of this activity for volunteers, the supervision of such activity and who would take notes about the diet's acceptance or refusal in the nursing report.