TEACHERS’ VOICES SEEKING HUMANIZED TEACHING IN NURSING: VIRTUAL EXPERIENCES DURING THE PANDEMIC

Objective: to describe the experience of implementing the online training entitled “Humanization of the training processes in Nursing, care for all”, targeted at Nursing teachers from a Chilean university, as well as to analyze their interventions in the virtual forum. Method: a qualitative research study, of the case study type, through content analysis based on the forum interventions of 12 training participants who gave their consent. The online training delivered to professors from a Chilean Nursing school carried out from May to November 2020 is described, and the categories obtained by means of content analysis are presented. Results: for the participants, humanized care has a personal dimension and a public-political dimension. In turn, humanized teaching in Nursing implies that teachers recognize their students as whole individuals in their generational and social contexts, but that they also recognize themselves


INTRODUCTION
The Nursing study object is human care, and humanization is considered as a quality referential for comprehensive care 1 .Care humanization overcomes its technical and scientific view, considering the patient's individuality, dignity and rights; as well as recognition of the professional as a person, establishing a subject-subject care relationship 2 .It is a Nursing theorist, called Jean Watson that, at the end of the 1970s, highlights the need to resignify care, recognizing human care as an intersubjective, reciprocal and transpersonal process.The same author states that -in the face of the risk of care dehumanization -it is necessary to recover the human aspects both in Nursing practice and in professional training 3 .The latter area is often in a state of tension, which is made evident in several publications that show verbal and non-verbal harassment from females teachers and clinical professionals towards their Nursing students [4][5][6][7] , normalizing the bullying culture 8 .The bullying culture exerts a negative effect on the students' motivation and commitment to Nursing and to humanization of care 9 .
The first stage of the Fondecyt Initiation Project that we conducted during 2019 in a Chilean public Nursing School that evidenced the need to enhance Faculty training processes regarding humanization of Nursing teaching, considering a multidimensional approach 10 .The teachers acknowledged individual, collective and institutional difficulties to develop more humanized training processes, which involved conceptual aspects of humanization; care and ethics; generational differences and social contexts; teaching strategies; self-knowledge, and institutional conditions that promote a more humanized culture 10 .Thus, the online training called "Humanization of the training processes in Nursing, care for all" was tailored, inviting 74 clinical practice teachers and 31 of these Nursing teachers from the school were the participants of the training where the research was conducted.Due to the pandemic context, the training was delivered online through the Moodle© platform, which allowed creating online learning communities 11 .The learning aim of the training was to understand the Nursing training processes from a humanized perspective, identifying personal, social, ethical, didactic and disciplinary Nursing dimensions to promote shared care experiences among the students.
The objective of this article is to describe the experience of implementing the online training called "Humanization of the training processes in Nursing, care for all", targeted at Nursing teachers from a Chilean University, as well as to analyze their interventions in the forum.This training and the research that we are presenting are part of the Fondecyt Initiation Project, approved by UCH's Committee of Ethics in Research with Human Beings.

METHOD
We conducted a qualitative research study, through a case study, exploring the reflections by the teachers participating in the virtual training.A content analysis was carried out based on their interventions in the forum.The case study concerns the virtual training called "Humanization of the training processes in Nursing, care for all" delivered to nursing teachers from a Chilean Nursing school from May to November 2020.Six training units were designed based on the results obtained in the phase-one of the Fondecyt Initiation Project concerning the needs for a more humanized training in Nursing 10 .The following Table 1 provides more details of the six training units: 74 Nursing teachers from a Chilean Nursing school were invited to the training who had participated as tutors in courses with clinical practices from 2018 to 2019.31 teachers were enrolled voluntarily in the online training and the virtual participation carried out from May to November 2020.Synchronous and asynchronous teaching were combined with individual and group activities as well as text readings, web page reviews, audiovisual materials and simulated situations, fostering debate and reflections in the forum.Individual training evaluations were conducted in pairs and groups, through essays, reflective diaries, and conceptual and experimental integration assignments.
Considering the complexity and human suffering imposed by the pandemic and confinement, we sought strategies to humanize the training.This meant flexible times to comply tasks and evaluations, as well as generating a cross-sectional unit called "Care Reliefs".The Care Reliefs unit included the participation of a female psychologist to support the training participants.In small groups, participants shared experiences and emotions concerning the pandemic, remote work and clinical care provided to people with COVID-19.The mental health professional provided explicit recommendations for selfcare and mental health as enhancers of a more humanized culture.
The study object corresponded to the comments in the forum made by 12 participants who consented to their use.Their comments were analyzed by content analysis 12 , which proposes criteria for data exploration, coding and treatment of the results through categorization.In this sense, a preanalysis was initially performed by means of a floating reading of the comments; then, thematic coding was performed with a previous analysis matrix including six dimensions based on the theoretical framework 10 and on the training objectives.Text fragments were extracted as meaning units from the comments made in the forum 13 .The Meaning Units were coded according to their pertinence regarding the training contents and their interrelations.A final version of coding with two dimensions emerged from this analysis, namely: Humanization of Nursing Care and Humanized Teaching in Nursing, to the extent that the ideas were repeated in the categories belonging to each of them.To safeguard anonymity, participants were coded as follow: Participant's Number.Training Unit.Forum Number: Meaning Unit.

RESULTS OF THE EXPERIENCE
Of the 31 training participants, four abandoned it due to personal or work-related reasons.27 participants met the passing requirements for a total of 80 hours.The main results of the analysis of the forum comments made by 12 participants who gave their consent for this purpose are described below.

Humanization of Nursing Care
For the participants of our training, humanized care is more complex than a mere list of standardized actions, as it is materialized in the comprehensive operation of any care setting, which considers relationship styles, leaderships, hierarchies, resources, infrastructure, working conditions and socio-political contexts.Providing humanized care incorporates a personal perspective of the Nursing professionals in their performance context, as well as the public and political perspective.

The personal perspective of humanized care
Nursing professionals who provide humanized care recognize themselves as human beings, and also as the care subjects in such dimension.This means that they need to see themselves as a member of a complex care setting, where their emotions and interaction skills exert an influence on the care they provide, as well as their managers' and peers' professional models and leadership styles.
[…] When we talk about humanization, many times we focus on concrete actions or practices in direct care provided to people, and we forget that humanization (inherent to care) is inserted in a complex environment of relationships, hierarchies and processes, and so on, which corresponds to the comprehensive operation of any unit in any health care context... these actions are performed "by someone" and "in a specific context" (E3.U1.F12:1).
In order to provide humanized care, the professionals need to foster self-knowledge, selfesteem and empathy, as well as to recognize their emotions and ways to face conflicts.Establishing affective contacts when interacting with the care recipients constitutes a strength for more humanized care, particularly during crisis periods such as the recent global pandemic.
[…] Being able to look at ourselves and recognize what happens to us in the face of some conflicting situation allows us to connect with the other from human kindness and respect (E1.U5.F1:3).
[…] Fostering sensitivity and empathy is not a sign of weakness, it is a strength, the necessary strength to face storms such as a pandemic (E4.U1.F9:1).
The professionals acknowledge obstacles in themselves and in the Nursing collective to provide humanized care, associated with low self-care and with their professional peers' neglect, acknowledging a highly demanding culture regarding their work performance.The aforementioned means difficulties for them to invest their time on personal development and self-knowledge, to foster spirituality, artistic or sports skills, healthy lifestyles, and not sacrificing their family or social spaces due to work-related bourn-out.
[…] Why did we get dehumanized?I believe that it is often due to low self-care and between us as coworkers... if I cannot take care of myself, how can I take care of the others?(E12.U1.F8:1).

The public and political perspective of humanized care
Nursing professionals who want to provide humanized care must construct citizenship through Nursing, having the advocate role of rights and protecting people's dignity as a political action.The aforementioned arises as resistance to an oppressive socioeconomic system that exerts pressure towards productivity, achievement of goals even with insufficient resources, work exploitation and maintenance of certain mechanical inertia in work and in the underlying health system.
[...] being a professional is also a way of being a citizen and, today, we need to hold ourselves accountable for how we do citizenship through Nursing… use such powerful indignation that hurts to become professionals who can really guarantee rights, protect people's dignity, and political, deeply political (E3.U1.F7:1).

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There are obstacles that are external to the Nursing professional that dehumanize the care provided, related to institutional issues such as rigid organizational cultures, authoritarian leaderships, performance models lacking innovation and inadequate infrastructure to protect people's dignity.In addition, insufficient human and material resources trigger work overload and exhaustion in the care teams, particularly in crisis situations.The COVID-19 pandemic being a faithful example and a risk for care dehumanization.
[…] Care dehumanization is multifactorial.Rigid organizational cultures that only promote production, regardless of the consequent cost for the health care team, inadequate infrastructure both for external and internal users, absence of leadership or leaders who don't promote teamwork, the "knacks or bad customs" that generate resistance due to denial to come out of the comfort zone, etc. (E1.U1.F12:1).
[…] the efforts are targeted at providing care and being able to ensure coverage without thinking about the quality of such care, about how the personnel is treated, about the working conditions...The pandemic context in which we are immersed generates a major obstacle regarding humanized care (E4.U1.F1:2).There is a dangerous convergence between a health and caring for users' lives.The system demands commitment towards caring for the users' life from its workers and the Nursing professionals' service vocation wrapped in a martyr-like or heroic halo that has been publicly repeated during the pandemic.The aforementioned exerts pressure towards dehumanization, not only of the health system due to the progressive exhaustion of the health personnel but likewise the professionals that not recognize themselves as individuals with needs and limitations.
[...] the working world has taken us to an important inertia.Beyond vocation.Beyond our deepest feelings, I believe that the socioeconomic system has driven us to robotize and, of course, dehumanize ourselves, regarding other aspects of our development, leading us through an imposed path, although somewhat concealed, somewhat disguised as success (E9.U3.F4:1).
[...] the phrase that reads "commitment to the service" is well-known in Nursing, as a kind of scapegoat to justify any degree of work-related over-exploitation (E3.U3.F4:2).

Implications and limitations of humanized teaching
Humanizing teaching implies that the educators understand their students as whole individuals, recognizing the human aspects that affect their learning processes as future professionals: communication skills, problem solving and teamwork.In turn, being able to recognize the students in their generational context and with characteristics and interests that differ from those of the teachers' generation acquires relevance for humanized training given the tensions provoked in the adults/teachers by the difficulties they encounter to adapt their relationship styles and training strategies to young individuals with multitasking cultural consumption practices, who extend their lives to the virtual space with significant use of social platforms and networks; even generating social revolutions and demands that are driven, disseminated and strengthened through the online world.
[...] it makes a lot of noise to me that young individuals can share hours and hours with people who are not near them, who are not with them [...](E7.U3.F3:7).
[…] Why do we get angry when the students make use of this new sensorium in the multitasking era in the context of university teaching?It is probably due to intergenerational distance and also to our inability as faculty to offer innovating, significant and transforming experiences [...] so that they can fit into their world of multiple information sources... (E3.U3.F3:5).

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There are also aspects inherent to the students that are more concealed, which require teachers to show their "being a person" to enhance a more humanized teaching.These aspects include the students' life stories, their fears, despairs, renouncements and social determinants; profoundly human elements that affect their training processes.Teachers will have to be aware of their possibilities to accompany the students, as well as of their own limits to manage the necessary support networks.
[…] It has been one of my saddest days as a teacher, where after a brief conversation with the student I was able to see how devastated and hopeless he was.It really broke my heart...I even felt that there was not much I could do but to articulate the necessary networks for him to be seen, because there were issues that I could not solve and needed help from other people […] I understood that we cannot be super teachers (E5.U1.F2:1).
[...] many of the answers that ease our duty of implementing the clinical practice in a significant learning space are in their stories, in their fears, in their social determinants...Even in those things that they will not tell us unless we show ourselves as open, human and understanding people (E3.U1.F2:1).
Likewise, educators face ethical conflicts when they see dehumanized attitudes in their professional peers regarding how they treat students or patients in clinical settings.The aforementioned generates moral distress when the educators do not feel capable of stopping, evidencing and intervening in such situation and proposing changes as a training possibility for the students and for humanized care.
[...] what I might identify as a cause of moral distress in my role as educator is being present in the face of ethical conflicts with the students and lacking tools to implement the change...It is shocking to see lack of empathy in health care professionals, therapeutic cruelty or materialization of the users and that the students realize that they are routine practices in these services (E4.U2.F2:1).

The possibilities for teachers' development towards a more humanized teaching
The participants of our training attribute importance to self-knowledge, recognizing their own emotions, mistakes and establishing limits within the training contexts, to enhance meaningful learning experiences in the students and the faculty teams from their human dimension.
[...] it seems to me that it is relevant to reflect on how we have learned to deal with our emotions and how this exerts an influence on us and on the way to establish bonds in our environment (E7.U5.F8:1).
Nursing educators recognize reflective teaching strategies such as diaries and reflective dialog as opportunities to humanize teaching in the sense that they create spaces for the students to account for their knowledge.This knowledge includes experiences and emotions, values and perspectives.It flexibilizes the teaching process, to the extent that it opens up leadership spaces in the students, both for them to make their lessons learned and uncertainties evident and to provide feedback regarding their teachers' performance in a space of respect, trust and search for mutual learning.
[...] the reflective teaching strategies humanize teaching because they acknowledge the others, their thoughts, ideas or even emotions.When going deeper into the others' feelings, their opinions or something that they want to highlight, we delve into their personal sphere, which, through active listening implicit in the reflective process, is given the importance and time it requires (E6.U4.F2:3).
[...] at each moment of reflective dialog with the students, they can feedback my work as a teacher; it helps me to watch those behaviors I need to work on (E8.U4.F2:4).

DISCUSSION
The analysis of the forum comments made by the participants of the virtual training about humanization of the Nursing training processes groups the content into two major areas: care humanization and humanization of training.Both reinforce previous knowledge and also show new and interesting perspectives to be discussed.

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Several authors [9][10]14 have already mentioned how relevant it is to recognize the patient as a person to provide humanized care, with the need to develop communication, emotional, reflective and self-knowledge skills on the part of the professional. Itwas also highlighted by the participants of our training, both in care management and teaching.In this sense, such skills are not only relevant to establish humanized care relationships with their patients and students but also with their peers and teams, in addition to raising awareness regarding self-care.Consequently, the care relationship between the professionals and the people in their environment is of the subject-subject type; based on Levinas' philosophy, understanding the care subject as an individual that is necessary to find selffulfillment in the "I" 15 .
Our research highlights a novel aspect that is linked to a public and political perspective of humanized care.This dimension imposes tension on three elements that require the right balance, namely: a) the health needs of the population, b) the availability and use of resources in the healthcare systems, and c) the Nursing professionals' vocation or commitment to the care practice.We know that deficient structural conditions, lack of resources and high workload affect care quality, and that authoritarian leaderships exert an impact on the health personnel's commitment and are grounds for conflict in teamwork [16][17] .Our participants associate the resource deficits and the authoritarian styles not only with a reduction in care quality but also with its dehumanization.The aforementioned imposes tension on the Nursing professionals' performance in a health system that often oppresses its workers 18 since, in periods of major crises, lack of resources can be sustained by use and abuse of the workers' commitment to their patients and to the institution.As Nursing professionals, we wonder if, in this pandemic crisis, we have been aware of the effects that the heroic view which society has attributed to us is exerting on us and on our teams.Workdays have been extended and breaks have been reduced to finish tasks, complex duties have been assigned for which there was not sufficient preparation, the professionals have distanced themselves from their family members to avoid contagions, care measures have been sustained with lack of inputs, there have been tensions between the teams, complaints from the patients' family members, changes in mental health and deaths 19 .Having a public and political perspective of humanized care means installing in our professional and institutional discussions a critical view of the political ideologies that sustain and ground resource distribution in the health systems and to exercise citizenship that advocates for the patients' rights to access good quality health services and care.The aforementioned also requires elucidating the impact of the working conditions we resist daily to provide humanized care not only for the patients' benefit but also with the possibility of positioning mutual and humanized care cultures within the health care teams with robust institutional support.In such context, the younger Nursing professionals of our training consider that: Nursing workforce that is overcommitted to the institution exerts a negative effect on their self-care.Similarly a study by Lara-Jaque et al. that reveals, that new generations of female nurse-leaders see commitment to the institution as a defect, differently from previous generations which consider it as a challenge 16 .
From another perspective, humanizing Nursing training implies recognizing the students as individuals in their generational context and understanding the macro-social structure that sustains them since post-modernity.Autonomy and social self-convenience prevail, which can respond to certain moral relativism where the truth is true for some and alien for others 20 .Thus, Nursing teachers need to deeply understand the students' context and incorporate dialogical, reflective and critical skills 20 to create meaningful learning spaces for multitasking young individuals who are permanently connected to the social medias.In the current pandemic context, the Nursing teachers have also faced limitations such as a set of emerging realities of their students, which have evidenced the impacts of the socioeconomic differences on people's lives.The moral distress mentioned by the Nursing teachers is an area that needs to be explored as a study phenomenon 20 to deepen on its causes, 9/12 support strategies and policies for Nursing teaching, understanding that younger teachers report more experiences of moral distress 21 .
The personal development of all members of the educational process (students, teachers and clinical tutors) would favor a mutual and humanized care culture with more horizontal and respectful relationships.Metacognition around emotions and feelings is a tool that allows for greater control over the repercussions in the Nursing students' performance during their practical experiences 22 .
Reflective teaching is recognized as an opportunity to humanize training, as it makes visible the knowledge, decisions and emotions involved in the dialog between Nursing teachers and students, where there is a description and reflection on the experience, perceptions, meanings, abstractions and later application 4 These central elements for humanized training should be integrated in an institutional approach in the Nursing professional-teacher transition 10 .
The experience shared in this article has been an opportunity to make visible possibilities and limitations for a more humanized Nursing care and training.In synthesis, contributing to devising and tending to a more humanized Nursing cultures, both in healthcare and university institutions.The pandemic and the consequent exhaustion in the Nursing professionals represented a limitation in the number of training participants, as well as in their dedication to the activities proposed but, at the same time, it was a source of reflection regarding the real meaning, desire, resistance and challenge of humanizing care and training.
We persistently wonder if our training represented a humanized care experience for the participants and the teachers in the institutional and health contexts we were living in, and it is a challenge for future research studies.

CONCLUSION
This online training during the pandemic and the analysis of the participants' reflections allowed us to understand that humanization of care and of training has a personal, a relational and a systemic dimension.Training is required, as well as coaching in relational skills and willingness on the part of the professionals/teachers; but it is also necessary to critically discuss about the heterogeneity between a culture of professional excessive demands and clinical/educational environments with policies, resources and cultures that impose tension on the possibilities for humanized care or training.These reflections were generated in our training, valuing self-recognition and acknowledgment of the students as individuals, disclosing aspects in which they can exert an influence for a more humanize care and training culture, along with the challenge of investigating and influencing on strategies at the institutional and political levels.

Table 1 -
Needs for humanized training in Nursing and units.