Humanization of health consonant to the social representations of professionals and users: a literary study
Rose Mary Costa Rosa Andrade Silva1, Denize Cristina de Oliveira2, Eliane Ramos Pereira1, Marcos Andrade Silva1, Patrícia da Silva Trasmontano1, Vanessa Carine Gil de Alcantara1
1Fluminense Federal University
2Rio de Janeiro State University
ABSTRACT
Aim: To perform a study that articulates the topic of humanization to the Theory of Social Representation (TSR) in the area of health.
Method: A reflective analysis was conducted over researches that dealt with many possible subtopics originating from humanization in health, which are also associated with TSR.
Results: It was evident that the topic of humanization relates to TSR and is especially related to health assistance. The social representations provide enough subsidies in important issues regarding the process of humanization in health, thus supporting changes in health professional praxis. These are leveraging elements in psychosocial history in health care. Besides that, humanization enables the possibility of building bonds, autonomy, and integrality in health care.
Conclusion: Studies related to the approaches of humanization in the area of health based on TRS enable better performance and valorization of the subjective and social dimensions in health care practices.
Descriptors: Humanization of Assistance; Health Policy; Nursing.
INTRODUCTION
Living in an even more fluid reality, senseless, and without the possibility of achieving satisfactory levels of happiness, which are depersonalized by the necessity of a working system that suppresses singularity, the post-modern man finds himself existentially lonely; under such circumstances, these elements of everyday life reflect upon the way work is experienced. Despite all the technological developments, there is a necessity to build a policy that makes the individual perform more solidary practices, and then, actin a more humanized way at work. This gap is increased by a sort of blockade of loving practices, as the liquid paradigm generates a fragility in human relationships.
It is known that everyday life is recognized by the clash and the crossing of subjectivities. In this sense, humanization can be interpreted as a process that confirms the essential bonds in men, which includes the “ways of caring and the ways of managing and appropriating oneself from this task, and also the affirmation of the role and the autonomy of the subjects and the collectivity, both understood as participants in the production of services, of one self, and of the world”(1:1188). It is evident that the preoccupation to humanize health care generates better success ratio in treatments and in relationships, built on various scenarios.
In Brazil, the Brazilian National Policy of Humanization of Care and Management of the Unified Health System (HumanizaSUS, in Portuguese), created by the Brazilian Ministry of Health in 2003, aims to make effective changes in the principles of the Brazilian Unified Health System (SUS, in Portuguese) and in the everyday life of healthcare practices and management and to educate the people in the public health system, motivating solidary and humanized exchanges among managers, professionals, and users. It recognizes that states, municipalities, and health service units that implement humanitarian practices generate good results, which contribute to legitimizing this practice of SUS as a general public policy.
It is important to highlight that the proposal of humanization arises in the scenario of public policies as an opportunity to propose, discuss, and understand a process of cultural change in the present assistance practices in the whole SUS network, breaking the imposed barriers created over history(2).
Therefore, in the area of health, humanization means an ethic-aesthetic-political bid that transcends the limits imposed by the biological standpoint. This bid is ethical, because it implies a change in attitude from users, managers, and health professionals who are committed and co-responsible; aesthetic, because it is related to the process of the production of healthcare and of autonomous and protagonist subjectivities; and political, because it refers to the social and institutional organization of healthcare practices and management over the SUS network(3).
Humanization is extremely relevant, once it is based on values, such as autonomy and leadership of the subjects, making them co-responsible among themselves, with a solidarity within the bonds established, about the rights of users and the collective participation in the process of management(3).
Taking into consideration the social aspect of humanization and its connections to social relations, and the ways of thinking, which subsidize professional everyday praxis, the perspective of the Theory of Social Representations (TSR) has been emphasized and progressively used, once it calls attention to the consensus, and empowers the social participants to emerge as a new format to interpret the behavior of individuals and social groups(4).
Hence, this study is motivated by the following question: how humanization is being articulated based on the social perspectives of representation in the context of healthcare? Based on what was demonstrated before, the aim of this research is to perform a reflective analysis of the connection between humanization and TSR, in the area of health. It is important to mention that the articulation of the topic, humanization with social representation is justified once the process of health-disease is filled with cultural, social, and economical elements, understood and experienced differently by the many actors who participate in this process(4)
This content can contribute to increase the studies in the area of humanities and of health, subsidizing the understanding of the different secondary concepts that are part of the socio-historical context of healthcare, this helping in a critical evaluation of practices and promoting future perspectives.
METHOD
This is a reflective analysis performed from a narrative review of literature, with electronic databanks that are part of the Health Virtual Library (BVS, in Portuguese), especially LILACS and MEDLINE databases, and those which belong to the journals sponsored by CAPES, as well as access to CINAHL and SCOPUS databases.
The review was based on articles from 2003 to 2014. The year 2003 was chosen for the temporal cut because it was when the Brazilian National Policy for Humanization was released in order to guide the principles of SUS in the everyday life of healthcare practices and management. To select the articles, the following keywords were used: “Humanization of assistance”; “Social Representations”; “Health Policies” and “Nursing”.
In order to proceed with the review, the first stage was a meticulous reading of articles. Later, the results were observed that were found in the publications: the analysis of thematic content of the 23 selected articles enabled a critical perception regarding the theme of humanization to be investigated from the social representation perspective of health professionals and users, as well as the contributions originated from this analysis under the construction and understanding of the situation described.
RESULTS
The scientific literature selected demonstrated that the issues related to humanization can be interpreted and re-signified under TSR in wider, important areas of research for further scientific inquiry, as demonstrated in the articles analyzed in this proposed study.
After an exhaustive analysis of a variety of selected articles three thematic categories arose: “Humanization and Social Representations: leveraging elements of psychosocial history in healthcare”; “The humanization of assistance: the social representations of the professionals, of the users, and of the caregivers of the health system”; and “The humanization as a possibility to build bonds, autonomy and integrity in healthcare”.
DISCUSSION
Humanization and Social Representations: leveraging elements of psychosocial history in healthcare
A general perception is that the studies of social representations demonstrate that the process of disease-illness is filled with cultural, social, and economic elements, being understood and experienced in different formats by the many people who participate in this process(4). Such inference is adequate and matches the directives and principles that regulate the proposal for humanization as a general health policy.
The social representation of family health of the users demonstrate the necessity of a change in the model of caregiving, based on the everyday work of the health teams, and in the relationship with the users, in pleasant moments in which exchanges or interdictions of knowledge and practices occur, in order to face any health issue, which are generally complex and destabilizing.(5:828)
The conceptual articulation gives an opportunity to rewrite history, or, in other words, the history of the life of real social participants. , the history of society, of time, and of temporality, as man must recognize himself in time, in a movement that influences the dialectics as the art of dialogue and discussion. In this sense, humanization and TSR can be considered elements that boost the psychosocial history.
The Brazilian National Program of Humanization in Hospital Care (PNHAH, in Portuguese), in 2001, created a global orientation procedure to many hospital healthcare services in the country, which gives priority to the humanizing characteristic of assistance, and therefore, it stimulates the creation and the permanence of spaces for the exchange of experiences, the sustainability of dialogues, the respect for social and cultural differences, and the establishment of supportive relationships.
TSR seems to take a position between the reality and men, considering that reality is characterized by the totality of the universe and occurs in an historical process, a result from each moment of multiple natural, social, and cultural determinants. The historical course to build reality follows “laws” that are not only found in the field of metaphysical determination, nor in the area of scientific necessity; they are not formalized based on an exercise of pure logic of identity.
And here there is a b adherence to the reference to give support to these reflections, once the concept of health, in a wider perspective beyond the lack of disease and to protect life, places in evidence the necessity of establishing a dialogue between the different areas of knowledge, according to the cultural necessities that are related to healthcare(6).
The humanization of assistance: the social representations of the professional, of the user, and of the caregivers in the health system network
While comparing the material produced in the studies analyzed, it was seen that the largest number of them have a focus on the approaches to the discussions of humanized labor procedures, as it is believed that TSR aims to understand the social representations of midwives, women who live in ghettos, and users of the public health system during pregnancy and puerperal cycles. Hence, the representations of puerperals about education in health are related to institutional educational practices, with an emphasis on seminars, family, school, and community education(6-7).
These concepts express the perspective of humanization from the social representations, and demonstrate the importance of transforming the practices with regard to pregnancy and puerperal cycles, especially regarding the interpersonal relationships once, as in the case of the midwives, the dialogue between their health practices is confronted with the practices of health technicians who favor social wealth(6).
Despite that, women’s experience of hospital labor was also studied based on TSR as the humanization of health policies. There was an emphasis on saying that social relationships are asymmetric and that there is a need to strengthen the perspective of a more humane, holistic relationship, one that takes into consideration the singularity of the users of these services, especially regarding the right to health and access to health services(8).
TSR, when used in the scenario and in the center of the discussions of humanized praxis, shows that assistance cannot be reduced to a simple biological phenomenon, as the relationships of the man with himself, with other men, and with the objects are not determined nor fixed. Such connections are weaved into a psychosocial horizon and, then, they must be recognized as part of the fundamental constitution of all men, under an ethic-aesthetic-ontological superposition.
As a result, it is important to mention that a more humanized professional approach that aims to valorize the other, considering the other’s subjectivity is fundamentally relevant to guaranteeing more effective results when treating diseases as a whole(4). This fact underlines the possibility of implications to a vast network of care and work within the context and the plot of each existence, of each life, that requires the network to protect their health. It needs to be an open dialogue that supports a diversity of points-of-view regarding the individual’s own care process.
With regards to the topic of humanization in healthcare assistance, it is seen that there is a certain preoccupation with the social representations produced by the caregivers of patients hospitalized in health institutions; there was a study that investigated the aspects of architecture and the environment built in the process of humanization of a children’s hospital, and the influences of such changes in the recovery of the hospitalized child, based on TSR(8). Despite these elements, the question of humanization in assistance was evaluated through TSR, in order to understand the relationship between the nursing technician and the user, through social representations of the act of touching(9).
Touching is associated to: the personal contact, being the first contact with the user; the model of welcoming, considered essential to transmit tranquility and care; to humanization, which is characterized in the standards of Family Healthcare Program as a good service provided to the user.(9:714)
Considering the question here posed, there is another research that tried to understand the social representations of users regarding the Family Health Strategy program (ESF, in Portuguese)(10). As it is visible in the published articles, there is a concern in learning the social representations of the caregivers, of the professionals involved, and also of the users of healthcare services(5,8-9) regarding the issues related to humanization, not limited to only one of the sides of the interpersonal relationship that occurs in healthcare procedures. Such analysis is coherent with the proposal of the TSR as a theory.
It is also interesting to consider that authors tend to emphasize the concepts described by nursing professionals about humanization of care, and these ideas are linked to the empirical care (scientific knowledge), aesthetic care (the art of nursing), personal care (self-understanding) and moral care (the ethic care practices)(6). The researcher understands that the process of humanization involves many aspects and from those, there are a considerable amount of categories that are still under discussion, and that need to be interpreted in the light of the complexity and the interdisciplinary nature of the humanization process itself. Because of that, humanization is more than an instituted policy; it is an instituting movement.
It is seen that other researchers are interested in identifying the presupposed ethical aspects involved in the social representations of patients regarding humanization and in discussing the implications of these presuppositions in nursing care. To perform such identification and discussion, TSR was crucial once this theory takes into consideration the social understanding of the subjects involved in the process(11).
Some analysts also mention that the question of humanization and articulation as a social representation supports the discussion of questions related to the social representations of labor and paternity, especially regarding the participation of fathers during labor in public maternity hospitals; there are institutional challenges in these environments, plus the motivation of the couple is analyzed, and there is no doubt that the birth of a child generates an irreversible change in the parental psyche(12).
The institutional issue was discussed by both the humanization process and TSR, as the health institution is also evaluated by the social subjects; it is understood that man is articulated to his history and to the institutions of his present time. This review demonstrates that there is a relationship between memory and institutions; man is not divorced from his own existence, his social surroundings, thus, of the social constructions, which exist also in the symbolic field. Hence, the social representations are a type of understanding that shows the dynamics of a social group based on history , temporality and social memory.
The matter of humanization in health is also an object of concern in the field of social representation, as there are studies that compare the representations of humanization in health among professionals, before and after orientation seminars, for those working in emergency care in a public hospital(3).
Humanization as a possibility to build bonds, autonomy and integrity in healthcare
In this direction, there is one research that aims to investigate the social representations of women assisted during labor, and healthcare professionals related to this activity, in maternity hospitals(13).
Taking into consideration the great psychological vulnerability of women during labor, […] and how the assisting context can interfere in their experience, there is the necessity to evaluate how important is the quality of the relationship between the health team and the parturient, in an effort to improve the quality of healthcare assistance provided in maternity hospitals and other institutions that provide such care in the area of prenatal/puerperal cycles.(14:9)
It is seen that the theory tries to give support to the reviews originated also in the field of health, and that the social representations and practices have an intimate relationship. This fact is proven by 172 research groups that study TSR in Brazil, which confirms this theory as a living theoretical and methodological standard(15-17). As a result, there are studies that also try to understand the meanings given by the family during the home visits of the ESF, observing the recognition of difficulties and potentialities of this practice. In that sense, the qualitative approach is used, in which data is collected through open interviews, and analyzed according to TSR principles(10).
It is interesting to note that it is recognized that the representations of the families regarding the process of health-disease must be considered in planning, organization, execution, and evaluation of healthcare promoting actions, given the importance provided by the theory.
The contribution to the understanding of the process of humanization by TSR occurs once humanization is part of the understanding and of the competency of the professional, when they emerge as two important aspects that can determine the decision-making process of the user in coming or not coming to a consultation.
There is a relevance in identifying and understanding the representations, in order to perceive this phenomenon of adherence to consultation, and above all, the importance of humanization for the good performance of a public health process in which subjects are effectively protagonists of the process, and autonomous, but related to it.
Authors emphasize in studies of social representations of patients and relatives the adoption of organs in transplantation procedures, before and after the studied events. The social representations of organ donation for transplantations express a necessity to humanize(17) the health teams, and the relationships between patients, relatives, and health professionals.
In researches aimed to understand the representations of nurses about the interrelated dimension of care, they warn that, in nursing, the relationship aspects are fundamental, and need to be balanced with the development of technology. In this area, humanization must be guided not only by the feelings that are expressed by the clientele – a personal affection, but also by the construction and exercise of citizenship in which the patient has all the rights related to care respected, and all the patient’s basic needs are fulfilled. A more humanized care is suggested, and also by an ethical concern once healthcare progresses to a more holistic approach.
Based on the facts here mentioned, it is understood that the articulation of humanization with TSR brings important contributions to the field of health with regard to the understanding of the subjects who are part of the area of health, whether they are users, professionals, managers, or caregivers. The consensus indicates that there is a development in healthcare practices, and that health is implied by ethics, aesthetics, and the technical elements without losing sight of a health system that empowers autonomy and the active role of the subjects here mentioned.
Because of that, the theory has been explored more and more in the area of health and education, especially in studies in which it is important to have access to the social understanding that dictates the practices of a certain population, regarding its concepts, dilemmas, and practices.
To know and to consider the representations of healthcare practices means to overcome the scientific view and to move on towards the understanding of the inherent complexity of the education in health(4:962).
One of the possible connections between humanization and social representation is the fact that they permit an interpretation and a construction of social realities, once they place the subject in his or her context in the world, and the existence of a singular perspective, aimed to interact with peers through real, symbolic, and imaginary exchanges.
It is also important to highlight that the topic of humanization makes complete sense in the area of health once it contributes to a mutual support, in a process of reorganization(18). This reorganization also understands that the educational curricula in the area of health have a gap in the theoretical and practical orientation, understanding that death is a symbol of defeat(12) and not a possibility of existence. This is the challenge for the professionals in the area of health: develop interpersonal abilities, which are the fundamental elements to human care, especially when facing death; and, from this point, opening a dialogue with the other person, giving meaning to coexistence, reframing the healthcare practices based on the inevitable, and living with these decisions that cannot be explained in words. Humanized care can work well through silence.
CONCLUSION
In the area of health, it is important to have a consensus which is known, so that the actions in health are not disconnected from the reality of the subjects.
Based on that, there are other factors, such as the exchange and construction of knowledge; the network of multiprofessional health teams; and the identification of the necessities, desires, and interests of the many subjects in the area of health, and on the other participants.
Consequently, it is suggested that more studies are performed, articulating the knowledge built about the issues of humanization in the field of health and TSR, in order to implement better the valorization of the subjective and social spectrums in all healthcare practices and management styles at SUS. This objective strengthens the compromise of the rights of the citizen, mainly those regarding the respect to the subjects in a broader way, thus boosting the strength of the multiprofessional working team, fostering transversal group practices, in a perspective that takes the consensus of social representation into consideration.
It is necessary to understand that, based on such assertions, the researchers must focus on humanization as a challenge in the area of health, which will demand that each one has a trans-disciplinary and ethical attitude, which is implied in a policy of social responsibility. Hence, studies of social representations can provide an understanding of many issues regarding the social relations as recognized in the approaches used to justify humanization of health, despite providing reflection and transformation of the collective practice, once the use of the premises of social representation contributes to building a common reality in a certain social group.
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Received: 06/12/2014
Revised: 11/13/2014
Approved: 11/13/2014