Abstract

This paper presents the pronouncements on humanization of professionals and users of a health care and research institution. Interviews were conducted with 16 professionals and 44 users. The analytical method employed was the Discourse of the Collective Subject, the results of which were discussed based on the theoretical framework presented, which includes the Theory of communicative action of Habermas and recognized authors in the public health area. The findings point to the importance of the set of hard, light-hard and light technologies for humanized practice. The articulation role played by communicative action was highlighted both for the creation of a network of professionals and in the relationship between professionals and patients. The practice of research was considered by professionals and users as a factor that increases the quality of care and contributes to humanization. Care at the institute was considered good, both by practitioners and users, who emphasized the importance of problem resolution for humanization. The professionals highlighted the working conditions and the autonomy of professionals and patients, with the appreciation of each person's knowledge. The intersectoral work revealed itself to be an important challenge for the Brazilian Health System (SUS).

Key words
Humanization; Communicative action; Conversation networks; Public health SUS

Introduction

The implementation of Brazil's Unified Health System (SUS, acronym in Portuguese) undergoes moments in which priorities change, placing greater or lesser emphasis on one principle or another according to strategies or policy options¹1. Mattos RA. Princípios do Sistema Único de Saúde (SUS) e a humanização das práticas de saúde. Interface (Botucatu) 2009; 13(Supl. 1):771-780.. Brazil's National Humanization Policy (Política Nacional de Humanização - PNH) reaffirms the need to invest not only in the expansion of the network and access, but also in the quality of care. Mattos¹1. Mattos RA. Princípios do Sistema Único de Saúde (SUS) e a humanização das práticas de saúde. Interface (Botucatu) 2009; 13(Supl. 1):771-780. highlights that humanization is central to health policy, despite not being among the core principles of the SUS.

Humanizing practices to promote better quality care and the respect and dignity of service users and healthcare workers was a major component of healthcare reform. Various measures have been taken by the government to promote humanization within the SUS, particularly in maternity and child health services²2. Pasche DF, Passos E, Hennington EA. Cinco anos da Política Nacional de Humanização: trajetória de uma política pública. Cien Saude Colet 2011; 16(11):4541-4548.

3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406.

4. Hennington EA. Gestão dos processos de trabalho e humanização em saúde: reflexões a partir da ergologia. Rev Saude Publica 2008; 42(3):555-561.^-55. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231.. Humanization prioritizes, first and foremost, the quality of healthcare and user satisfaction, followed by issues related to healthcare professionals³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406.. Regardless of programs or policy, humanizing practices have always found their niche in healthcare services.

Created in 2003, the PNH seeks to encourage the adoption of humanizing practices within the SUS⁶6. Brasil. Ministério da Saúde (MS). HumanizaSUS: Política Nacional de Humanização: a humanização como eixo norteador das práticas de atenção e gestão em todas as instâncias do SUS. Brasília: MS; 2004.^,77. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008.. However, the humanizing and participatory practices that this policy advocates were already present within various services, serving as inspiration for its creation. This article analyzes the discourse of healthcare professionals and service users to gain an insight into the perceptions they hold of humanization and humanizing practices beyond any formal knowledge they might have of humanization policies.

Health organizations are professional, and therefore complex, organizations⁸8. Mintzberg H, Lampel J, Quinn JB, Ghoshal S. O Processo de Estratégia – Conceitos, contextos e casos selecionados. Porto Alegre: Bookman; 2006., given the autonomy of health care professionals afforded by the specificity of their knowledge. In such a context, where professionals typically participate in decision-making, mutual adjustment is the preferred coordination mechanism⁸8. Mintzberg H, Lampel J, Quinn JB, Ghoshal S. O Processo de Estratégia – Conceitos, contextos e casos selecionados. Porto Alegre: Bookman; 2006.. The target institution of this study, a teaching and research hospital that offers masters and PhD programs, is particularly complex and therefore requires communicative management methods⁹9. Artmann E, Andrade MAC, Rivera FJU. Desafios para a discussão de missão institucional complexa: o caso de um Instituto de Pesquisa em Saúde. Cien Saude Colet 2013; 18(1):191-202.. The communicative spaces that permeate healthcare practices enable the development of a humanizing culture through communicative action⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231..

Ensuring access to comprehensive healthcare through health care networks requires the involvement of workers, managers and service users in the work processes that have historically made up the SUS¹⁰10. Santos Filho SB, Barros MEB, Gomes RS. A política Nacional de Humanização como política que se faz no processo de trabalho em saúde. Comunicação Saúde Educação 2009; 13(Supl. 1):603-613.. Given the importance of the relationships between care providers, the effective integration of healthcare professionals into a wider network of services and interdisciplinarity are essential elements of humanizing practice⁶6. Brasil. Ministério da Saúde (MS). HumanizaSUS: Política Nacional de Humanização: a humanização como eixo norteador das práticas de atenção e gestão em todas as instâncias do SUS. Brasília: MS; 2004..

In Brazil, humanizing practices are regarded as relational technologies³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406.^;1111. Deslandes SF. Humanização: revisitando o conceito a partir das contribuições da sociologia médica. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 33-48. and the concept of humanization is closely linked to comprehensiveness¹1. Mattos RA. Princípios do Sistema Único de Saúde (SUS) e a humanização das práticas de saúde. Interface (Botucatu) 2009; 13(Supl. 1):771-780.^,1111. Deslandes SF. Humanização: revisitando o conceito a partir das contribuições da sociologia médica. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 33-48. as a means of upholding this set of principles³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406.. The discussion of humanization places changing practices and quality of care at the center of the debate¹1. Mattos RA. Princípios do Sistema Único de Saúde (SUS) e a humanização das práticas de saúde. Interface (Botucatu) 2009; 13(Supl. 1):771-780.

2. Pasche DF, Passos E, Hennington EA. Cinco anos da Política Nacional de Humanização: trajetória de uma política pública. Cien Saude Colet 2011; 16(11):4541-4548.^-33. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406..

But how can we humanize care? It is through this ‘how’ that humanization captures the changes in care practices necessary to achieve quality care. Accordingly, care and care management are inextricably linked⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231., in so far as work processes transform not only practices, but also the subjects involved in these processes³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406.. The work process and process of subjectification are linked in a circular relationship, which may either be virtuous, producing positive health outcomes for both healthcare professionals and service users, or cause the subjects - and the health system itself - to become sick, resulting in poor treatment or total lack of proper care.

Far from being static, the SUS is subject to constant modification and the complexities of public health in a country of continental proportions like Brazil require a constant search for new solutions. Problematizing the role healthcare professionals play in building this network, paying due regard to the comprehensiveness of healthcare, is critical to improving the way the system works.

Humanization and communication

According to Habermas' Theory of Communicative Action, language is assigned the function of intersubjective mediation, enabling human actors to achieve shared understanding by judging shared validity claims in order to coordinate actions¹²12. Artmann E. Interdisciplinaridade no enfoque intersubjetivo habermasiano: reflexões sobre planejamento e AIDS. Cien Saude Colet 2001; 6(1):183-195.. Habermas describes three distinct worlds that relate with each other through the “life-world”: the objective world, corresponding to things that exist in the physical world; the social world, which is linked to the social and cultural norms of social groups; and the subjective world of inner feelings and perceptions. Composed of culture, society and personality, intertwined with one another through language, the lifeworld represents the terrain of the pre-interpretations that guide our actions. Day-to-day actions are performed in two distinct spheres: the system and the lifeworld. The latter is a medium of dialogic space and is reproduced through communicative action, while the system is characterized by instrumental and strategic action¹²12. Artmann E. Interdisciplinaridade no enfoque intersubjetivo habermasiano: reflexões sobre planejamento e AIDS. Cien Saude Colet 2001; 6(1):183-195.

13. Fiedler RCP. A Teoria da Ação Comunicativa de Habermas e uma nova proposta de desenvolvimento e emancipação do humano. Revista da Educação 2006; I(1):93-100.^-1414. Habermas J. Teoria do agir comunicativo. São Paulo: Martins Fontes; 2012..

This understanding forms the basis for the discussions of several authors⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231.^,1515. Teixeira R. O acolhimento num serviço de saúde entendido como uma rede de conversações. Mattos RA, Pinheiro R, organizadores. Construção da Integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: UERJ/IMS, Abrasco; 2003. p. 49-61.

16. Campos GWS. Saúde Paidéia. São Paulo: Editora Hucitec; 2003.^-1717. Merhy EE. Saúde – A cartografia do trabalho vivo. São Paulo: Hucitec; 2007. who have conducted assessments of humanizing care initiatives. Acolhimento-diálogo (dialogue-based welcoming), for example, helps to form redes de conversações (conversation networks) that guide users on a pathway through the services¹⁵15. Teixeira R. O acolhimento num serviço de saúde entendido como uma rede de conversações. Mattos RA, Pinheiro R, organizadores. Construção da Integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: UERJ/IMS, Abrasco; 2003. p. 49-61., while Clínica Ampliada (expanded care) combines traditional clinical care with a patient-centered approach, taking the focus of clinical intervention beyond disease to include the patient and his/her context¹⁶16. Campos GWS. Saúde Paidéia. São Paulo: Editora Hucitec; 2003.. Merhy¹⁷17. Merhy EE. Saúde – A cartografia do trabalho vivo. São Paulo: Hucitec; 2007. describes healthcare as the shared intersection between service user and health worker, which continually materializes in the form of living work in progress and should be grounded in a user-centered approach and, in our view, be necessarily anchored to language⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231..

We understand care provision as a process involving hard, soft-hard and soft technology¹⁷17. Merhy EE. Saúde – A cartografia do trabalho vivo. São Paulo: Hucitec; 2007.. Communicative action promotes the linkage to and coordination of care and includes all types of technology, since communicative action is the only action capable of articulating the different worlds mentioned above and their respective types of action. Although hard technology requires a type of instrumental action related to strategic contexts of action, it does not prescind from communicative action, since the adoption of a given technology in a healthcare setting calls for consensus on how and when to use it, obtained for example through linguistically mediated protocols. Thus, although humanizing practices are often associated with soft (relational) technology, they cannot prescind from the good use of hard and soft-hard technology, without which the quality of care, a theme at the heart of the PNH, would be compromised.

This article discusses humanization drawing on discourses on the theme proffered by healthcare professionals and service users from two laboratories in a leading teaching and research hospital.

Study design

The study that forms the basis of this article comprises a postgraduate research project undertaken as part of a wider study conducted at the Evandro Chagas Clinical Research Institute (Instituto de Pesquisa Clínica Evandro Chagas -IPEC) – formerly called the National Institute of infectology (Instituto Nacional de Infectologia – INI) – entitled Humanização nos serviços de saúde: gestão estratégica no trabalho, produção de saúde e análise cultural (Humanization in health services: strategic management at work, care provision and cultural analysis) and coordinated by Elizabeth Artmann, researcher at IPEC. The study was approved by the Ethics Committees of the National School of Public Health (Escola Nacional de Saúde Pública - ENSP), on 07/9/2007 (application number: 360/07), and IPEC, on 11/29/2007.

Drawing on Habermas' theory of communicative action, the study focused on conversation networks as the key cross-cutting theme⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231.^,1515. Teixeira R. O acolhimento num serviço de saúde entendido como uma rede de conversações. Mattos RA, Pinheiro R, organizadores. Construção da Integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: UERJ/IMS, Abrasco; 2003. p. 49-61., addressing humanization in the light of the fragmentation of healthcare and of the communicative dimension inherent in the area¹²12. Artmann E. Interdisciplinaridade no enfoque intersubjetivo habermasiano: reflexões sobre planejamento e AIDS. Cien Saude Colet 2001; 6(1):183-195.

13. Fiedler RCP. A Teoria da Ação Comunicativa de Habermas e uma nova proposta de desenvolvimento e emancipação do humano. Revista da Educação 2006; I(1):93-100.^-1414. Habermas J. Teoria do agir comunicativo. São Paulo: Martins Fontes; 2012.. The study design was anchored in the theoretical framework underpinning the strategic management approach Démarche Stratégique⁹9. Artmann E, Andrade MAC, Rivera FJU. Desafios para a discussão de missão institucional complexa: o caso de um Instituto de Pesquisa em Saúde. Cien Saude Colet 2013; 18(1):191-202.^,1818. Andrade MAC, Artmann E. Démarche estratégica em unidade materno-infantil hospitalar. Rev Saude Publica 2009; 43(1):105-114., in which communication, solidarity and interdisciplinarity – major premises of humanization – are viewed as essential components of healthcare.

Semi-structured interviews were conducted with healthcare professionals and service users working/receiving treatment at IPEC's mycology and clinical dermatology laboratories between September and October 2013. The laboratories were chosen according to the role they played in the institution and their working partnerships based on suggestions made by the directors of the hospital. A total of 16 healthcare professionals – six from the clinical dermatology laboratory and 10 from the mycology laboratory – and 44 service users participated in the study. Nine support workers were also interviewed, comprising five nurses, two social workers, and two psychologists.

Participant observation workshops were also conducted in the laboratories, providing a space in which the researcher was able to build a closer relationship with participants and make observations in the field. The data obtained from these discussions was used to complement the data from the interviews.

The service users were randomly selected in the waiting room on alternate days and shifts in order to cover all the periods worked by the various professionals. The only inclusion criterion was that participants should be receiving treatment at the laboratories under study. Participation was voluntary and all participants signed an informed consent form. Interviews were halted when data saturation was reached.

The interviews were analyzed using the method Discurso do Sujeito Coletivo (Discourse of the Collective Subject)¹⁹19. Lefèvre F, Lefèvre AMC. O sujeito coletivo que fala. Interface (Botucatu) 2006; 10(20):517-524.^,2020. Lefèvre F, Lefèvre AMC. Pesquisa de Representação Social – Um enfoque qualiquantitativo. Brasilia: Líber Livro Editora; 2010., which suggests that the discourse of the subject is intertwined with the institutional context, enabling the emergence of the social representations²¹21. Jodelet D. Representations sociales: en domain en expansion. Jodelet D, organizador. Representations Sociales. 7a ed. Paris: PUF; 1989. p. 45-78. that circulate this world. Discourse of the Collective Subject (DCS) comprises four methodological components:

1. Key expressions (KE): literally-transcribed passages describing content and representing discursive arguments, which constitute the raw material for elaborating the discourses of the collective subject.

2. Central Ideas (CIs): reveal the essential elements of the discursive content by identifying the central ideas of each statement.

3. Discourse of the Collective Subject (DCS): unification of key expressions that have central ideas with a similar or complementary meaning to clarify a way of thinking about a fact, norm or human conduct. It is part of the imaginary of a group of people or social actors and, from a Habermasian perspective, permits the researcher to capture the fragments of the lifeworld shared by these actors.

4. Anchoring: comprises the assumptions, theories, concepts or ideologies that underpin the discourse, which may be expressed through clear linguistic markers or underlie day-to-day practices.

Based on an analysis of the individual discourses, collective discourses were elaborated using similar key expressions (KE) that appeared in the statements grouped into central ideas (CI)¹⁹19. Lefèvre F, Lefèvre AMC. O sujeito coletivo que fala. Interface (Botucatu) 2006; 10(20):517-524.^,2020. Lefèvre F, Lefèvre AMC. Pesquisa de Representação Social – Um enfoque qualiquantitativo. Brasilia: Líber Livro Editora; 2010.. Anchoring was performed drawing on the theoretical framework and relevant social representations.

The representations in the individual statements or discourses are part of the lifeworld, often in an uncritical way, revealed through anchoring, which are, as Habermas would say, often uncritical, are part of the lifeworld. Through the DCS method, those representations are revealed through anchoring. It is important to note that the meaning of discourse adopted here is the same as that adopted by the DCS explained above.

For the purposes of this study, we selected two questions that brought important reflections for thinking humanization and healthcare based on the work developed at IPEC/INI: 1. ‘What do you understand by humanization?’, which was answered by the healthcare professionals; and 2. ‘For you, what is being well taken care of?’, which was put to the service users. It is important to note that, in accordance with the DCS methodology¹⁹19. Lefèvre F, Lefèvre AMC. O sujeito coletivo que fala. Interface (Botucatu) 2006; 10(20):517-524.^,2020. Lefèvre F, Lefèvre AMC. Pesquisa de Representação Social – Um enfoque qualiquantitativo. Brasilia: Líber Livro Editora; 2010., different questions were used for healthcare professionals and service users to avoid inducing institutional discourse and make sure the participants felt free to use expressions that are part of their world. Furthermore, the semi-structured interview technique also allows interviewees to articulate their thoughts with greater fluency and affords greater flexibility than other methods.

Results

Discourse of the Collective Subject (DCS): healthcare professionals

The polysemic nature of the term humanization is evident from the large number of different ideas expressed in the interviews with healthcare professionals, from which 16 collective discourses were identified. Chart 1 shows these discourses organized alongside the central ideas, some of which are complementary.

The following section discusses these results anchored in the theoretical framework outlined above to obtain a better understanding of the content of these varying discourses.

Discourse A.1 addresses the notion of conversation networks, highlighting the roles played by the different actors involved in healthcare - healthcare professionals and service users alike – who interact, thus contributing towards decision-making. It also reveals the dynamic nature of this network, which, by listening to patients, helps enable them to actively participate in their care¹⁵15. Teixeira R. O acolhimento num serviço de saúde entendido como uma rede de conversações. Mattos RA, Pinheiro R, organizadores. Construção da Integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: UERJ/IMS, Abrasco; 2003. p. 49-61. and the coordination of actions²²22. Lima JC, Rivera FJU. Agir comunicativo, Redes de Conversação e Coordenação de Serviços de Saúde: uma perspectiva teórico-metodológica. Interface (Botucatu) 2009; 13(31):329-342.. It emphasizes the collaboration of various types of professionals who contribute towards decision-making, although treatment is clinically-oriented given the types of problems treated.

Discourse B.1 provides another meaning for the term humanization, addressing another aspect of networking: creating linkages between different health services through referral and counter-referral in situations where the service does not offer the appropriate treatment to ensure that the patient receives the proper care. In this sense, humanization aims to ensure the provision of comprehensive care through the effective management of existing patient flows, making referrals that result in effective health outcomes⁷7. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008.. This meaning of humanization reveals a broader understanding of the term and patient care, highlighting the linkages with other services and openness towards the external environment, exemplifying one of the principles laid out by the PNH – the cross-cutting nature of health services, which presupposes that the health system is an organized network³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406.^,77. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008..

The vision of humanization shown by discourse C.1 is oriented towards health workers and the conditions they need to carry their work with quality, respect and freedom. Promoting the dignity of health workers is one the main lines of action of the PNH⁶6. Brasil. Ministério da Saúde (MS). HumanizaSUS: Política Nacional de Humanização: a humanização como eixo norteador das práticas de atenção e gestão em todas as instâncias do SUS. Brasília: MS; 2004.^,77. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008.^,2323. Pasche DF. Política Nacional de Humanização como aposta na produção coletiva de mudanças nos modos de gerir e cuidar. Interface (Botucatu) 2009; 12(1):701-708.. This discourse places special emphasis on freedom, which is related to autonomy, a socially recognized aspect of this concept. As we have seen, this is an essential and incisive feature of professional organizations⁸8. Mintzberg H, Lampel J, Quinn JB, Ghoshal S. O Processo de Estratégia – Conceitos, contextos e casos selecionados. Porto Alegre: Bookman; 2006., particularly in the laboratories under study, which boast highly specialized professionals.

It is important to note that the majority of DCSs about humanization address the relationship between healthcare professionals and service users. These discourses are complementary and contain the following central ideas that highlight the uniqueness of this relationship: ensuring patients are involved in their treatment through active listening, clarification and respect; empathy between health worker and service users and treating others the way you would like to be treated; building a link with the patient; and professionals who champion quality care tailored to the specific needs of patients. These types of humanizing practices are strongly associated with relational technologies, reflecting current practice in Brazil³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406.^,55. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231.^,1111. Deslandes SF. Humanização: revisitando o conceito a partir das contribuições da sociologia médica. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 33-48..

Discourse D.1 highlights the importance of taking time to listen to what the patient has to say and enabling patient participation in the treatment process. According to Habermas, the communication process involves a reciprocal flow and there is an active aspect to listening²⁴24. Echeverria R. Ontologia del Lenguage. Santiago: Dólmen Ed.; 1997., given that subjects are only able to engage in communicative action because they share pretensions of validity concerning the lifeworld⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231..

Discourse E.1 addresses another way of including service users, emphasizing the importance of not seeing practices and procedures in isolation and placing patients at the center of care adopting a patient-centered approach that prioritizes patient well-being¹⁷17. Merhy EE. Saúde – A cartografia do trabalho vivo. São Paulo: Hucitec; 2007.. It is interesting to note that this discourse contains key expressions contained in statements made by professionals who do not having frequent contact with patients and but, despite this, who do not hesitate to place service users at the center of care, which shows that they know their work context well.

Discourse F.1 emphasizes that the doctor-patient relationship should be more humane and that the patient should be treated as a person in need rather than a client. This is an allusion to technically based relationships, where patients are often treated as service ‘consumers’. These professionals point out that humanized care goes well beyond this, requiring healthcare workers and institutions to make patients feel comfortable and welcome. Discourse G.1 adds the notion of caring, highlighting the importance of listening to patient needs and expectations. For Ayres²⁵25. Ayres JRCM. Cuidado: trabalho e interação nas práticas de saúde. Rio de Janeiro: CEPESC, UERJ/IMS, Abrasco; 2009., restorative care takes place at this junction, where doctors place their technical knowledge at the service of patient needs, acknowledging their otherness.

Discourse H.1 mentions concern for others and the importance of attempting to understand what they are feeling and preventing pain, reflecting an other-oriented approach. In a similar vein, discourse I.1 contains the expression “putting yourself in the patient's shoes”, highlighting the importance of identifying with the patient and empathy. The central idea of this discourse is providing the patient with the type of treatment you would like to receive, thus ensuring that everyone receives good care. Complementing this idea, discourse J.1 states that humanization is stripping yourself of all prejudice with a view to improving the quality of care. This remains a challenge despite the following understanding of humanization of the SUS outlined by the baseline document for the PNH: “defense of SUS that recognizes the diversity of the Brazilian people and provides the same treatment for everyone without distinction as to race/color, origin, gender and sexual orientation”⁷7. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008..

Discourse K.1 highlights the idea of respecting patient autonomy, which is one of the underlying principles of the PNH laid out in the 2008 baseline document⁷7. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008.. This discourse is anchored in the popular expression ‘give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime’ and is theoretically grounded in the keywords “paternalism”, “infantilize” and “responsibility”. We can therefore say that humanized care should promote autonomy by recognizing “the other” and his/her responsibilities and knowledge of him/her self. In early emotional development, where one is absolutely dependent on another's care, it is the maternal gaze that establishes a difference between mother and child by revealing to the child his/her ability to affect others. Even after achieving independence it is necessary to accept that it is not absolute, since the subject is constantly relating to others and therefore continues to need the recognition of others to confirm his/her existence²⁶26. Winnicott D. O brincar e a realidade. Rio de Janeiro: Imago; 1975.. Paternalism and infantilizing patients or, as is popularly said, “giving a man a fish”, are ways of depriving the patient of the opportunity to participate in his/her treatment process, denying the existence of otherness. Honneth²⁷27. Miranda L, Rivera FJU, Artmann E. Trabalho em equipe interdisciplinar de saúde como espaço de reconhecimento: contribuições de Axel Honneth. Physis 2012; 22(4):1563-1583. distinguishes between three spheres of recognition: love, which refers to affective relations; social order, which legitimizes the freedom and autonomy of people as legal subjects; and solidarity, which confers individuals the capacity for social interaction, respecting their particularities and the particularities of others. Interaction between subjects, where everyone has the same opportunity to participate, presupposes recognition and generates more autonomous subjects, which promotes the care of the self²⁵25. Ayres JRCM. Cuidado: trabalho e interação nas práticas de saúde. Rio de Janeiro: CEPESC, UERJ/IMS, Abrasco; 2009..

In discourse L.1 humanization is understood as considering the patient as a whole, beyond the disease, as conceived by Clínica Ampliada, pooling the body and care services together with the uniqueness of the subject and the context in which he/she lives¹⁶16. Campos GWS. Saúde Paidéia. São Paulo: Editora Hucitec; 2003.. Thus, as expressed in the above-cited discourse, Clínica Ampliada expands the traditional vision of care adding new elements to the therapeutic relationship⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231.^,2828. Brasil. Ministério da Saúde (MS). PNH da Atenção e da Gestão do SUS. Clínica ampliada e compartilhada. Brasília: MS; 2009..

Discourse M.1 falls within this logic of expanded care, suggesting that treatment should be tailored to patient context, which includes psychosocial aspects, exemplified by the case of patients with HIV, a disease which has major social and emotional consequences, and the precarious financial situation of many patients who seek public health services. The discourse also highlights the challenges posed by the precarious living conditions of some patients, which hinder access to healthcare, highlighting the limitations of the health system and need to for an intersectoral approach to care. In this respect, while it is necessary to widen the frame of reference of health workers to meet patient care needs, there is also a need to recognize the individual limitations of these professionals⁷7. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008.^,1515. Teixeira R. O acolhimento num serviço de saúde entendido como uma rede de conversações. Mattos RA, Pinheiro R, organizadores. Construção da Integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: UERJ/IMS, Abrasco; 2003. p. 49-61.^,2929. Camargo Júnior KC. Um ensaio sobre a indefinição de (in)tegralidade. Pinheiro R, Mattos RA. Construção da integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: IMS, Abrasco; 2003. p. 35-43., showing that the provision of more comprehensive and effective care along the lines of the care models of welfare states continues to be a major policy challenge. Magalhães and Bodstein³⁰30. Magalhães R, Bodstein R. Avaliação de iniciativas e programas sociais em saúde: desafios e aprendizagem. Cien Saude Colet 2009; 14(3):861-868. show that the effectiveness of social programs depends on an intricate network involving decision makers, managers, technicians and the population and the mobilization of resources, forming a complex multi-sectoral arrangement. They highlight that it is impossible to tackle complex problems such as healthcare using sectoral approaches, which are doomed to fail because they do not recognize the multiple dimensions of the needs of the population³⁰30. Magalhães R, Bodstein R. Avaliação de iniciativas e programas sociais em saúde: desafios e aprendizagem. Cien Saude Colet 2009; 14(3):861-868.^,3131. Rivera FJU, Artmann E. Promoção da Saúde e Planejamento Estratégico Situacional: intersetorialidade na busca de maior governabilidade. Czeresnia D, Freitas CM, organziadores. Promoção da Saúde – conceitos, reflexões, tendências. Rio de Janeiro: Fiocruz; 2009, p. 183-206..

In the same vein as discourses L.1 and M.1, discourse P.1 highlights the importance of having a multidisciplinary perspective and being attentive to the support network, associating humanization with comprehensiveness. According to Mattos¹1. Mattos RA. Princípios do Sistema Único de Saúde (SUS) e a humanização das práticas de saúde. Interface (Botucatu) 2009; 13(Supl. 1):771-780.^,3232. Mattos RA. Os Sentidos da Integralidade: algumas reflexões acerca de valores que merecem ser defendidos. Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Abrasco; 2001. p. 39-64., despite its polysemic nature, the term comprehensiveness implicitly rejects reductionism. A comprehensive approach to care requires a broad vision of both the patient, together with his/her needs, and care practices, drawing on, for example, other disciplines and services. In this respect, Camargo Júnior²⁹29. Camargo Júnior KC. Um ensaio sobre a indefinição de (in)tegralidade. Pinheiro R, Mattos RA. Construção da integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: IMS, Abrasco; 2003. p. 35-43. draws attention to the risk of confusing comprehensiveness with wholeness, which can lead to comprehensive medicalization and loss of autonomy.

Campos¹⁶16. Campos GWS. Saúde Paidéia. São Paulo: Editora Hucitec; 2003. addresses the importance of building a bond with the patient expressed by discourse N.1. Creating links is essential for building a relationship of trust between the patient and health professional and contributes toward the continuity of treatment. This discourse highlights certain attitudes of healthcare professionals, such as taking time to listen and interest in the patient's treatment, that favor bond building. Artmann and Rivera⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231. highlight that link is a core device of humanized care strategy consolidation.

Discourse O.1 highlights the importance of valuing the well-being of both service users and professionals and presents a broad conception of humanization, highlighting the overarching cultural features of the institution. This definition alludes to a cross-cutting institutional culture, supported by the PNH as a way of promoting networking, connecting healthcare professionals and service users through a humanizing mentality and, consequently, practices grounded in common values. Drawing on Habermas, Artmann and Rivera⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231. explain that, as one of the structural components of the lifeworld, culture conditions our perspectives and actions through symbolic configurations and assumptions stemming from the historical tradition of groups. The authors support a communicative model of cultural evolution that enables the emergence of new discourses, including humanization.

This discourse also differs because it draws attention to the need to address the working conditions of health workers⁴4. Hennington EA. Gestão dos processos de trabalho e humanização em saúde: reflexões a partir da ergologia. Rev Saude Publica 2008; 42(3):555-561. and, more especially, considers both sides: that of the health professional and that of the service user. The baseline document for the PNH⁷7. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008. highlights that the undervaluation of health workers is a continuing problem in the SUS and confirms that promoting improved working conditions is one of the challenges of this policy, defining humanization as “the valorization of the different subjects involved in the health production process: service users, workers and managers.” Given that health workers and service users are the main actors engaged in the health process, each should be taken into consideration by actions aimed at improving care. As highlighted above, the large majority of discourses about humanization refer to the relationship between these actors, showing that humanization occurs at this interface and that the actions oriented towards one influence the other. With respect to service users, the provision of quality care, humanized care is achieved by combining available resources with relational technologies. However, as subjects involved in both care provision and management, health professionals need to have good working conditions to be able to deliver quality care³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406.. It is this perspective therefore that underlies the discussions surrounding changes in practices; after all, change can only occur when the work process is also a process that produces subjects who are healthy and, therefore, able to produce health⁴4. Hennington EA. Gestão dos processos de trabalho e humanização em saúde: reflexões a partir da ergologia. Rev Saude Publica 2008; 42(3):555-561..

The humanization of healthcare seeks to improve the quality of care by promoting change in both practices and the subjects, valuing the types of relationships that promote the active participation of both healthcare professionals and service users in the care process³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406.^,44. Hennington EA. Gestão dos processos de trabalho e humanização em saúde: reflexões a partir da ergologia. Rev Saude Publica 2008; 42(3):555-561.. Participatory management mechanisms and coresponsibility are ways of promoting joint engagement in care work, ensuring they take a more active role and favoring the formation of networks.

In this respect, Benevides and Passos³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406. highlight that humanization should be incorporated as core component of the system, while Hennington⁴4. Hennington EA. Gestão dos processos de trabalho e humanização em saúde: reflexões a partir da ergologia. Rev Saude Publica 2008; 42(3):555-561. suggests that the role of healthcare professionals should be rethought, confirming that they should be seen as key actors in the development of a humanized care network grounded in solidarity.

Discourse of the Collective Subject (DCS): service users

Chart 2 shows the DCSs based on the results of interviews with the 44 service users.

Nine different discourses were identified in the interviews with the service users. Discourse A.2 mentions the high quality of patient care at Fiocruz, showing that this opinion is held even by those who have health insurance, revealing a social representation of health services where the quality of care provided by private health services is seen to be better than that of public services. In discourse H.2, being well taken care of is seen as timely booking of medical appointments and respecting appointment times, showing that lengthy waiting times are common even in private clinics, revealing the same social representation as discourse A.2, i.e. that private services are better than public services.

Discourse B.2 refers to soft technology, valuing the fact that doctors are genuinely concerned about patient well-being and highlighting an underlying assumption of communicative action, which is speaker authenticity, requiring the subjects involved in the interaction to be sincere in their pursuit of a common purpose⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231.. The discourse also highlights the different ways in which the speaker is treated, showing that healthcare professionals are generally good-humored, kind and polite. The statement person to person also suggests that one of the characteristics of a good patient care is horizontal relationships between healthcare professionals and service users, highlighting another requisite of communicative action: non-coercion, which enables the active participation of tall actors within a nonhierarchical interaction in the search for consensus.

Discourse C.2 mentions the importance of having access to “good resources”, which encompasses good doctors, medications and examinations, emphasizing the provision of free medications.

Discourse D.2 highlights that doctor should be interested in the case, in discovering the patient's problem and carrying out research to provide a diagnosis and solve the problem, emphasizing the importance of professional competence. This discourse refers to soft-hard technology¹⁷17. Merhy EE. Saúde – A cartografia do trabalho vivo. São Paulo: Hucitec; 2007., since it addresses professional knowledge and underscores the importance of specialized knowledge¹⁶16. Campos GWS. Saúde Paidéia. São Paulo: Editora Hucitec; 2003.. The three discourses mentioned above (B.2, C.2 and D.2) show that a good patient care requires access to three types of technology - soft, soft-hard and hard, represented in the discourses by relational technology, professional knowledge and material resources, respectively³³33. Artmann E, Rivera FJU. Gestão comunicativa e democrática para a integralidade e humanização do cuidado em saúde: desafios. Roseni P, Muller Neto, Ticianel FA, Spinelli MAS, Silva Júnior AG, organizadores. Construção Social da Demanda por Cuidado: revisitando o direito à saúde, o trabalho em equipe, os espaços públicos e a participação. Rio de Janeiro: UERJ/IMS/CEPESC/LAPPIS/Abrasco; 2013. v. 1. p. 225-239..

Discourse E.2 addresses tailoring patient care to individual needs and characteristics, such as age and schooling, which can be anchored in the PNH guidelines, which promote the valorization of the subjective and collective dimensions of care practices and the management of the SUS, supporting the rights and needs associated with these dimensions⁷7. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008.. Expanded care¹⁶16. Campos GWS. Saúde Paidéia. São Paulo: Editora Hucitec; 2003. also addresses this issue, combining traditional clinical care with the Clinic of the Subject, to provide individualized care tailored to the specific needs of each case⁷7. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008.^,2828. Brasil. Ministério da Saúde (MS). PNH da Atenção e da Gestão do SUS. Clínica ampliada e compartilhada. Brasília: MS; 2009..

Discourse F.2 addresses the theme of communication between doctors and service users, underlining the importance of listening to patients and understanding their needs rather than imposing what the doctor regards as important on the patient to be able to provide adequate care. This discourse highlights the importance of patient knowledge and of the recognition of this knowledge by healthcare professionals. It also highlights the importance of establishing a genuine dialogue between patients and professionals, which requires real listening and real responding to the patient, which according to Teixeira¹⁵15. Teixeira R. O acolhimento num serviço de saúde entendido como uma rede de conversações. Mattos RA, Pinheiro R, organizadores. Construção da Integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: UERJ/IMS, Abrasco; 2003. p. 49-61. are important elements of effective healthcare professional-service user communication and welcoming, the latter of which should take into account user concerns and involve active listening⁷7. Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. 4a ed. Brasília: Editora do Ministério da Saúde; 2008..

Discourse G.2 highlights the importance of using clear nontechnical language that is understandable to the patient and clearing up doubts. This discourse highlights the assumption of intelligibility¹⁴14. Habermas J. Teoria do agir comunicativo. São Paulo: Martins Fontes; 2012., which states that the language used should be understood by all participants in the conversation. This discourse and the one before it (F.2) complement each other and involve some of the elements of communicative action as, through their shared lifeworld and seeking mutually acceptable validity claims, health professionals and service users negotiate and reach a noncoercive understanding, building consensuses in pursuit of the continuity of treatment⁵5. Artmann E, Rivera FJU. Humanização no Atendimento em Saúde e Gestão Comunicativa. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 205-231.^,1414. Habermas J. Teoria do agir comunicativo. São Paulo: Martins Fontes; 2012..

Discourse I.2 concerns resolutividade (“resolvability”, or the capacity of health services to solve individual health problems), highlighting the importance of the treatment having an effect and the patient being cured of the illness. This is the ultimate goal of all patient care: solve the patient's problem and promote health by improving the quality of life. According to Benevides and Passos³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406., the position of service users in the debate about the humanization of the SUS is historically tied to claiming their rights or, in other words, to atenção com acolhimento e de modo resolutivo (welcoming and resolutive patient care)³3. Benevides R, Passos E. Humanização na saúde: um novo modismo? Interface (Botucatu) 2005; 9(17):389-406..

On balance, it can be said that the service users interviewed in this study associate good patient care with the type of treatment they receive at IPEC, highlighting the high standard of care provided by professionals and interest in solving problems based on active listening and research.

Final Considerations

According to the collective discourses elaborated from the interviews conducted with healthcare professionals and service users, we can affirm that good patient care depends on the balanced use of three types of technology, all of which play an important role in humanizing practices: hard technology, soft-hard and soft¹⁷17. Merhy EE. Saúde – A cartografia do trabalho vivo. São Paulo: Hucitec; 2007.^,3333. Artmann E, Rivera FJU. Gestão comunicativa e democrática para a integralidade e humanização do cuidado em saúde: desafios. Roseni P, Muller Neto, Ticianel FA, Spinelli MAS, Silva Júnior AG, organizadores. Construção Social da Demanda por Cuidado: revisitando o direito à saúde, o trabalho em equipe, os espaços públicos e a participação. Rio de Janeiro: UERJ/IMS/CEPESC/LAPPIS/Abrasco; 2013. v. 1. p. 225-239..

Although in Brazil humanization has traditionally been associated with relational (soft) technologies¹¹11. Deslandes SF. Humanização: revisitando o conceito a partir das contribuições da sociologia médica. Deslandes SF, organizador. Humanização dos Cuidados em Saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006. p. 33-48. and the majority of the DCSs of the professionals highlighted the importance of this type of technology, the interviewees, particularly service users, also underlined the importance of the “resolvability” of patient care, which requires articulation between the three types of technology mentioned above.

Research, which demands special attention to work processes, was highlighted by both professionals and service users as a factor that contributes to quality of care and, therefore, to humanization. Another study³⁴34. Ferreira CL. Humanização e gestão estratégica numa instituição de pesquisa: o caso do IPEC [dissertação]. Rio de Janeiro: ENSP/Fiocruz; 2011. also highlighted that the ethical aspects of clinical research were factors that were capable of contributing to humanization.

The service users equated the patient care provided at IPEC with humanized care, suggesting that it stands out from other services from the SUS network and private services, highlighting the superiority of its service over other services.

The healthcare professionals emphasized working conditions and professional and patient autonomy, valuing the knowledge of the “other”. They also highlighted the importance of teamwork and the limitations of the patient care provided by the institution, suggesting the need for an intersectoral approach and greater integration into the network.

Acknowledgments

To grant: CNPQ, CAPES, FAPERJ, INI/Fiocruz e ENSP/Fiocruz.

References

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