Health facility environment as humanization strategy care in the pediatric unit: systematic review

El ambiente como estrategia de humanización de la asistencia en la unidad de pediatría: revisión sistemática

Abstracts

Objective: To identify and analyze the production of knowledge about the strategies that health care institutions have implemented to humanize care of hospitalized children. Method: This is a systematic review conducted in the Virtual Health Library - Nursing and SciELO, using the seven steps proposed by the Cochrane Handbook. Results: 15 studies were selected, and strategies that involved relationship exchanges were used between the health professional, the hospitalized child and their families, which may be mediated by leisure activities, music and by reading fairy tales. We also include the use of the architecture itself as a way of providing welfare to the child and his/her family, as well as facilitating the development of the work process of health professionals. Conclusion: Investments in research and publications about the topic are necessary, so that, the National Humanization Policy does not disappear and that the identified strategies in this study do not configure as isolated and disjointed actions of health policy.


Child, hospitalized
; Humanization of assistance
; Health Facility Environment
; Pediatric nursing
; Review

Objetivo: Identificar y analizar la producción de conocimiento sobre las estrategias que las instituciones de salud implementaron para humanizar la asistencia al niño hospitalizado. Método: Revisión sistemática a partir de la Biblioteca Virtual en Salud - Enfermagem y de SciELO, usando los sietes pasos propuestos por el Cochrane Handbook. Resultados: Fueron seleccionados 15 artículos cuyos resultados indican el uso de estrategias que envuelven relaciones de intercambio entre el profesional de salud, el niño hospitalizado y sus familiares, las cuales también pueden ser trabajadas por actividades lúdicas, por la música y por la lectura de cuentos infantiles. También, formó parte el uso de la propia arquitectura para proporcionar bienestar al niño y su familia, además de facilitar el desarrollo del proceso de trabajo de los profesionales de salud. Conclusión: Se destaca la necesidad de inversión en investigaciones y publicaciones sobre el tema para que la Política Nacional de humanización no deje de existir y para que las estrategias identificadas en este estudio no se configuren como acciones aisladas y desarticuladas de una política de salud. 


Niño hospitalizado
; Humanización de la atención
; Ambiente de Instituciones de Salud
; Enfermería pediátrica
; Revisión

Objetivo: Identificar e analisar a produção de conhecimento acerca das estratégias que as instituições de saúde têm implementado para humanizar a assistência à criança hospitalizada. Método: Trata-se de uma revisão sistemática realizada a partir da Biblioteca Virtual em Saúde - Enfermagem e do SciELO, utilizando os sete passos propostos pelo Cochrane Handbook. Resultados: Foram selecionados 15 artigos cujos resultados apontam o uso de estratégias que envolvem relações de troca entre o profissional de saúde, a criança hospitalizada e seus familiares, as quais podem ser mediadas por atividades lúdicas, pela música e pela leitura de contos infantis. Compreendem também o uso da própria arquitetura como forma de proporcionar bem-estar à criança e sua família, além de facilitar o desenvolvimento do processo de trabalho dos profissionais de saúde. Conclusão: É necessário investimentos em pesquisas e publicações acerca da temática, para que a Política Nacional de Humanização não deixe de existir e para que as estratégias apontadas neste estudo não se configurem em ações isoladas e desarticuladas de uma política de saúde.


Criança hospitalizada
; Humanização da assistência
; Ambiente de Instituições de Saúde
; Enfermagem pediátrica
; Revisão

Introduction

Health facility refers to the treatment provided to the physical location, social aspects, professional setting and interpersonal relations, directly involved with health care, which should, therefore, provide a welcoming, resolute and human care. Through health facility construction, it is possible to qualitatively advance the debate on humanization, because its conception requires both the enhancement of medical technologies that make up health services, aesthetic or sensitive components learned by the sense organs (such as brightness, noise and environment temperature), as well as the interaction between users, managers and workers(¹).

Thus, the consolidation of humanization requires commitment to health facility and its three guiding principles: constructing settings that aims comfortability, the production of subjectivities, and that can be used as a tool facilitating the work process. The first principle, comfortability, covers elements that act as modifiers and qualifiers of the setting, such as color, smell, sound and lighting. The combination and balance between these elements can create welcoming ambiance to users and workers, significantly contributing to the health production process. The second principle, the production of subjectivities, involves the gathering of individuals - users, managers and workers - those that use the setting to act and reflect on the work process and establish actions from the integrality and inclusion. The third and last principle, the setting used as a tool facilitating the work process goes beyond architecture, seeking to establish the desired environment by users and healthcare professionals(¹).

It is noteworthy that when constructing health facilities, one should know and respect the values ​​and characteristics of the place in which they are acting, so as they effectively contribute in promoting well-being and dispel the myth that the hospital environment is cold and unfriendly. If the setting in question is a pediatric unit, the child, beyond dealing with the discomfort caused by illness, will be away from his/her family, friends and school. Conducting numerous painful and invasive procedures, these facts will contribute so that children loose references about their daily life, their culture and their desires, making the hospitalization experience traumatic(²-⁴).

A study conducted in the pediatric unit of the Clinical Hospital of San Borja Arriarán (HCSBA)(⁴) in Chile revealed that 50% of the children presented emotional changes during hospitalization, being pointed by them that the diagnostic and treatment procedures, as well as their parents’ and friends separation, were the environmental factors that most affected them. The study also showed that children who are hospitalized in poor hospital facilities were more likely to being emotionally affected(⁴).

A research conducted with caregivers of patients attended in a pediatric hospital, seeking to identify the needs and questions for the setting adequacy, found that care, medications, organization and hospital improvement are essential factors to humanization(⁵). According to caregivers, if they could build the hospital, they would prioritize setting adequacy and the improvement of environmental comfort (ventilation, lighting, colors, privacy), in addition to the expansion and higher quality of care, as the organization, information and infrastructure. This research showed, therefore, the importance of setting geared towards children as aid in the healing process(⁵).

Even with the existence of pediatric units, specific for children hospitalization, the hospitalization negative experiences are not eased, often because the activities that take place in these environments are directed to meet the needs brought to the child’s condition, often neglecting their needs to play, learn, explore and communicate with other people of the same age(⁴). Considering that when the setting is designed for the child’s hospitalization, it may be perceived positively(⁵), constructing welcoming health facilities is imperative, structured to assist the child integrally, providing the best way to face hospitalization.

Aiming at making the pediatric environment less traumatic as possible and support the practice of health professionals in building welcoming facilities, this study aimed to identify and analyze the production of knowledge from the perspective of health facility, i.e. strategies that health institutions have implemented to humanize the care of hospitalized children in the pediatric unit.

Method

This is a qualitative systematic review, method used to synthesize the knowledge of research and methodologies used in primary studies, whether quantitative or qualitative, through descriptive analysis(⁶). It constitutes an important resource for improving care, since it amplify the capacitation of health professionals due to knowledge synthesis about a specific subject in an objective and reproducible way. Thus, as we highlight evidence about praxis, the use of research findings in nursing practice is encouraged(⁷).

For the implementation of this systematic review, we used the seven steps proposed by the Cochrane Handbook(⁸): protocol development - a guide for researchers to follow the same steps to make the selection of studies; formulation of the question that will outline the research; search and selection of studies; critical appraisal of the studies; collecting and synthesizing data.

The review was guided from the following question: from the perspective of health facility environment, which strategies have healthcare institutions implemented in order to humanize the care of hospitalized children in the pediatric unit? In order to elucidate and lend credibility to the findings, we carried out a double search for studies by different researchers, in October 2013, in the Virtual Health Library - Nursing (VHL Nursing), using all national and international databases available, and in the Scientific Electronic Library Online (SciELO). The search was carried out using the keywords Health facility environment, Humanization of Care, Pediatrics and Hospitalized Child, according to the classification of Health Sciences Descriptors (DeCS) and refined using the Boolean operator AND, following the strategy presented in Chart 1.

Chart 1

Search results of studies in electronic databases - Rio Grande, RS, 2013

For the selection of studies, we established as inclusion criteria: original research; published in Portuguese, English or Spanish; with abstract, allowing the verification of consistency with the objectives of the study; published between 2003 and 2012; with availability of online text in full and free for download. The historical period chosen is justified by the interest in cover research published from inception to the current implementation of the National Policy of Humanization, in which health facility environment is one of its principles.

From the inclusion criteria, the selection of studies proceeded in three steps: 1) exclusion of repeated publications in databases; 2) reading of the title and abstract of remaining publications, excluding those that did not meet the objectives of this review; 3) critical appraisal of studies through full reading, followed by the preparation of summary charts with data.

Data are presented in two steps: 1) selection process of studies; and 2) descriptive analysis, including the following aspects: journal and year of publication of study, descriptors or keywords used, training of authors, methodology (type of research, subjects/sample, data collection and analysis instrument) and strategies highlighting humanized care of hospitalized children.

Respecting ethical issues and principles of authorship, the selected study are cited and referenced throughout this study, as provided in Law No. 9,610 of February 19, 1998, which deals with Copyright(⁹).

Results

Following the characterization of the included studies and strategies that health care institutions have implemented to humanize the care of hospitalized children in the pediatric units from the health facility environment perspective will be presented.

Characterization of the included studies

Through our electronic search, 193 publications were found: most in VHL Nursing, 189 (97.9%); in the databases: Latin American and Caribbean Health Sciences (LILACS), 73 (37.8%); Nursing Database (BDENF), 58 (30.1%); Medical Literature Analysis and Retrieval System Online (MEDLINE), 53 (27.5%); IBECS, 2 (1%); Coleciona SUS, 2 (1%); CENTRAL-Register of controlled trials, 1 (0.5%); and located in the Scientific Electronic Library Online (SciELO), 4 (2.1%). Of the total, 140 (72.5%) were excluded for not meeting the inclusion criteria for this study, thus 53 (27.5%) studies were pre-selected.

In the first stage of selection of studies, 10 publications were excluded due to duplicity in databases, reducing our sample from 53 to 43 studies. From reading the titles and abstracts, publications that did not meet the objectives of this review were excluded, reducing the number of selected studies to 15 to the second stage (Figure 1).

In the third step, in order to analyze included studies, it was found that 10 studies were published in nursing journals, namely: Journal of Pediatric Oncology Nursing, Investigación y Educación en enfermería, Revista Enfermagem UERJ, Online Brazilian Journal of Nursing, Escola Anna Nery Revista de Enfermagem, Revista Latino-Americana de Enfermagem, Texto & Contexto Enfermagem. Seven were from Brazil, two from Colombia and one from the United States of America.

The remaining studies were published in journals of child’s health, pediatrics, education and health, which are: Journal of Child Health Care, Einstein, Pain Magazine, Interface - Comunicação, Saúde, Educação. Three were from Brazil and two from England.

Figure 1

Flow diagram of the study selection process – 2003 to 2012

Whereas the proportion of studies published per year, there was an increase in 2009 (seven studies), followed by a decline in publications related to the theme, which culminated in the absence of publications in 2012 (Figure 2). Regarding keywords used for indexing the topic, it was showed the use of 26 descriptors, highlighting Humanization of Care (seven studies), Pediatric Nursing (six studies), Hospitalized Child (four studies) and Pediatrics (four studies).

Figure 2

Distribution of included studies by year of publication-2003-2012

On average, studies presented three authors, most of whom had academic training in Nursing (31), Architecture (5), Psychology (3), Medicine (3), statistics (1), occupational therapy (1), social sciences (1), Law (1), and Philosophy (1). Only one study did not have nurses among the authors.

Study samples showed great diversity in number and characteristics, ranging from 2-129 subjects, with a focus on hospitalized children, in the health care team and/or nursing staff, and/or caregivers and/or reading mediators. The setting of research development included four countries, especially Brazil with 11 studies; followed by the United States of America and the UK, both with 2 studies.

The 15 analyzed studies were the result from the search, 10 with a qualitative approach, 1 with a quantitative approach and 4 with a quali-quantitative approach. Data collection consisted of tools such as interviews, observations, focus groups, scales, questionnaires, documentary analysis, including records of the professionals in patients chart, standardized instruments (Child -Teen Self -report PedsQL™, Parent Proxy Report e Child-Teen Self-report), in view of the proposed research objectives. Likewise, the data analysis was according to the approaches adopted in studies, using abstractions of subject, content, or theoretical, beyond the use of the Collective Subject Discourse and softwares such as Statistica and Excel.

Regarding the limitations of the studies, only one study made them explicit, demonstrating the ethical commitment of researchers with consumers of research, enabling adjustments and restatements for future replication of the study in other contexts. Moreover, the majority referred to the approval of the study by the Ethics Research Committee and the use of a Consent Form.

Humanization strategies of Pediatric Units through the health facility environment

The need to humanize the health facility environment and improve health care prompted efforts to alleviate the daily life of hospitalized children. The studies analyzed pointed to strategies that maximized the exchange between health professional, hospitalized children, their families as well as among health professionals themselves. They are: use of leisure practices; music; reading mediated by fairy tales; proposal of new ways for the reconfiguration of nursing work and coordination between the teams; attitudes that give character to the humane care; construction of shared care with family; pain assessment and rational use of analgesics; architecture use to provide social interaction and privacy to hospitalized children and their families; beyond the child’s participation in the choice of topic, color and art that composes the pediatric unit. Chart 2, below, presents the description of the analyzed studies in relation to the title, reference, year of publication, country, study design, number of participants, interventions and outcomes/contributions of the study to the pediatric humanization health facility.

Chart 2

Description of analyzed studies, 2003 to 2012 – Rio Grande, RS, 2013

Discussion

Based on the results, it was found that the search for strategies that humanize the hospital environment for child care have been the focus not only in nursing journals, but also in specific journals of child’s health, pediatrics and education and health. From the 15 studies analyzed, 5 were published on international journals and 6 were indexed on the Web of Knowledge and cited by the Journal Citation Report (JCR)(⁶). It is noteworthy that, of the total, 10 studies that were published in nursing journals, only 3 were international journals and two journals were indexed in Web of Knowledge and cited by the JCR. It is evident, therefore, that there is need of nursing journals to invest in editing systems that allow dissemination of the results of research with significant impact for the National Humanization Policy (NHP) gaining visibility and consolidation in the field of health sciences internationally.

By analyzing the year of publication, it was observed that since the development of the NHP, the topic got more evidence on the quantitative works in 2009, when we held the 2nd National Seminar of Humanization, whose aim was to gather and provide visibility to the successful initiatives in the area and discuss the transformative capacity of health practices and management. However, thereafter, we had a decline, culminating with the absence of publications in 2012. Evidencing a reduction or even disinterest of researchers to investigate the humanization of the hospital environments, since there were no events nationwide that encouraged the publication of new research.

Considering the descriptors used for indexing studies, it is emphasized that the use of these, exceeded the use of keywords, a feature that facilitates the search, besides that, we point out that studies consulted specifically reflect the theme under study. Regarding authorship, seven studies included coauthors of several professional areas, demonstrating consistency with the assumptions of humanization, which necessarily involve different sets of professionals who work to build the health facility as a setting for reflection. Thus, a variety of approaches and understanding of the institutional and professional realities are contemplated, with a view to creative solutions to challenges encountered and consequently improve the care of hospitalized children(¹).

Through the study design, predominantly qualitative, and subjects investigated, it appears that the main focus of researchers have been the perception and experience of hospitalized children, the health team and/or nursing, caregivers and reading mediators. The fact that most of the studies used a qualitative approach revealed that the theme of humanization of the hospital environment, with a focus on pediatrics, have been explored and detailed, making some of its aspects well-defined, and allowing the use of this approach by the researchers to assess relationships of cause and effect, or effectiveness of a strategy(²²). Moreover, other researchers combine both approaches to abstract different facets of a reality and add strength to the argument and the quality of knowledge production.

Methodological approaches used in the studies show the trajectory of knowledge production about health facility. Initially releasing the NHP and exploring experiences, reaching a moment of monitoring and evaluation of the strategies used for consolidation, leading to the need to analyze the process of implementation, results and impact; but paying attention not to make simplifications or reductionist and decontextualized analysis(¹). Therefore, the need to produce new levels of knowledge about the humanization of the hospital environment emerges, through the use of mixed or multiple methods, combining qualitative and quantitative approaches, enabling new insights of perspectives(²³) on the understanding that support better child care.

The strategies identified in the studies present contributions that transcend the well-being of children, encompassing relational aspects between the health care team, the child and family. Regarding the use of leisure practices in pediatric care, it is emphasized that the toy, music and reading, although a distraction to the child, which minimizes the stress of hospitalization, provides relaxation and tranquility. Thus, these actions are configured as therapeutic interventions that facilitate interaction between children and staff, generating a joyful, serene atmosphere, contributing to the quality of human relations as necessary to provide nursing care(³,¹⁵-¹⁶,¹⁸,²⁴).

The studies were analyzed considering the everyday in pediatrics, in which care is built through interdependence which establishes the relationship between the health care team, the child and family and showed how imperative it is to value and focus forces to relations that culminate in protagonists subjectivities production and responsible for care(²⁵). Accordingly, we discuss the proposition of new ways for the reconfiguration of nursing work in such a manner that provides the adoption of a participatory management, which promotes dialogue and integration with users and other categories of professionals working in care for children(²¹,²⁶).

Moreover, the importance in having the material resources (including the architecture itself) and humans to better assist the hospitalized child are highlighted. We also recommend the active participation of the child in building the facility by adding personal accessories such as cushions, paintings and carpet, in order to configure the pediatric unit in a home away from home(¹²-¹³).

Nevertheless, there is a gap when it comes to strategies aimed at improvements in the work process and well-being of health professionals as a way to humanize the pediatrics environment: low motivation, lack of commitment and initiative of health professionals and lack of resources for the performance of the strategies(²). The absence of these elements seems to reflect on barriers to health facility environment.

For their promises to the health facility environment in fact take place, the adoption of more humane forms of care are imperative, both for individuals and for health professionals. In this sense, developing more humanized standards to the professionals refers to the improvement of working conditions and assistance; more humanized institutional relations between employees and supervisors, among their own colleagues and people with different backgrounds and responsibilities(²⁷).

Only with the appreciation of different subjects involved in the health production process of health-responsibility between them, it will stimulate solidarity bonds and collective participation in the humanization process. Therefore, it is essential to raise the awareness of managers of health services to the ideas proposed by the health facility: building an environment that fosters interpersonal relationships and provide welcoming, human and resolute assistance, considering some elements that functionally act as catalysts for new experiences(¹).

The strategies found offer subsidies to health professionals so that they may replicate them, expanding and improving their reality. However, it is noteworthy that in creating these health facilities environment, we should know and respect the uniqueness of the institutions, so we can compare and evaluate if the use of the strategy will result in benefits(¹).

Conclusion

This study found that since the development of the National Humanization Policy (NHP), health institutions have implemented strategies to build welcoming and harmonic health facility environments that contribute to improve care of hospitalized children in the pediatric unit. Such strategies involve relationship exchanges between health professionals, hospitalized children and their families, which may be mediated by leisure activities, music and reading of fairy tales. Also, understanding the use of the architecture itself as a way to provide well-being for children and their families ease the process of work development of health professionals.

The strategies found in this study helped to improve the care of hospitalized children, showing that health facility is a principle for the humanization of the pediatric unit, acting sensibly in the restructuring of the health production process.

Whereas the decline in recent years and little quantitative expression of publications on the topic of humanizing the pediatric environment occurred, we highlight the need for investment in research and publications. Otherwise, NHP will become invisible and the strategies identified in this study will represent isolated and disjointed actions of health policy.

As gaps to be investigated by future studies, we suggest the investigation of strategies that professionals working in pediatrics as a focus for constructing pleasant ambiance and consequent deconstruction of paradigms that shape this setting as cold and unfriendly. It is also necessary to recognize the manager as implied in the subject of health production process, which must be the subject of research that attempts to improve the care of hospitalized children. Therefore, it is imperative to be alert to the process of implementation of the NHP, outcomes and impacts, thereby recognizing new requirements that are being created in the pediatric environment.

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Publication Dates

• Publication in this collection
  June 2014

History

• Received
  11 Oct 2014
• Accepted
  20 Mar 2014