HUMANIZATION IN NEONATAL INTENSIVE CARE UNIT: A REVIEW

Abstract

In Brazil there is a high rate of newborn preterm infants, a fact that places child mortality into the spotlight, thus becoming a major public health issue. However, hospitalization in the Neonatal Intensive Care Unit introduces the baby to an inhospitable environment. Given that, humanization claims for an association between the technical and scientific assistance with respect to individual-oriented actions, caring for the baby and his/her family, emphasizing care for a better development of the newborn, always attempting to improve their quality of life and survival. The aim of this study was to present a review of the literature regarding the importance of humanized care in Neonatal Intensive Care Units. Thus, search was conducted to review books, dissertations, journals and scientific articles, based on the following databases: LILACS, MEDLINE, PubMed and SciELO. After analyses of the most relevant articles, the results showed that humanization, that is, the caregiver and cared being relationship should have as a common thread sensitive listening skills to build a practice that is able to combine the best technology available with the promotion of acceptance and emotional attachment, providing the development, growth and recovery of the newborn in a satisfactory way, minimizing the harmful effects caused by hospitalization. It is concluded that when assistance is to be based on comprehensiveness and respect for life, technological breakthroughs with the indissolubility of both mother and child, creating a bond of trust between family and staff, fundamental factors for the recovery of high-risk newborns.

Keywords: Humanization of Assistance; Child; Child Care

Introduction

Each year there are 20 million newborns (NBs) in the world with low weight, many as a result of a premature birth. This contributes substantially to the high neonatal mortality rate still present in various regions, especially in poor countries.¹

In Brazil, since the beginning of the 1990s, neonatal mortality has become the main cause of child mortality, mainly due to the proportional reduction of post-neonatal deaths.²

Nowadays the World Health Organization (WHO) adopts the classification related to gestational age of the newborn as follows: preterm is anyone born with less than 37 weeks of gestational age (or less than 259 days of gestation) term is anyone born between the 37^th week and 41st week and six days of gestation and post term is anyone born at 42 weeks or later.^1,3

Newborns (NBs) preterm (also called premature) can be classified into three groups: late preterm is a gestation of 35 to 37 incomplete weeks, moderate preterm is a gestation of 31 to 34 full weeks and extreme preterm of less than 30 weeks of pregnancy.⁴

Premature infants often require hospitalization for several days or months in a Neonatal Intensive Care Unit (NICU) where they are kept in an incubator for special care, being exposed to hostile stimuli such as pain, stress, bright light, loud noise, invasive, painful and unstable temperature.⁵

The preterm infants are forced to interact in a new environment to which they are not fully adapted and become more susceptible to several neonatal complications.⁶ Moreover, the lack of pleasurable stimuli in early life can lead to a difficulty of sensorial adaptation. The lower the weight and gestational age at birth, the greater the impairments of neurobehavioral development of the preterm infants. Their systems, especially the nervous one, are not yet mature at birth, and are not exposed to motor and sensorial experiences, making difficult the interaction of the NB with the environment.⁷

The child is a unique being, full of potential, living a number of changes that will be decisive in their healthy growth from womb life to birth.⁸

The Neonatal Intensive Care Unit of the Environment (NICU) provides the newborn an experience quite different from the uterine environment, since the latter is ideal for the fetus growth and development since it possess distinct characteristics, such as pleasant and constant temperature, softness, warmth and filtering and reduction of extra uterine sounds.⁹

Hospitalization in Neonatal Intensive Care Unit introduces the baby in a harsh environment, where intense exposure to hostile stimuli such as stress and pain is frequent. In the neonatal unit in question there is constant noise, intense and continuous light and invasive clinical procedures.¹⁰

Despite the great importance of NICU for sick neonates, contradictorily, this unit, that should ensure children’s well-being in all its aspects, stands out as an agitated, impersonal and even fearful environment for those who are not suited to their routines. Such an environment is full of strong and constant light, noise, temperature changes, disruption of the sleep cycle, as they are required repeated assessments and procedures, often leading to discomfort and pain.⁹

Baby care should be structured and organized in order to aid a population subject to risk. Therefore, there must be material resources and people that are skilled and able to ensure strict observation, besides suitable treatments to NBs that present pathologies capable of causing death or sequelae that interfere in their development.¹¹

about the concern with the humanization of care in a Neonatal Intensive Care Unit should not be restricted to the health act itself. To consider the improvement of care quality at hospitals means to change management practices, improve infrastructure and affirm the sense of commitment among staff members.¹²

A baby’s survival depends on a highly specialized and that poses a number of challenges for the infants and their parents. Humanization represents a set of initiatives aimed at promoting health care, being able to combine the best technology available with promoting acceptance, ethical and cultural respect to the patient, as well as to create a conducive workplace that is favorable to the proper technical exercise that also aims to satisfy health professionals and users.¹³

The humanization of neonatal care advocates several actions proposed by the Ministry of Health, based on Brazilian adaptations of the Kangaroo Care Method for low-weight newborns (LAMY; GOMES, 2003). These aim at the respect for individuals, the assurance to technology that provides security to the newborn and the sense of belonging of the baby and his/her family, with emphasis on care focused on the development and psyche, seeking to ease the mother-infant bond during their hospital stay and after discharge.¹⁴

The current hospital humanization policy, combined with technological advances and the development of policies aimed at better conditions of recovery of premature newborns, has made it possible for parents to be able to closely monitor their children. In this context, the family is essential for the premature infant’s introduction in society and constitution as a being, having his/her participation improved, becoming an integral part of the group of people responsible for the recovery and healthy development of premature infants.¹⁵

To separate a mother from her baby before she is ready to share him/her with other people may jeopardize the mother’s feeling of competence and importance towards the baby.¹⁶

In an attempt to reduce the effects of this separation, there have been programs and methods that seek to ensure the opportunity of mother and child to be together after childbirth or other hospitalization cases so that the development of their bond is not impaired. Among the programs, one that can be mentioned is rooming, which aims to ensure the mother the right to remain with the child during hospitalization; and the one of breastfeeding, that strengthens the bond between mother and NB and ensures better physical development for children, and lastly, the kangaroo care, defined by the Ministry of Health (1999) as a “type of neonatal care that involves an early face-to-face contact between the mother and the low-weight newborn, which happens gradually, and for as long as they both understand to be pleasant and fulfilling, thereby allowing wider participation of parents in the care of their NBs”.¹⁷

The NICU humanization must be based on individual care, comprehensiveness, and on respect for life. It depends on the relationship between the caregiver and the cared being. It is about paying attention, taking responsibility, nurturing, respecting the each and every one’s singularities, and especially promoting a wholesome care of the baby and family.¹⁸

Despite the great effort that professionals might be investing to humanize care at the NICU, this is an arduous task since it demands sometimes individual attitudes against an entire dominant technological system. And many times the dynamics of working in a NICU does not allow moments of reflection on their work process.⁹

The effective presence of the staff with a sensitive listening is as important as the technical procedure, since not always the expertise works so well in the face of stress. Only by observing, listening and feeling the newborn and his/her family as a whole, we will be assisting and understanding the essence of human care.⁹

Facing this new reality, many professionals, including physiotherapists, consider important to highlight the benefits of humanized care for the development of newborns. Physiotherapy in Intensive Care Units can be considered a new therapeutic modality, which gives the NBs stability of respiratory and heart rate, blood pressure and oxygen saturation, besides deepening the interaction between children and the environment through visual, auditory and tactile stimuli, leading to obtain responses to near normal range and inhibiting learning abnormal movements and postures.¹⁹

The physiotherapist, as well as other neonatal professionals, should base their service on comprehensiveness and respect for life. The common thread that ties the relationship between the caregiver to the cared being should be bound by sensitive listening skills, attempting to build of a care practice able to merge the best technology available with the promotion of receptiveness and bond, further benefiting high risk newborns.²⁰

This study aims to provide a review of the literature on the importance of humanized care in Neonatal Intensive Care Units.

Method

Since this paper is a bibliographic review, books, theses, dissertations and scientific papers were used for research, based on the following databases: LILACS, MEDLINE, PUBMED and SCIELO, with articles published both in Portuguese and in English. The most relevant published articles in the literature on humanization in NICUs were selected using the following keywords: prematurity, humanization and Neonatal Intensive Care Unit, being included in this research original studies published between 1996-2010.

Discussion

After an analysis of the subject, the most relevant articles were selected, as follows:

The Neonatal Intensive Care Unit is one of the most specialized sectors in health institutions and in this restricted space there is a wide range of professionals, technologies and body of knowledge concentrated in one place. The assistance offered to newborns is diagnosis and therapy oriented in the search for biological recovery of the premature ones or the cure of the disease.²¹

The study on the work in health services reveals that the word ‘humanization’ can be understood as the way to see and understand the human being from a global view, seeking to overcome the fragmentation of care. One of the aspects involved in the practice of this nature is related to the way we deal with the others.²²

Humanizing essentially consists, in making a practice beautiful, as much as it deals with what there is of most degrading, painful and sad in the human nature: suffering, decline and death. According to these authors, the key point of the humanization practice is to enhance the management between an already structured and known technical-scientific care, with a care practice that incorporates the need and acceptance of the unpredictable.²³

The humanization practice in the health care sector goes beyond holding technical-scientific competence, but it also incorporates the development of interpersonal relationships that find its roots in the respect for life, solidarity and sensitivity of perception of the unique needs of the involved individuals.¹²

To Humanize is to embrace the need for rescue and articulate inseparable aspects: feeling and knowledge.²⁴

In the study on hospital care humanization of premature infants, the author reported that the quality of life maintenance of babies determined the search for personalized customer service driven to the full development of the newborn and his/her family. There, the father and the mother have been included in the work process, aiming to provide sensory stimulation to the neonate, besides establishing bond, attachment as well as previously introducing them to home care.²¹

The actions of humanization for baby care and family demonstrates the attempt to modify how care has been developed. However, it is the individual behavior that needs to be discussed by the communities of professionals, making room for projects that enable collective and far-reaching actions, but as respect for parental rights of each family that has a child in NICU.¹⁷

The humanization of a Neonatal Intensive Care Unit starts with the participation of a multidisciplinary team of nurses, neonatologists, neurologists, psychologists, speech therapists, physiotherapists, occupational therapists, and not to forget the fundamental participation of the family.²⁵

In the neonatal environment, humanization stands for a set of initiatives aimed at a health care able to combine the best technology available with the promotion of acceptance, cultural and ethical respect toward the patient.²⁶

Humanization cannot be thought without simultaneously considering the issue of education as a priority in an agenda of change. That is, what we see today in the field of health care is that education is reduced to computer and instrumentalization knowledge.²⁷

It is necessary to invest in training and sensitivity of NICUs healthcare professionals, not only promoting technical training, but also increasing their sensitivity to plan an assistance based on the foundations of humanization and comprehensiveness of care so as to provide the baby and the family a peaceful and welcoming environment, despite being hospitalized.⁹

The humanization of the NICU care is to be based on individual care, integrity and respect for life. It is dependent on the caregiver and cared being relationship. This construction of the notion of comprehensiveness should not become a concept only, but indeed a care practice that deals with the value of life, respect for others and with the differences between human beings. Therefore, the profession exercise of NICU health care professionals (physiotherapists included) should target the family and child’s needs, encouraging their affective attachment in caring for their offspring, an important element for their recovery.²⁸

Conclusion

The technology apparatus at a NICU loses its meaning if it is not integrated into the humanization process of care and if it is not linked to the ethical principles for life maintenance and value.

The NICUs cannot be only a physical and functional infrastructure environment. It should also be a place where the human feelings, the attention to family and solidarity are present. A team committed to humanized care for the baby is necessary, that is, looking, listening to and feeling him/her family as a whole. It is also important to provide humanized care for the family because only then we will be understanding the value of human care.

Humanized care is intended to bring comfort to the newborn, improving their quality of life and survival, since it can prevent the onset of multiple sequels common to prematurity, once technological resources can reduce mortality, but not always reduce the hospital neonatal stay time.

Humanization leads to a closer contact to a more human relationship between the baby, family and even to neonatal professionals themselves. The hospital is not an ideal environment for newborns, though many need this type of assistance, especially the premature ones. Nowadays professionals are increasingly technical wise, leaving a gap to create a more suitable space for humanization, not treating newborns as numbers. It is necessary to show that although they are fragile and small, first, these babies deserve respect as human beings.

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