Comparative Analysis of Humanization Present in Nursing Assistance Between Brazil and New York : a Lived Experience

Method: The study was based on the exchange linked to the Bounce project, funded by the US government, which took place between May 21 and June 20, 2015, and was attended by 8 (eight) FIP scholars from Paraíba, Brazil. Through the study it was possible to perform a comparative analysis between the Brazilian hospital reality, seen in the FIP curriculum internship field, through the Deputy Janduhy Carneiro Regional Hospital, located in the municipality of Patos Paraíba, Brazil, and the North American, evidenced by the visit to the hospitals of Hudson and New Paltz.


Introduction
The humanized hospital is one that contemplates in its physical, technological, human and administrative structure, the valorization and respect for the dignity of the human person, be it patient, family or the professional who works in it, guaranteeing conditions for a quality care.
The humanization of this environment and for the health care does not materialize if it is focused solely on external motivational factors or only on the user.Humanization is a broad, time-consuming and complex process, to which resistance is offered, because it involves behavioral changes that always arouse apprehension and fear.Humanizing the work environment also involves interacting with the colleague in a welcoming way, valuing their knowledge, skills and competences, looking at the other in their fragilities and needs, under the lens of ethics and solidarity, and betting on interdisciplinary networks of professional relationship [1].
In Brazilian reality, nursing professionals are the ones who spend more time near the patient, a role that goes beyond the specific care of the profession, nurses listen, talk, and they are a little psychologist, friend, companion, and sometimes even clown if it is necessary.Its manual work makes that this contact between patient and professional increase, making a humanized work, leading to the improvement of both involved in the caring process: the patient, for being cared for with dexterity, dynamics and responsibility, and the nurse, which makes their work more rewarding, fun and enjoyable.
In the United States of America (USA), the country with the greatest existing technologies, the nursing team performs the work in a mechanized way; Usually appliances take possession of the nursing actions, making the professional doesn't need to be close to the patient at all times [2].
Is evident that the technical-scientific efficiency is extremely important for the success of the actions developed in the health services, but if it is not accompanied by essential human values and principles in the relationship between professionals and users, it will be insufficient for the existence of quality in health care [3].
Nowadays, with the digital inclusion present in health as a whole, in the need to work together with a tangle of equipment used in care, it is necessary that the nurse understands the importance of living with the patient's pain and feelings .It must be learned to define and utilize technology without diminishing or negating the side of the human soul that cares for another human soul.
The need to work the humanization present in nursing care came through the experience lived in an exchange involving some North American cities and our field of curricular internship, where I could observe similarities and differences in some aspects that characterize this assistance.
Knowing other realities, I saw the opportunity to us to analyze the best possible way we have, and to compare possible difficulties in providing a humanized assistance between both places.In this way, we can identify improvements for our service, as well as review and value our positive points, which are usually ignored and go unnoticed.Faced with this context, some questions have arisen: Could we unite the potentialities of both countries and put into practice better quality assistance?What successful experience could we add to our academic and professional practice?This study allowed to obtain a greater knowledge about the nursing care provided in a first world country, describing its assistance model, the use of its technologies, working hours, and the characteristics of its hospital environment, always comparing the country that obtains one of the largest financial centers on the planet with Brazil.It was possible, through the results, to describe ideas for our health system, joining the positive points of the nationalities, providing improvements for the entire population, as well as for the nursing team, who can enjoy better working conditions.
The purpose of this study was to report differences in the humanization present in the nursing care practice at a hospital level between a Brazilian city and two cities in the United States of America, as well as to show potentialities and fragilities about the humanization present in the care provided in both cities frequented by Students of Patos Integrated College -FIP.

Method
This work is a descriptive study, based on an experience report, elaborated from the exchange experienced by eight (8) academics from Patos Integrated College, Paraíba -Brazil, in which 04 (four) were students of the Bachelor's Degree in Nursing and 04 (four) from the Nutrition Course.The students were selected according to two stages: written test in English, with questions that asked the interest for the project, and interview with coordinator of each course, respectively.
The exchange took place between May 21 and June 20, 2015, totaling 29 (twenty-nine) days.The students were assigned to participate in a project called Bounce, which is an American program aimed at obese children, whose purpose is to propose strategies and methods of how to work on weight loss in childhood, thus trying to obtain a healthy life future.The name Bounce, means "jump", through the term, was created an acronym indicating steps to combat obesity.B: behavior modification; O: optimization of metabolism; U: union with the family; N: food notation; C: counting steps; and E: elimination and diet.The project, which began in the city of Oswego, New York, with 17,954 inhabitants, also involved fathers, mothers and children's families.
The project was funded by the US Government with the goal of reducing childhood obesity, which is growing in all US states.It was thus able to provide us with a better preparation with this specific group, in order to rethink our behaviors and clinical management against childhood obesity.Not only as a theoretical basis or source of information, it served as a training so that we can continue with this work here in Brazil.Through this, we obtained the opportunity to know the hospital reality of two cities in New York: Hudson and New Paltz.
Hudson is a city located in the US state of New York, its area is 6 km², its population is 7,524 inhabitants, where we visited Columbia Memorial Health, general hospital, and specialized in emergency care, orthopedic and plastic surgery.New Paltz is a New York state village in the United States, part of Ulster County and the Municipality of New Paltz, has an area of 4.6 km², a population of 6,034, where it was possible to visit The Kingston Hospital, which has oncology, neurology, cardiology and other types of services, similar to Primary Care here in Brazil.The geographical division of New York is made by spaces called islands, these islands are small towns belonging to the cities.The city itself has 29 million inhabitants and the hospitals also cover about 15 neighboring cities/islands.
Given the experience lived, it was possible to make a comparative analysis between the American reality and the national reality, highlighting the humanization present in the nursing care offered in foreign hospitals and in the hospital that is used as a curricular internship field by Patos Integrated College -FIP, Deputy Janduhy Carneiro Regional Hospital, located in the municipality of Patos -Paraíba, in which it is a reference for 50 municipalities in Backwoods and High Backwoods of Paraíba, dispensing care for more than 180,000 inhabitants, including some of the RN, PE and CE states.
Patos is a Brazilian municipality in the state of Paraíba, located in the Patos microregion, in the mesoregion of Paraiba Backwoods.Distant 307 km from João Pessoa, its headquarters is located in the center of the state with road vectors interconnecting it with the whole of Paraíba and providing access to the states of Rio Grande do Norte, Pernambuco and Ceará.According to IBGE (Brazilian Institute of Geography and Statistics), in 2016 its population was estimated at 107,067 inhabitants.Patos is the third pole city in the state of Paraíba, considering its socioeconomic importance.
It is noteworthy that, contrary to the Brazilian reality, all American hospitals are private, with this it was noted a high level of technology, well-paid and valued professionals, an organized operational flow within hospitals and services provided to the patient and his family of high quality.
Based on the objectives adopted, the experience report was described and analyzed, where it was then possible to compare the humanization present in nursing care between a Brazilian city and two of New York, in the United States of America.After the description of the experience lived, the discussion was based on the relevant literature.

Results and Discussions
The experience lived through the exchange gave me great professional and personal growth.I was able to observe in a critical way the assistance provided in both countries, making it possible mainly to compare the potentialities and weaknesses of the health service, where I was able to guide points of improvements that can be implemented in local health services.
One of the basic premises present in the supporting discourses to the internationalization of higher education is its ability to promote multiculturalism, through the constant interaction of people from ethnic and cultural origins of the most diverse.This exchange of experiences triggers in the educational institutions the development of more critical and reflexive curricula, seeking to embrace the different visions about the world, proper to the cultural diversity of its students [4].
The exchange achieved great success, given the opportunity to observe some of the values present in our service, considered as surprising, but which, for many, go unnoticed.Despite the many weaknesses that our health system presents, we are privileged to enjoy it.
The American care model adopted is the private one, where every health service available to the population has to be funded by the patients themselves and/or their families.Due to this, they receive with great quality the service that financed, it has of promptness in the attendance and easy access to exams and important procedures.
Unlike the Brazilian reality, we adopted SUS (Health Unic System), a totally free service, with some private partnerships for improvements.In this reality, the limitation of resources for the health system in Brazil provides large queues, delay in care, overcrowding of hospitals and even absence of workers due to lack of hiring.The great advantage is access to the poorest population, who do not have the purchasing power to pay for certain treatments (including organ transplants), as well as providing individuals with specialized services, procedures of high complexity and the right to medications provided by public agencies.
With the construction of this model, Brazil expands the rights in health, consolidating, in article no. 196 of the Federal Constitution, the principle that "health is the right of everyone and the duty of the State", based on the principles of universality, integral care, preservation of autonomy, equality of health care, right to information, dissemination of information, use of the epidemiology to establish priority and community participation [5].
The universality is one of the fundamental principles of the Unified Health System (SUS) and determines that all Brazilian citizens, without any type of discrimination, have the right and access to health actions and services [6].
The professional practice of nursing depends on a consistent and healthy health system that allows the technical-scientific and humanistic development of the area.This because the professionals constitute the largest contingent of health professionals, acting in most of the care processes [7].
In the US, there are no nursing technicians, only nurses.Even so, the number of patients in the nurse's responsibility is much smaller, which reduces the risk of harm.Each nurse is responsible for 8 (eight) patients during daytime and 6 (six) during night time; Depending on the patient's problem/risk, a 24-hour nurse is available for a single patient.Faced with the small number of users in their responsibility, they obtain greater readiness in the attendance and great power of administrative resolution.However, their contact with the user is very small, mainly due to bureaucratic assignments, which makes their work mechanized.
In the reality of the Brazilian municipality, there are technicians and nursing assistants.The nurse is responsible, on average, for about 18 (eighteen) patients, and is responsible for manually filling out all paperwork, updating medical records, manually attending to all the needs the patients need, in addition to all the time spent on each one.With this hand-to-hand work, it is possible to diagnose problems that are not related to technology and only seen in the human eye, attending to the needs of the patient through a conversation, a smile, a look, demonstrations of attention and affection.
American health professionals are highly valued, such an appreciation is that within the hospitals themselves, the names designated to call the inhospital environments are of nurses who have made a landmark in the history of the place.Wages are decent and the workload is not exhaustive, thus increasing the quality of life of these professionals and improvements in the work done.It was observed that the American salaries turn around 3 (three) thousand dollars, which would give approximately 10 (ten) thousand Reals; In local reality, the salaries generally vary between 1 (one) thousand and 3 (three) thousand reals.
Brazilian nursing suffers great difficulties on a daily life, although it is a profession that demands a lot of responsibility, its work is often not recognized and valued.With the evolution of science and technology, the scope of nursing practice has become broad, ranging from individual care to patients in clinics and infirmaries, to the administration of health services and the management of problems at all levels of complexity [8].
Daily stress, excessive work hours and low wages are among the main difficulties encountered by professionals.Besides this condition perpetrated by the material and environmental situation plus the performance of unhealthy work; Another form of labor violence that is intensifying, especially with recent changes in the organization of work, is that linked to the burden and pace of task execution [9].
One favorable aspect to patient's recovery in the USA is related to the use of technology in health services.The ease, agility and practicality with which they deal with the equipment make the environment more dynamic and resolute, bringing results in the short term, improvements for the patient and facilities for the worker.
In many cases, the nursing professional usually sees technology as the main tool used in the care of the internal person.Frequently, the actions of this professional evidences aspects that show absence of concern with the humanization in care, transferring the focus of attention to technology as a priority [10].
It is worth remembering that care must be focused on technology, but also or essentially in the care of human needs, from the perspective of other factors that can influence the restoration of the individual's health.From that point, it is important to reflect on the extent to which technology will be characterized as a problematic factor for humanization [11].
In Brazil, we are gradually using more advanced technological models, an example of this are electronic medical records and computerized prescriptions that are slowly becoming reality, but which have been used for some time by the Americans.
Although we are not totally working with more mechanistic methods, it is noticed that the Brazilian nursing team is the one that spends the most time with the patients, being this a relevant characteristic, since the contact for the accomplishment of the procedures allows the patient to feel more secure and important, being able to contact them, ask questions, clarify their fears and desires.
What stands out our assistance is the human form with which we approach the patient, seeing it in a holistic way, valuing its particularities, observing every detail, without only seeing the disease, its procedures or its monitoring.Care goes beyond nursing care.Professionals stop, talk, play, listen, go from nurses to psychologists, and even social workers, doing a work in which it is possible to transmit love and dedication, leaving aside software, machines or other technologies, which greatly contribute to distancing the contact between patient and professional.
The nurses usually through this contact humanize their care acts more and more, they notice that their patients need a greater attention, attention given by the "human being", totally despised the robotic model.The concern with the next, is what makes us manage the rights of its users and workers.The interaction favors the exchange of knowledge, which goes beyond what is acquired through the books, it was noted that each day with the patient, that each encounter can serve as a key of great relevance to be able to comply with the true meaning of the word health.
In the 1990s, the Brazilian population was dissatisfied with hospital care in the country and there were a large number of complaints from hospital users.The seriousness of this situation led the Ministry of Health to elaborate the National Humanitarian Assistance Program (PNHAH), with the objective of promoting cultural changes in health services in Brazil, improving relationships between health professionals and users, changes In the professionals' relationships among themselves and in the hospital's relations with the community.The PNHAH presents a set of actions that aim to change the standard of care in hospitals [12].
Humanization in care is understood as a set of guidelines and principles that affirm the valuation of the different subjects involved in the process of health promotion: users, workers and managers; Support the promotion of the autonomy and protagonism of these subjects; Aim at increasing the degree of co-responsibility; The establishment of solidarity bonds and collective participation in the management process; The identification of social needs of health, users and workers; And the commitment to the environment, with the improvement of working conditions and service [13].
Changes in the logic of care in health services to improve the quality of care provided are increasingly necessary, especially in hospital services, whose specificities induce workers to position themselves technically, in an impersonal way.This position is due to structural deficiencies in the health system as a whole, the high demand for care, the fragmentation of care and the absence of principles and values that characterize humanization in care [14].
Humanization in nursing care aims to establish a relationship with the human being under their care through a vision of their integrality.This relationship is bilateral, involving at least two people (health professional and user) in their biological, psychological, spiritual, cultural and religious aspects.In this relationship, people are concerned with both the sickness components, related to the disease in question, and the health of the being, through experience, scientific knowledge, technology and critical sense.They are two human beings that meet, bringing to this relationship their fears, their doubts, their beliefs, their hopes, their life plans and their intentions [15].
Each day of exchange was experienced with great admiration, demonstrating how much knowledge is primordial for the improvement of services.In addition, it was possible to note with more relevance some landmarks between the two services, which, in turn, present significant differences.
Regarding the American workload for nursing professionals, it was observed that they only totaled 24 hours per week, maintaining a hospital routine of 3 shifts, 8 hours each.Thus, it allows them to provide quality care, not exerting exhaustive loads, minimizing errors, occupational stress, exposure to risks, among other problems.In addition to the workload benefit the health of the professional, these are also well paid, this being one of the most valued professional classes in the USA.
In contrast, the Brazilian reality indicates that the work of nurses can reach 40 hours per week, as is the case of some health services in Patos.These professionals are responsible for a large number of patients and do not receive decent wages for the execution of their work, thus necessitating the search for more than one job.In addition, they present physical, psychological, financial wear, and may even cause some errors during the work developed.
The Bill of Law No. 2295/2000 is in progress in the Brazilian Congress, which presents arguments that justify the 30-hour workday for nursing.By municipal law, it is already adopted in Patos.The 30-hour workweek is not to gain privilege, but rather to seek decent working conditions, thus offering better quality of nursing care.The importance and necessity of this claim have been recognized in health conferences, in the Legislative, in the Judiciary, by the media and by the entities representing professionals and users of health services [16].
The increased work rate implies physical and psychological energy consumption of these individuals, leading them to develop a stress scenario in their personal and professional life [17].
In particular, the nurses' performance is evaluated as a trigger for physical, emotional and stress exhaustion.This means that, in addition to dealing with unforeseen events, it is exposed to physical, chemical, biological and psychosocial risk factors [18].
Nursing is said to be one of the professions with a high level of stress in professionals.Specifically, nurses require extensive technical and scientific knowledge in their training, that enables them to act in different situations that are present in a hospital institution [19].
Is essential for the nursing worker to acquire full working and living conditions, a fact of fundamental importance for the execution of any activity, especially nursing, which focuses on improving the quality of life of the population [20].
Another point that drew attention in the North American reality were the physical characteristics of the hospital environment, being these cozy, comfortable and pleasing to the eye; they present different colors, leaving the white standard, leading to the improvement of the patient.Such measures aim to leave the hospital similar to a family environment, or even a home, so that the patient feels at home and softens their discomforts.
In American hospitals, it was observed that each room had its own utensils, individual to each patient, such as thermometer, sphygmomanometer, descartex, gloves, bathtub and even incubator.It has windows of glass, providing the solar clarity, walls of diverse colors, some presenting artistic paintings, decorations, paintings, wardrobe and televisions.
Inside the hospital there are shops, book sales, clothes, key rings, and a library where it can be used for their staff during their free time or when they have any doubts about certain procedures, something new that can be found and the professionals have not yet taken note of, can be used for research.It has a chapel, with standard of our Brazilian churches, with altar, several benches, images, sound, microphone and an illumination that transmits the lightness of the environment.
The nursing stations are quite large, have easy access to all rooms and, if necessary, can also be used by other professionals.It has an airy environment, all computerized, with few papers, signaled vertically and horizontally by signs and arrows in the middle of the corridors to make it easier for users to find it.
In the external areas of the hospitals I could find gardens, taken care of by the nursing team in the moments of rest and/or recreation; Also has a square with grass, benches, images of saints, stones, waterfalls between them representing a small waterfall, making the environment comfortable and very pleasant.Denominated as "Healing square", it is destined to the professionals and companions of the patients; When they are worried, discouraged, they go there to pray, to breathe, to make their requests and to thank.
I also found a cemetery, where only children were buried there, killed in one of the attacks of local history.They transformed the area into a place of comfort and learning, where the green of the plants, the grams and all its decoration with colorful drawings and children's characters, convey tranquility, and capacity for reflection on the problems.They question the fact that they face problems with their relatives in the hospital, problems not so great, compared with the injustice suffered by those children who left innocently.
Brazil also has great hospital environments, although the hospital under study appears to have an uncomfortable climate for its users, with totally white walls, many beds in a single room, and the possibility of extra beds.Due to the higher number of beds (6 per room), the patient's privacy is diminished, often impairing their rest.
The utensils are collective, worn by all patients, these are in the nursing station, supervised by the staff on duty.The station is small, gets paper accumulation, because the medical records are still up to date by hand, and the place is also used by other professionals.It has a single exit, distancing itself from some rooms, making work and access difficult.Inside the hospital, there is a small chapel, where people can direct and perform their prayers.
White walls, staff dressed in white garments too, leave some patients nervous.These relations can be affected by the circumstances of the professional daily life and aggravated by the work environment in which they work, bringing diverse confrontations with stressful situations experienced within the work environment [17].Is relevant to understand, evaluate and monitor the perceptions of patients and health professionals about the quality of the hospital's physical environment and for this, valid and reliable measurement instruments are necessary [21].
The hospital as an institution should consist of comfortable physical spaces, diverse equipment, technologies and the provision of specialized personnel to offer services efficiently and effectively to the user population.Thus, hospitals should have controlled and restricted access, direct link to diagnostic services and specialized treatments, have ele-vators, an emergency room, large surgical center and instrument lining, recovery rooms, Intensive Care Units, laboratories and Spaces for leisure and reflection [22].

Conclusions
Currently, due to the strong digital influence on health and the need to follow scientific evolution, needing to work in the assistance with technologically sophisticated equipment, it is necessary that the nurse understands the importance of living with the patient's pain and feelings, in order to they do not leave to see the patient of holistic form, using the technology in their favor, without this one does not diminish or cancel the way that the human being/patient must be treated.
In view of all the problems encountered in our country, having the privilege of enjoying its good points gives us the certainty that we need to value our system a little more.In health, mainly, we approach the patient in his fragility and we understand that the reception, the humanization present in the care, the small gestures are the main indicators to obtain a good care.
With the differences identified in the hospitals visited in both countries, the great work carried out by Brazilian health professionals is emphasized, which is not only a technical-scientific efficiency, but also the humanized care.Knowing the two realities, it allowed us to have a more critical vision on the situation in which health is in our country, seeing also that some things can be improved.It is fundamental to look for tools that improve our Health System, consequently, providing benefits for both employees and users assisted.
It is noteworthy that, despite all our weaknesses, we have the best health system in the world.Obviously, technology, organization and professional appreciation are important aspects, but we can not forget the main thing, the humanization, the need to know how to live with people at all times, how to listen to different stories, tolerate any religions, share their problems with others, difficulties, and especially their pain.
In order for humanization to be part of this whole process, it is necessary to build bridges based on human values, acceptance and mutual respect.Thus, it can be said that humanization does not depend only on technological resources to be shared, it is a characteristic intrinsic to the human being, that can be stoned in their lives through education.