Context of the act of care

Since the beginning of human history, medical praxis has been related and advanced in an associated way, relating this practice to the cure of diseases. One of the distinguished characteristics of the healer in those times was exemplary moral conduct ³.

The first ancestral and mystical figures are the shamans, who were part of the native people and are a representation associated to medical practice. These healers were in charge of health in the community and their image included a strict ethic, which is why the members of the tribe assigned the value of respect and trust towards him ³.

Years later in the classical period is Higienia or Aescalepio, who were in charge of protecting the sick. To carry out their work, there were intermediaries (priests-doctors), who carried out the diagnosis, prescription of treatments, and often there were potions that they delivered to achieve health recovery ³.

The above, generates the emergence of medicine defined as "the art of healing." One of the first exponents, in this field, was Hippocrates, considered the father of medicine, and who transformed the art of healing into an objective and experimental science. Within its multiple legacies, there is the Hippocratic oath, witness and model still in force in ethics ³.

At the end of the Middle Ages, William of Ockham (a monk who presented the objective of knowing the truth), tired of the frequent magical attributions with which medical science used to adorn himself, decided to propose what centuries later would become known as the “Ockham's razor”. His proposal seeks not to attribute questions of a metaphysical nature to physical health problems, currently called symptoms and signs ³.

The natural evolution of medical science, due to scientific advances in areas such as biology, chemistry and microbiology, simultaneously triggered a change in the professional-patient relationship and how this binomial faces factors that provoke mechanisms and actions that maintain or improve health ⁴.

From the Nursing discipline, Florence Nightingale, the first pioneering theorist of modern Nursing, defines the profession as ⁵: “The responsibility to watch over the health of others. Actions of caring for the person and their environment, based on the development of skills such as intelligent observations, perseverance and wit. Profession based fundamentally on the cultivation of the best moral qualities”.

Proposing in this field the art of care, where the dynamics of care requires the triad: user-environment, professional-user relationship and professional-environment relationship. With the above, the nursing practice is focused at the beginning of the scientific-practical development.

From the perspective of Florence Nightingale, is relevant the context in which care must be generated by the Nursing professional ⁶, that is, it manages to visualize the influence of the environment, therefore, it identifies that contexts are not unique, since they respond, to a greater or lesser degree, at political and structural moments of the countries and their health systems ⁷, they will directly or indirectly influence the state of health of the population.

Currently the health needs of the population are structured under the health system of each country, therefore, the functioning is established in relation to the political and social context of that nation ⁸. For the transversal development of criteria, they are developed based on models and approach, which mainly emphasize the delivery of guidelines with an specific focus on safeguarding fundamental elements, people's rights, respect for human dignity, value of life and communication.

The different health systems try to deliver quality care in their different areas: direct (changes in health status), Indirect (related to resources), perceived (based on the perception of the individual and family) and demonstrated (based on indicators), measured in various systems with the user satisfaction indicator ⁹.

Now, the perception of the relationship between professional - user, presents an evident reduction of the concept and even more, the reduction of the vision and meaning of humanized care to which they generally attribute terms such as: dignified care, humanization as care holistic, personalization of care, empathic and comprehensive care ^1,2,10,11.

Nature of care

To begin the theoretical review, is relevant the analysis of the attributes that make up humanized care. We will designate attributes to the fundamental or closely related properties that it presents according to Aristotle ¹².

It seems appropriate to deepen from a multidisciplinary approach, mainly because they directly or indirectly contribute to the debate from their specialty. In this section the visions of scientific and humanistic areas (biology, philosophy, bioethics, nursing and law) are compiled.

First attribute: The human being.

From the area of human biology, the human being is considered as a complex system. It has genetic characteristics, conjugated with exposure to the environment, allows adaptation and evolution ¹³. From this approach, it does not provide a delimitation of the concept, but rather an approach aimed to answer who is the human being.

For its part, the Royal Spanish Academy (RSA) defines a person as one ¹⁴ "individual of the human species", a second definition presented is "subject of law capable of owning rights and contracting obligations". Separately, each conceptualization limits being a person, the first achieves a greater extension of the concept, while the second provides a decrease in the number of beings that could be considered in this categorization, because in order to become a subject of law, they should present self-awareness.

According to the RSA, human is defined as ¹⁵ "said of a being, which has the nature of man (rational being)." This conceptualization presents a differentiated vision based on the capacity to make judgments based on thought and reason, therefore decreasing the number of beings that could be under this concept.

In the legal field, very closely with bioethics, important debates converge on issues that arise in the life sciences, Chilean legislation will be used for analysis to frame the conceptualization. Natural persons are defined as “natural persons or human beings”. A theoretical basis used to understand such a definition comes from philosophy, framed in human nature ¹⁶.

For Thomas Aquinas ¹⁷, the person is understood as "the most perfect thing that exists in all of nature, that is, the subsistent being in rational nature" (Pp.21). This characteristic of rationality gives the ability to be responsible for their acts, which makes this being possessor of inalienable dignity and therefore subjects of duties and rights.

A second contribution delivered by Thomas Aquinas ¹⁸, is found to the concept of natural law, defined from the “innate or culturally acquired characteristics”, considering in it two areas: physical-biological (based on basic needs for survival ) and psychic-spiritual (natural or invariable, mediated by reason and intelligence that allows self-awareness). For Aquinas it is relevant to consider, within the attributes that personality grants in a natural or physical person, legal capacity can make a difference in people who do not have self-awareness.

In the discipline of law, with a focus on bioethics, we find Andorno R. ¹⁹ who, based on Boecio, defines the person as "the individual belonging to a rational nature". This conceptualization becomes relevant in matters that involve both currents, on the one hand, identifying being a person with the necessary characteristic of self-awareness inevitably triggers, thinking of a possible distinction with individuals who do not yet possess such a characteristic or who have already lost it. hopelessly (embryos, fetuses, newborns, seriously mentally ill, etc.). On the other hand, there is a current that considers the body element as constitutive of the person's being and defines it as an individual belonging to human nature.

On the other hand, it is possible to build it from the disciplinary vision of nursing. Watson J. ⁶ in his philosophical and theoretical design of transpersonal care, uses interchangeably human being, person and personality, whose definition is “a unity of mind / body / spirit / nature” (Pp. 85).

Marx K. (1818 - 1883) reflects on humanity, stating the following ¹⁰: “to be rich in humanity, is to restore full dignity and equal rights to anyone who is in difficulties and cannot fully participate in social, political and cultural life”. This idea states the importance of respecting the ethical dimension of health practice, based on the exercise of the relationship between nurse-subject of care, which allows living with others and being for others as part of being social.

In the search to answer what is the subject of care, the definitions give characteristics with a focus on who it is, allowing to expand the extension of the concept, increasing the number of people. According to Acuña L. ¹¹ The human being, firstly, presents a soul-body duality (incarnated spirit), secondly presents a spiritual capacity (rational creature, with will, feelings and freedom), rational capacity (reason and intelligence) and being sociable (ability to live with the other, communicate) ¹¹. On the other hand, from the point of view of Watson J. ⁶ considers the triad body, mind and soul, as a unit, which is influenced with energy and nature.

Second attribute: Professional-user relationship.

Within the context of the health area, understanding the person invites us to reflect about the professional-user relationship, as basic attributes in the nature of humanized care. From the point of view of professional ethics, it is relevant to indicate that Thomas de Aquinos ¹⁷ is the one who provides a relevant contextualization of the life sciences, indicating that working “allows us to tend towards self-improvement, obtain satisfaction of their vital needs and contribute to the increasing humanization of the world and its structures ”(Pp.27).

Therefore, a new concept is introduced to understand the nature of care: dehumanization. Although the meaning of this concept is widely used, during recent years, one of the authors who has studied and contributed to the discussion, from the discipline of theology is Bermejo J. ¹⁰, who defines it as: “ a process by which a person or a group loses or is stripped of their human characteristics ”(p18). The analysis of the exposed, is understood in the first instance, as removing or omitting one, several or all the capacities that a human being presents: the dual (body-soul), spiritual, rational and that of being sociable. A second reflection points to the value that is possibly also stripped, dignity. Before, the characteristic that it presents is being inherent in all people, therefore it does not accept gradualness. And a third reflection focuses on rights and duties, which are directly related to the value of dignity.

However, the Nursing discipline considered by the author Watson J., as the science of care, points out the following about dehumanization ¹⁴: “It is the fragmentation or breakdown of the methodology that has led to the science of care to trigger actions that involve the knowledge of the needs of the other and the integral and continuous approach, which will allow the correct adaptation of the person in the environment in which he resides ”.

Third attribute: The act of care.

The reflection of both conceptualizations invites us to understand the responsibility that comes with generating care for another, which is mediated by a third attribute, the act of care. In the 21st century, subjectivity is presented in practice versus theory. The why, possibly occurs due to the gradual decline presented in the health system in general, about the nature of the person, from a two-way professional perspective - subject of care. The importance of producing this action, allows the focus on the nature of the act of care, which in this case represents the end.

From the theological discipline, the author Bermejo J., Director of the Center for Humanization of Health, is on the search for answers to address and reflect on the subject, in his text entitled: “humanize healthcare”, exposes the problem and an erroneous trend that seeks to equate the humanization of care with synonyms that structure and minimize the act of care in words such as: dignified , welcoming and empathetic treatment in care relationships ^8,9.

An interpretation of the act of caring, carried out by the German philosopher Heidegger M. (1889 - 1976), quoted by Humberto G. in his text “metaphysics are you”, focuses on the act of caring as part of the essence of being human, therefore, the form of development of such an act would present a direct relationship in the quality of life and freedom ²⁴.

From the discipline of Nursing, Watson J., indicates that the performance of the act of care requires "a serious call to moral, ethical, epistemological, ontological, philosophical and practical effort" to ensure that the science of care is presented as a fundamental support of humanized care ²⁵. Appeal that in a clear way leads to not forgetting the values ​​that the human act must present: the will and reason (knowledge), mediated by freedom, thus granting an ethical dimension ¹⁷.

To extend the concept, the search for characteristics that allow the understanding of the third attribute will be used, for which the act of care must present: professional relationship - subject of care (which requires understanding the descriptive edge of the person, and a prescriptive with focus on the treatment of this being), stable (must reside in the person), continued over time, adaptable (according to the person's need), and in turn, to incorporate the sense of the transcendence of the human condition, that is , it is the other care subject who gives the meaning of an "I", understood as a reciprocal act where both carry out an exchange producing correspondence or mutual benefit in the relationship ^6,20,24.

It should be noted that the act of care must be sustained under the premise of social and individual responsibility, where each person is responsible and the health professional acts as a mediator to achieve the maintenance or improvement of the state of health ^21,25. Such interaction can sometimes be perceived as empty or not perceivable, leading to the non-existence of a relationship but rather of procedural delivery what is known as attention.

The second characteristic, indicated for the professional relationship - subject of care, is triggered by the need for full knowledge of the descriptive edge of the person and the prescriptive edge. Which requires the development of knowledge: knowing how to be, conjugated with knowing (cognitive), practical (knowing how to do) and knowing how to be. The full achievement of this characteristic would allow the care plan to be approached in a consensual way by the binomial.

Fourth attribute: Communication.

The fourth attribute in humanized care is communication. From the multidisciplinary perspective, it is explained by the Chilean philosopher Giannini H. (1927 - 2014) in his text "Metaphysics is you", where in addition to pointing out that communication is an attribute of the human being, he says that "only by communicating is when we reach real closeness ”²⁴. Therefore, it becomes an indispensable attribute of the nature of care.

In this sense, according to Salas JM. et al, it is necessary to perceive communication with "a moral ontological sense, that is, communication raises the way of being of men in the world" ²⁶. By this premise, an evolution over time can be recognized, going from the transmission of information for persuasive purposes to a way of getting people to lead their decisions to do or to generate reasoning for doing ²⁷.

Habermas J. (1929) introduces the Theory of communicative action, this reflection seeks to understand communicative action from a subjective world, in which experiences become necessary, from which inter-subjective relationships are established between humans through the language and symbols ¹⁰. From what the author indicates, there would be factors that could influence the perception of the relationship between human beings, and it is therefore relevant to consider them when analyzing humanized care.

This intersubjectivity mediated by experiences and the factors that can influence them can trigger, as the author Gafo (1994), by Bermejo J., explains ¹⁰ “dehumanization is determined by the conversion of the user into an object, objectified, neglecting the emotional and value dimension”. Therefore, nursing practice requires the integration of knowledge and practices, in addition to understanding the impact that communicative action can trigger as a facilitating and articulating tool for change ^24,29.

The understanding of communication in philosophical terms, explains Giannini H., is understood in the following terms: "An act that needs people to carry out, to communicate is to communicate with another and primarily human action that occurs between two subjects" ²⁴. Then, generating an activity that presents the combination of the act of caring and communication would trigger humanized care.

When opting for an integrative view in the social and holistic approach, as indicated by Gusella and Ward, (in an evaluation carried out on the perception and satisfaction of a group of adolescents) there are five basic needs that must be present in the act of care: privacy, accompaniment and visits, activity and mobility, independence and educational continuity. But it is required to understand the need to guide the processes of hand care with the act of communicating constantly, in order to achieve the proposed objectives and adaptation to the environment of the individuals who make up the community ^10,30-32.

Fifth attribute: Holistic Paradigm.

A fifth attribute, presented in the nature of humanized care, is the holistic paradigm. The first documented evidences, according to Graham cited by Vega P. et al ³³, were made by the first Hippocratic school of medicine. The vision presented is based on the integration of the forces of nature in the care of the person, the objective is that they generate favorable conditions for recovery and healing, as a result of the energy balance achieved.

The analysis of its Greek roots identifies olos, which presents everything as meaning. Therefore, if we reflect on this approach from its different cultural approaches as in eastern philosophy, it appears centered on the person as an energetic being, where the different interactions with elements produce energetic exchanges. The great difference with the integral concept, mainly occurs the vision that the person presents, when we talk about an integral approach, we point to a person shaped by the sum of its parts ³⁴.

Without a doubt, the visualization of the other as a human being proposes a change of exercise in the health sector, with a focus on a real vision of a whole. Being fundamental the multidisciplinary approach in practice, not being required the generation of norms or protocols for the exercise of inherent characteristics of the human being, such as for example the action of communicating and caring for the other, oriented towards the good.