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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.19 no.58 Murcia abr. 2020  Epub 18-Mayo-2020

http://dx.doi.org/eglobal.392321 

Reviews

Training guidelines for humanised nursing care: an integrative literature review

Mercedes Díaz-Rodríguez1  , Lucía Alcántara Rubio1  , David Aguilar García1  , Esther Puertas Cristóbal1  , Mercedes Cano Valera1 

1INDESS (Instituto Universitario de Investigación para el Desarrollo Social y Sostenible), Universidad de Cádiz. Cádiz. España.

ABSTRACT

Introduction

Communication and interpersonal relationships are the most essential elements of humanised care. The process of recovery is fostered by establishing relationships outside of physical care through the humanisation of actions in the care plan. However, in both nursing training and nursing practice, the inertia of a technical and neo-positivist approach persists and such aspects are therefore neglected.

Objective

To provide more specific knowledge on the importance of considering nursing care from a biopsychosocial perspective, with a humanised approach, placing special emphasis on communicative skills and interpersonal relationships as essential elements.

Methods

An integrative literature review, with a critical analysis of the literature consulted, including original articles and reviews published in Spanish, Portuguese, and English from 2013 to 2018. The SciELO, MEDLINE/PubMed, Web of Science, and CUIDEN databases were searched.

Results

The following four categories emerged from this analysis: 1) communicative and emotional skills as essential elements of humanised care; 2) the necessary emotional and communicative training in nursing education; 3) other factors contributing to humanised care; and 4) methodological changes and pedagogical resources for the communicative and emotional training of lecturers, students, and nursing professionals.

Conclusions

There is a need to develop, in a more pedagogical and profound way, training programmes in nursing on emotional skills and communication for humanised care.

Key words: Nursing Education; Humanisation of Assistance; Nursing Care; Communication; Nurse-Patient Relations

INTRODUCTION

At present, care delivery is proving to be insufficient in terms of both health professional practice and training. Healthcare institutions adhere to the biomedical approach, where care actions are focused on the procedure or technique, not on individuals and their integrity. This approach, rooted in the positivist paradigm of categorisation, has led to the dehumanisation of care, thereby reducing humanity to biology, and care to the cure of illnesses, moving nursing care away from its humanistic and holistic vision and mission.

In this sense, in view of the increasing dehumanisation of healthcare, it has become necessary for nursing professionals to restore the human aspect of care, as it is professionals who have the final and personal responsibility of deciding the type of relationship that is to be established between themselves and patients and their families, and how it is to be established.

Thus, reflecting on and paying attention to how we interact with and relate to people requiring care from a humanised approach is especially important when it comes to the nursing profession.

There is consensus in the literature in considering communication as a mediating instrument and tool for the humanisation of care1. Effective communication should be used as part of nursing work. The development of communication skills is crucial to ensuring the effectiveness of health services. Communication should be one of the core areas of focus, as it is through communication that effective interpersonal relationships are built, so that mutual trust, emotions, and feelings of well-being and tranquillity are expressed and achieved. As a result, the phenomenon of the provision of care becomes apparent through a communicative and interactive process2. It has also been stressed that establishing a relationship outside of physical care, through the humanisation of the actions performed, enhances the recovery process3.

However, the studies consulted pointed out the limited training in communicative and emotional skills that the nursing professionals themselves acknowledged having. In addition, the scarcity of learning spaces where nurses are trained in these competencies within undergraduate and postgraduate programmes is also noted4. Where such spaces are available, training is usually provided in a masterclass format that does not provide much help in the development of such skills.

Making changes and improvements to treatment and to the training of communication and emotional skills is a need that must be prioritised in academia. Curricula should make more room for training in communication and emotional skills. Methodological changes should be implemented in order to facilitate experiential learning. Communication and emotional skills should also be prioritised throughout the postgraduate professional career, as they are instrumental in achieving good quality of care. Improving nursing professionals' training in these skills by incorporating new methodologies and teaching resources conducive to significant learning will result in greater humanisation of care, better professional performance in nursing, and improved satisfaction and recovery of individuals requiring healthcare.

We therefore considered the present study to be relevant, as it reports on an integrative literature review on the topic in order to provide more specific knowledge on the importance of considering nursing care from a biopsychosocial perspective, with a humanised approach, placing special emphasis on communicative and emotional skills from a comprehensive humanising approach to care delivery.

We set out the following objectives:

  • - To justify the importance of developing communicative and emotional skills for establishing meaningful interpersonal relationships for humanised care in the nursing profession.

  • - To reflect on the need to improve training in the nursing degree in order to promote communicative and emotional skills in future nursing professionals.

  • - To highlight methodological changes and pedagogical strategies proposed to improve education and training in communicative and emotional skills in nursing students.

METHODS

The present study focuses on an integrative review which, from a critical and reflective approach, seeks to collect the most relevant information from the scientific literature on the importance of the humanisation of care and the need to develop communicational and emotional skills in nursing professionals. To this end, a literature search has been conducted based on references published in three databases: SciELO, MEDLINE/PubMed, and CUIDEN. The search was carried out in the first half of 2019. The following descriptors were used: “Nursing Education”; “Humanization of Assistance”; “Communication”; and “Nurse-Patient Relations”. The DeCS and MeSH platforms were used to ensure the use of standardised descriptors.

The method used in this study relied on the following steps: exploratory reading (the title and abstract of the articles being related to the study subject), selective reading, analytical reading, and interpretative reading. Original articles and reviews published in Spanish, Portuguese, and English between 2013 and 2018 were included. Theses, dissertations, epidemiological bulletins, and books were excluded, as well as articles which had not been published in that specific period of time and articles which were not directly related to the objectives of this research.

Source: the authors

Figure 1. Flow chart 

A total of 788 records were initially found. After eliminating of duplicates and after exploratory reading, 308 publications were selected. After the selective reading, 196 records were eliminated, resulting in a final sample of 29 articles. Through critical reading and an integrative analysis, all of the articles were grouped by thematic areas and four core categories were identified.

RESULTS

Below is a Table with the highlights of the 29 selected articles.

Table 1: Selected articles 

Authors Method Results
Mastrapa Y, Lamadrid M (2016) Integrative literature review Nursing professionals in different nursing settings relate to patients and their families mainly through communication, by applying a variety of elements. This encourages nurses to create personalised care plans based on a reciprocal relationship. A good nurse-patient relationship improves nursing activities and contributes to maintaining both health and the care plan in place.
Cestari V, Moreira T, Pessoa V, et al. (2017) Theoretical-reflective study “Caring is an interactive process that reveals itself in the relationship with the other. Respecting the integrity of the Being in vulnerability must be a priority in nursing care, through behaviors that privilege the Being.”
Pott FS, Stahlhoefer T, Felix JVC, Meier MJ. (2013) Quantitative descriptive study The establishment of communication was present in 37.5% of the procedures performed by the multiprofessional team. The human aspect of care is not taken into account when providing care to individuals. This may be related to the use of advanced technology, which permeates critical care settings. The distancing of the healthcare team, the patient, and the family compromises the quality of care. Communication is established as an instrument to mediate the humanisation of care. The establishment of a relationship outside of physical care, through the humanisation of the activities performed, fosters the good quality of the recovery process.
Moreno, I., Siles, J.(2014) Descriptive thematic review “Reflective practice and critical thinking are shown as being necessary to understanding socio-critical nursing.”
Michelan VC de A, Spiri WC (2018) Qualitative study “(…) humanization (…) involves the holistic care of the patient, relating it to the family and social context”. “The worker must rethink his actions, in order to guarantee the dignity of the human being not only in caring and watching, but in other aspects that go beyond the technique, as well as work environment, in its subjectivity and in the cultural aspects”.
Uno M, Tsujimoto T, Inoue T. (2017) Qualitative study “(…) five categories, namely, inference, empathic understanding, listening attitude, individual treatment, and reliable skills and explanations.”
Sharon D, Grinberg K. (2018) Multimethodological study “A positive correlation between the level of EI and the degree of success in nursing studies among nursing students was found.” “There is a need to increase the importance of EI in the terms of nursing student's admission and basic nursing curriculums.”
Oliveira KRE, Trovo MM, Risso ACM da CR, et al. (2018) Qualitative study “The development of communication skills is influenced by factors such as the experience of practical activities, students' individual characteristics, use of active methodologies, access to the mass media, relationship of proximity between student and professor, and knowledge of theoretical concepts of communication and nursing.” “The use of active methodologies seems to favor the development of communication skills.”
Beltrán Salazar OA. (2015) Qualitative study “The patient's situation, the nurses' communication skills, and the condition of both, as human beings, influence upon the words, gestures and attitudes during the nurse-patient relationship, where the presence, that which is done, and how it is done permit leaving an important impression on patients and their relatives.”
Ruiz R, Caballero F, Monge D, et al. (2017) Qualitative study The results obtained show positive results which are educationally significant, both in terms of the set of communicative skills and the completion of a clinical record, as well as regarding the specific skills for communicating bad news or changing behaviours.
Tejada S, Ramirez EJ, Díaz RJ, Huyhua SC. (2018) Descriptive exploratory qualitative study The following categories were identified: I) Coexistence and care/neglect relationships in nursing training; II) Theoretical-practical (dis)organisation in the teaching/learning of nursing care: towards lecturer-assistant integration; III) Lecturer/student complementarity for generating knowledge and teaching strategies through problem-based learning, hypothetical cases, experiential laboratories, and socio-dramas, including care and research as cross-sectional themes.
Santos BM dos, Silva RMCRA, Pereira ER, et al. (2018) Integrative literature review “(…) the knowledge from the undergraduate will subsidize their practice, guiding, facilitating or making difficult their practice over of your work day, according to how it was learned. The university, having knowledge of the understanding and perception of humanization by its clientele, has the possibility to intervene with strategies that best suit them.”
Lee H, Kim A, Meong A, Seo M. 2017 Qualitative study To provide holistic care for children and families, all necessary patterns of knowledge must be acquired through continued professional development and individual reflection on personal practice.
Dalcól C, Garanhani ML, Fahl L, Gimenez B.(2018) Qualitative study “The strategies used to develop the communication were theoretical classes, tutorial, seminar, written evaluation, portfolio, training, the Interdisciplinary and Multiprofessional Practices, nursing internship and feedback.” “The curriculum examined favored the development of communication skills through the use of active methodologies and modular structuring.”
Oliveira A. y Soares E. (2018) Descriptive convergent qualitative study “The results point out the relevance of studying the communication process, because, by putting it into practice, there is an improvement regarding the nurse's communication skills, and then avoiding any interference that may affect the information provided.” “The significance of the nurse/patient relationship stands out, which enables understanding the educational information and the way in which they are provided, then constituting a powerful tool (...).”
Siles-González, J., Noreña-Peña, A.L. y Solano-Ruiz, C. (2017) Quantitative study Innovative strategies should be developed for raising awareness of, reflecting upon, assessing, and analysing the emotions and feelings arising from activities developed by nursing students during their clinical practice. The exclusively psychometric approach to emotional intelligence does not seem to be the most relevant and reliable solution. In order for the learning of emotions and feelings to be meaningful for learners, it is necessary to involve learners through processes of awareness where the importance of aspects such as metacognition, reflection in action, critical thinking, and aesthetics are clarified.
Murillo MA, López C, Torrente S, et al. (2014) Cross-sectional study “Nurses tend to inform more about technical aspects than feelings related to the families. Patient comfort is the most referred item regardless of years of experience and the kind of intensive care unit.”
Guerrero R, Meneses M, De La Cruz M. (2016) Quantitative descriptive cross-sectional study “The humanized care is given regularly and is necessary to implement strategies, improvement plans and ongoing training in order to generate awareness of nurses to apply good treatment to the patient from a human values-based approach.”
Rojas MM, González ME (2018) Historical-logical study Developing communication skills is essential to ensuring the efficiency of health services. Development-related difficulties point to the need to take into account the developmental vision of education that is currently being promoted when addressing university training processes in the medical sciences.
Hernández LE, Díaz A, Martínez JF, et al. (2018) Quantitative longitudinal study “The educational intervention was effective to increase knowledge and it is recommended that nursing staff continue to be trained on aspects of the dignified treatment indicator to improve the care provided to patients in hospital services.”
Hobson WL, Hoffmann K, Loue S, et al. (2018) Quantitative study “Participants reported that their confidence level in using theater techniques as a tool for medical education increased from low-to-medium confidence presession to high confidence postsession. All survey respondents who were actively teaching said they had made changes to their teaching based on the workshop. All commented that they appreciated the active learning in the session.”
Reuter C, Santos V, Ramos A, et al. (2018) Exploratory qualitative study The effectiveness of “interprofessional and intersectoral actions” is highlighted. “Intersectoriality and interprofessionality make it possible to carry out holistic and integral health actions, optimizing Nursing care practices.”
Moraes M, Tarcila P, Rêgo Lopes TM (2019) Qualitative study When there is effective communication and there are good interpersonal relationships, families feel safer and more at ease. It was observed that health communication is an excellent working tool in healthcare, because it promotes greater interaction and facilitates the building of a relationship of trust. In addition, a higher degree of satisfaction is achieved in the services offered by both the client and the staff service. Moreover, family members feel supported when professionals show feelings of respect, affection, understanding, and attention, and that type of care transcends any procedure. Making professionals aware of the importance of the presence of family members is the first step towards change. Awareness of the family's perception of nursing care is essential for performing more welcoming actions to help families cope with the hospitalisation of a loved one.
Villar F, Serrat R. (2017) Literature review “We describe the relevance of a narrative approach for understanding the experience of the old person who receive care in institutions, with regards to individual aspects as well as to her/his relationships with professionals and the institutional discourse which contextualize these relationships. Secondly, we specify different ways in which the use of narratives could have an impact on the improvement of the quality of attention and well-being of older people receiving care in institutions.”
Siles González J (2018) Quantitative and statistical experimental study The most important contribution of poetry to nursing lies in the clarification of the transcendental nature of nursing by disclosing its subject matter: human beings. The individual as the core, as the raw material with which nurses work to “produce their work”.
Guillaumet M, Amorós G, Ramos A, et al. (2017) Qualitative study “Raising awareness of own experiences in the process of death can help to define relevant aspects that may improve professional care. The recognition of the behaviors observed during the grieving process contributes to optimize the sensitive accompaniment of people in processes around death. The pedagogical chronicle, as a teaching strategy, is useful in nursing education given that allows the comprehension of the significance and impact of complex situations. Reflection on the lived experiences and contrasting them with the literature allows guiding the process of comprehensive care.”
Ceballos LM, Rodríguez LA,González SC (2018) Literature review “It was concluded that the latest tendencies in higher education demand a change from an instructional paradigm to a cognitive one developed by the students themselves in which the qualitative research along with the quantitative research become the central part in the construction of scientific knowledge, and bring about a qualitatively higher leap in medical practice that take into consideration the human being as a biological, social, and psychological unit, by putting into practice research skills that include qualitative research in such a way that achieve a higher professional practice according to the current social requirements.”
Gomes G, Xavier D, Pintanel A, et al. (2015) Qualitative study “Interactions between family members and the nursing team contribute to the significance attributed by the family to the nursing care received by the child. Nurses should be aware of the attitudes of the nursing team regarding the child and their family, prioritizing humanized care.”
Azevêdo AV, Launchoni AC, Crepald MA. (2017) Literature review “The establishment of interpersonal relationships in a technical and formal way causes difficulty in communication and in the actions aimed at providing care. Care has been the main theme in these researches. Companions demand increased attention to child and family needs from health professionals, and greater involvement of everyone in the process of care.”

Source: the authors

The following four categories emerged from the analysis of the selected studies: 1) communicative and emotional skills as essential elements of humanised care; 2) the necessary emotional and communicative training in nursing education; 3) other factors contributing to humanised care; and 4) methodological changes and pedagogical resources for the communicative and emotional training of lecturers, students, and nursing professionals.

Communicative and emotional skills as essential elements of humanised care

Numerous studies confirm the importance that the improvement of communication in care processes has for the establishment of a nurse-patient relationship5. The type of relationship and the type of care established between the nursing professional and the user may have therapeutic effects, resulting in increased adherence to and tolerance of medical treatment and nursing procedures3.

This can be observed in the results of the recent qualitative study carried out by Michelan and Spiri6, which concludes that holistic care is necessary and has a positive impact on the patients' recovery, since dialogue and listening can be compared to drug treatment.

When individuals feel well cared for, listened to, and respected, and when they maintain a bond of trust, their adherence to treatment tends to be higher. Similarly, some studies relate nurses' entrance into the patients' emotional spheres and favouring the expression of emotional experiences with improved satisfaction and recovery. Some studies even consider this to be decisive in the healing process6,7. Furthermore, we found that ineffective communication on the part of healthcare professionals may lead to depression, increased anxiety, helplessness, hopelessness, and impaired quality of life for patients.

Thus, Pott et al.3identify as factors that impair the quality of care, on the one hand, any form of ineffective communication and/or lack of communication during care actions, neglecting the emotional and social aspects of the individual requiring care. On the other hand, other factors identified were the mechanisation and routinisation of daily care, showing that many professionals focus on treating and curing the sick body, without taking into consideration the other humanistic aspects that make up each being. However, the review of the literature on the subject reveals that users are increasingly demanding more human treatment and not merely seeking treatment. Users perceive that interpersonal relationships and the type of rapport established between the nurse and the patient are the most valued characteristics, even over effectiveness. Emotional intelligence should be one of the objectives in health training and practice, and should be recognised as one of the indicators of improvement in the quality of health services, since individuals with high levels of emotional intelligence are more capable of empathising with others and are more likely to help, cooperate, and establish more satisfying interpersonal relationships. Also noteworthy is the recent study by Sharon and Griberg8, which focuses on reviewing the relationship between the level of emotional intelligence and the degree of success of nursing students. Their results point to a positive correlation between these variables, arguing that emotional intelligence should be considered as a criterion for the admission of students to undergraduate nursing programs.

The above highlights the importance of emotional care and good rapport which, by establishing interpersonal relationships of trust, with special emphasis on the type of communication, can become a therapeutic element that influences the well-being, health, and/or recovery process of individuals in need of care.

Other factors contributing to humanised care: attention, reflection, and self-awareness

There are other factors that contribute to developing humanised care which depend directly on professionals. The individual's personality and character directly influence how they treat patients, the way they address patients and their families, as well as their behaviours, thus promoting or neglecting a more or less humanised practice9.

This is why reflecting on nursing practice in daily care is essential. According to these authors, in order to attain the humanisation of care, it is necessary to engage in a permanent reflective process that allows us to keep in mind the values and principles that govern professional practice, since nursing, in and of itself, is a humanised practice.

Jean Watson's theory of Human Caring may be considered here. This theory attaches special importance to reflection on the self, on personal introspection, and/or self-awareness as factors in the care process. Watson10claims that individuals who fail to recognise their own feelings will find it hard to understand someone else's feelings. Similarly, accepting the expression of one's own and others' feelings (both positive and negative) leads to a form of empathy that transcends one's own self and favours the process of human caring11. Hence, self-awareness, reflective practice on the care that is being provided, and the ability to self-motivate are all elements that need to be incorporated into the professionalisation and training of nursing staff12.

Another issue considered to be essential for humanised care is “attention to detail”. The study by Beltrán-Salazar13, whose purpose was to understand the meaning of humanised care as experienced by inpatients, their families, and nurses, points to the importance of details and how details can be perceived by individuals in need of care. This author concludes that, although it may not be important for nurses to perform certain actions or paying attention to certain details, the following may be crucial for individuals in need of care: being greeted, being addressed by their name, complicit looks, nurses knowing their interests, body contact and caresses, etc. These are important elements of interaction, in the establishment of trust-based interpersonal relationships from the humanised care perspective.

Thus, attention to detail, reflective practice, and self-awareness are considered to be factors that contribute to humanising care.

Emotional and communicative training in nursing education for humanised care

At present, educational curricula in the Spanish context include emotional and communication skills within the set of competencies that nursing students must attain to obtain a degree in Nursing4. Clinical communication has been embraced as an important component of nursing curricula and has been acknowledged as an essential competency by accreditation bodies and international organisations14.

In spite of this, it has been reported that training in communication and emotional skills in nursing has stagnated. It is even nursing professionals themselves who stress that learning to listen to, manage, and convey emotions are skills that should be taught during basic training across the board. It has also been pointed out that this type of training must be developed from new approaches and more participatory and experiential methods that ensure significant learning15.

According to Santos et al.16, dehumanisation begins during nursing training, where emphasis is placed on the mastery of knowledge, scientific evidence, and the development of technical skills, to the detriment of patient-centred skills and competencies from a holistic perspective, while ignoring the critical, creative, and sensitive-affective approach inherent in care. Lee et al.11draw similar conclusions and stress the need to introduce specific training in emotional aspects using methods that encourage and promote more reflective learning in order to attain the competencies necessary for comprehensive caring. As a result, these authors state that the training of students should privilege communication with the individual rather than the performance of their technical role, so that students are able to clarify the needs and feelings of each individual being cared for (p. 40).

It is also worth highlighting the current educational interest in studying the presence of family members and how they are cared for, as this aspect is essential for the humanisation of care and directly influences the recovery and improvement of individuals in need of care17. The results obtained by Gomes et al.18also show that the presence of relatives is an element that promotes the physical and emotional recovery of the individual being cared for, especially when it comes to child care. It is apparent that, among the meanings of humanisation, the inclusion of the family in patient care must be acknowledged as a practice inherent in the nursing profession in order to provide more comprehensive, holistic and humane care19. As a result, it has been suggested that family should be included in nursing training programmes to help trainees acquire skills and competencies to work with family members, and above all, to understand the importance of including families in the care plan20.

However, it is not sufficient to incorporate this type of training in academic degrees. It should also be provided as continued professional development throughout the nursing profession. In this regard, Tejada et al.15stress the need for continuous educational and professional updates to contribute to the integration of innovative strategies for meaningful learning. Similarly, Guerrero-Ramírez, Meneses-La Riva and De la Cruz-Ruiz21conclude that it is necessary to implement strategies, improvement plans, and continuous training in order to raise awareness among nursing professionals and humanise patient care, while placing utmost importance on communication, support, patient-family relations, and empathy.

Universities must be as sensitive as they are scientific22and must bring about the changes necessary to ensure that university graduates acquire the competencies and skills necessary to provide humane care. In this sense, in accordance with Ruiz-Moral et al.14, it is worth noting the curricular modifications made in the Faculty of Medicine of the Francisco de Vitoria University (Spain), where certain new organisational particularities have facilitated the integration of communication and care skills across the board.

The results of the study by Hernández et al.23are particularly noteworthy. In this study, an educational intervention was implemented with the aim of improving the use of the indicator dignified treatmentin inpatient nurses. The purpose of the study was to analyse whether their training was reflected in their relationships with patients and patient care. Regarding the results of the pre- and post-intervention evaluations, the means increased significantly. In conclusion, the educational intervention had a significant impact on the acquisition of knowledge by nurses, as well as on the improvement of the implementation of the indicator.

The above shows that making changes and improvements in the treatment and training of communication and emotional skills is a need that must be prioritised by scholars, researchers, and professionals alike, as they are instrumental in achieving good quality of care.

Educational strategies and resources for the communicative training of lecturers, students, and healthcare professionals

Students report feeling underprepared or not at all prepared to cope with communicative and emotional demands. The evidence provided by the studies consulted also supports the ideas we have been proposing. The scientific results suggest that it is necessary to improve the training of future nursing professionals with regard to communicative and emotional skills. However, it has also been observed that both the acquisition and the development of these skills require special work. Simply providing knowledge in an explanatory manner, following the masterclass model, and offering occasional lectures or seminars on these competencies may not suffice to help the student body develop the empathy and communication skills necessary to provide efficient and affective education and care14. According to the literature consulted, there is a call for incorporating new methodological approaches to replace the insufficiency of explanatory lectures and contribute to generating significant learning processes24. In this regard, Tejada et al.15point to the need to incorporate learning processes based on participatory, reflective, and dialogical methods that respect students' autonomy and teamwork in order to build, rebuild, and exchange knowledge. The results of their study highlight that pedagogical practices play an essential role in the teaching-learning processes of care in future nursing professionals, by contributing to the development of a special human sensitivity and by awakening affective, creative, and critical approaches. Similar results were obtained by Oliveira et al.9. The objective of their study was to understand, from the lecturers' perspective, what are the facilitating and hindering factors in the development of communicative skills in nursing students. The following factors were found to contribute to learning: the use of practical activities, students' individual characteristics, use of active methods25, relationship of proximity between student and lecturer, and organisation in small groups.

In consonance with the above, the recent contributions of Rojas and Gonzáles22stand out. These authors indicate that the participatory teaching-learning process acquires an added value when it is intended for the development of communicative skills, as their acquisition requires educational scenarios in which exchanges, reflections, and mutual influences are the dynamic driving force of educational practice. As emphasised by these authors, pedagogical spaces and environments where personal reflection, exchange of opinions, and open and respectful discussion predominate must be stimulated, thus promoting meaningful learning and personal and collective development linked to the communication process.

Interdisciplinary work is another element indicated in the literature to be incorporated into the learning processes with a view to improving emotional and communication skills and competencies. The results of a recent study indicate that 90% of studies show that interprofessional training is vital for health students22. So much so that, in 2016, the United Nations, in collaboration with the World Health Organization and other agencies, proposed interprofessional and interdisciplinary education in basic health training, aimed at promoting good quality transformative education and integrated skills from all fields.

Recent studies suggest that interdisciplinary work can offer a multiplicity of approaches and alternatives to understand the aspects involved in patient care, thus contributing to the creation of a new culture of nursing care, which must be translated into the educational sphere26.

Narration is another of the resources proposed to contribute to a change in nursing care practice towards the humanisation of care. Narration improves training in communicative and emotional skills centred on individuals and their families, with autobiographical narratives being especially relevant27.

Self-ethnography may be mentioned at this point. Writing one's own history as a way of understanding one's own vital processes and those of our patients allows us to reflect, create, and learn as individuals and as nursing professionals. A self-ethnographic process requires conscious observation, while focusing on connecting with patients, how we relate to patients, how we interact with them and bond in interpersonal relationships, and whether we put into practice experiences, skills, and teachings in which effective and affective communication is the driving force of our interaction with others. Self-ethnography is thus used as a resource to work on our feelings, on our ways of communicating and relating to others, starting from our own history and that of others, so that we are able to understand them and come closer to understanding others28.

When nursing professionals use this method on patients and their own experiences of illness, patients are able to express their feelings and emotions with others. As a result, nursing professionals contribute directly to improving the self-care of patients while becoming aware of the position of the individual in need of care.

Considering the above, it is safe to say that qualitative, narrative, and interpretative methods force us to constantly (re)question our views of human beings, our personal, social, physical, mental, and spiritual problems, which directly influences our stance in relation to one another29.

Finally, it should be noted that, despite the positive influence of these methods on health research, their subjective nature and the expression of feelings in contact with the most rigorous science is also pointed out as an obstacle. However, as argued by Siles28, sociopoetics has arisen in an attempt to address this obstacle, as it allows the expression of feelings to be studied in an intersubjective way, thus attaining certain objectivity. Several authors have described the utility of poetry in nursing.

The possibility of conducting self-narratives that are shallow on the interpretative plane has also been mentioned, which can be counterproductive, as they neglect the main goal, which is to link the personal side of self-ethnography with its social side.

Hence, some authors have put their efforts into trying to provide guidelines for placing this research method within the framework of sound social research by suggesting the creation of an Educational Model Based on Narration (EBN)28,30, which is meant to serve as a bridge between the qualitative subjectivity of this research method and the scientific objectivity of EBE (Evidence-Based Education).

CONCLUSIONS

Since the 1980s, when the paradigm shift began to unfold, many claims have focused on restoring the human approach in healthcare institutions. However, this literature review shows that we are currently continuing to do research on and advocate such an approach to humanised care. This is due to the fact that in nursing professional practice and training, the neo-positivist paradigm is still in place, limiting the scope of nursing to that of experimental, quantitative, and objective methods, thus distancing nursing from its authentic epistemological epicentre: humanised care. In this regard, the importance of clarifying and understanding the characteristics considered by the paradigm shift that we have been advocating needs to be highlighted. This paradigm shift calls for the adoption of participatory and qualitative theories and methods, where reflection, insight, and subjectivity take on value when it comes to improving training in communicative and emotional skills, as these are essential elements for the humanisation of care. In addition, the importance of other factors such as attention to detail, reflection, and self-awareness are stressed as contributing elements to the humanisation of care.

Accepting and putting into practice all of the above, in the current circumstances and realities, implies taking a new educational and practical approach. The studies analysed suggest that it is necessary to incorporate, in a more pedagogical and profound way, training programmes in emotional and communication skills into the nursing degree and throughout the professional career.

In this regard, interdisciplinary training and narration are presented as research and pedagogical methods that may contribute to the acquisition and development of such skills. Writing one's own history as a way of understanding one's own vital processes and those of our patients allows us to reflect and learn from our vital and experiential processes as individuals and as nursing professionals. Self-awareness while focusing on more comprehensive care is the starting point for the reconsideration, reflection, and transformation of one's own beliefs, thoughts, and behaviours.

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Received: August 02, 2019; Accepted: September 18, 2019

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