Pensar Enfermagem / v.29 n.Sup / Jan-Dec 2025

DOI: 10.71861/pensarenf.v29iSup.426 / e00426

Qualitative Original Article

How to cite this article: Campino S, Dixe MACR. Guidelines for the humanization of care provided by the

multidisciplinary team in the adult emergency department

. Pensar Enf [Internet]. 2025 Jan-Dec; 29(1): e00426

Available from:

https://doi.org/10.71861/pensarenf.v29iSup.426

Guidelines for the humanization of care provided by

the multidisciplinary team in the adult emergency

department

Abstract

Introduction

Portugal ranks among the leaders in the OECD for access to emergency services, where

users require immediate, efficient, and highly technology- and staff-intensive care.

Multidisciplinary team professionals deliver care in a routine, high-pressure therapeutic

environment that generates suffering and increases the vulnerability of care recipients.

Humanism regards human dignity as the highest value of life; when applied to health, its

principles call for realigning care goals beyond the biomedical perspective — a process we

term “humanization of care.”

Objective

To define guidelines for providing humanized care in the emergency department through

an integrative review of the literature; and to validate the content of those guidelines for

emergency department practice using a panel of experts and the Delphi methodology.

Methods

A simple descriptive observational study. For content validation of the 170 items composing

the guidelines, 20 health professionals with advanced training participated. The 170 items

were identified through an integrative review and organized into three levels: structural,

professional, and care. The ethics committee approved the study.

Results

After drafting the guidelines via an integrative literature review, a panel of experts was

convened, and two Delphi rounds were conducted to validate the content. Of the 170 items

initially evaluated, 167 were confirmed as valid after the second round. I-CVI values ranged

from 0.85 to 1.00, and S-CVI values ranged from 0.90 to 0.98.

Conclusion

Caring for others while feeling valued — by combining technical and scientific competence

with empathy and active listening — is the path toward a future in which health

professionals can make small but meaningful changes in the lives of care recipients, “making

them human.”

Keywords

Emergency unit; Humanization of Assistance; Delphi Technique.

Sara Campino1

orcid.org/0000-0001-9035-8548

Maria dos Anjos Dixe2

orcid.org/0000-0001-9035-8548

1 Master. Unidade Local de Saúde da Região de Aveiro,

Portugal.

2 PhD. Escola Superior de Saúde do Instituto

Politécnico de Leiria, Leiria, Portugal

Corresponding author

Sara Campino

E-mail: sara.campino.91@gmail.com

Received: 13.02.2023

Accepted: 08.10.2025

Editor: Pedro Lucas

Campino, S.

Qualitative Original Article

Introduction

Portugal leads the OECD in access to emergency

departments (EDs), with approximately 6.3 million ED

episodes per year, a volume often attributed to citizens’

inappropriate use of these services to meet their health

needs.1 Open 24 hours a day, seven days a week, the

emergency department is used by many as the first point of

contact with the Serviço Nacional de Saúde (SNS, National

Health Service), since it does not distinguish social classes

or economic status and follows a universal, general, and

largely free-of-charge philosophy that welcomes everyone

who presents.2 When a person turns to the ED, they expect

immediate, efficient care that is highly differentiated in

terms of technology and human resources.3 As access

increases — much of it driven by people with low-urgency

or nonurgent health problems — the challenges of

providing care in the ED setting grow.

In pursuit of rapid and efficient care, a routine, high-tension

therapeutic environment is frequently created, generating

anxiety and stress that heighten in the care recipient’s (CR)

feelings of vulnerability, anguish, and fear of death, pain, and

loss of functional capacity.4 Lemos5 notes that even when

surrounded by familiar persons and highly qualified health

professionals, an adult experiences the impact of an

emergency episode through physical, psychological,

emotional, and existential suffering, accompanied by a

profound sense of abandonment and isolation. All this often

culminates in conflicts stemming from misunderstanding

the service’s operating dynamics and from the conviction

that one’s own health problem requires immediate attention,

even when there are other situations of greater complexity

and severity.6 However, the burden of suffering caused by

death, pain, and disease — and by emergency department

overcrowding — does not fall solely on CRs and their

families: health professionals, as human beings, also suffer

in specific ways, since working in an ED entails biological,

social, and psychological risks often masked by a smile or by

a supposedly cold and distant demeanor.7

The biomedical model implemented in EDs arises from

professionals’ disease-centered focus, underpinned by

advances in biotechnology, pharmacology, radiology, and

other fields that provide objective and specific data about a

person’s clinical condition; these developments have

enabled increasingly specialized procedures for treating and

curing diseases that, until recently, had poor prognoses and

now offer new hope to CRs and professionals facing life-

threatening problems.8 However, the drive to avert death at

all costs and to reduce the person to a diseased body whose

problems are to be solved by complex, high-technology

therapeutic protocols has eroded the meaning of caring for

the human being as a biopsychosocial person with feelings,

beliefs, concerns, and agency. This approach creates a

barrier between the person and health teams, who may view

death as a failure and suffering as a consequence that can be

sedated or suppressed with medication.9

This posture of distancing and abstraction of the care

recipient as a human being, often adopted by professionals

as a defense against their own frustrations and fears,

compromises the quality of care by affecting ethical

decision-making, the development of therapeutic bonds,

and the establishment of trust between the care recipient

and the health team, so that the person feels supported and

listened to in all their individual needs.10 From this shift in

how the care recipient is conceived in the emergency

context arise paternalism and the “disappearance of the

human subject,” which Ávila-Morales11 classifies as the

dehumanization of health: a loss of fundamental values in

the efficient pursuit of curing organic diseases, leading to

depersonalization through disease codifications, the absence

of a relationship with the care recipient, the failure to

recognize individual dignity by applying principles of

equality to all, the lack of participation of the care recipient

in decision-making, the imposition of a power dynamic over

the care recipient and their decisions, and the conception of

the care recipient as a biological entity defined by a

pathology (psychiatric patient, HIV positive, etc.). In the

ED, these aspects take on greater significance, since the CR

is in an acute situation in which decision-making capacity

may be compromised, and the goal is rapid and effective

treatment to remove them from a life-threatening condition.

This depersonalization of care multiplies immeasurably

when demand for services is excessive, physical conditions

are inadequate, and staff-to-patient ratios are

disproportionate, reducing the time available for care.12 The

physical and psychological fatigue of professionals, as well

as the increasing complexity of patients in the ED, are

identified as indicators of the lack of implementation of

quality practices, particularly in the personalization of care,

which Barros13 highlights as the driving force for initiating a

profound reflection on the quality of ED care practices.

Thus, a research problem emerges: the promotion of

humanization of care provided by the multidisciplinary team

in adult emergency departments.

Health care services adhere to scientific principles in the

systematization and organization of work, with the

overarching goal of preserving life through advanced

technological means in diagnostic and therapeutic areas.14

When discussing the humanization of health services, the

first temptation may be to associate such projects with

criticism of how care is currently provided, even considering

it an affront to the supposed lack of humanistic capacity

among professionals working in these services, which

generates negative reactions and resistance to

implementation.15 Another temptation is to assume that the

humanization of care undermines scientific methods, as if

the intention were to turn professionals into “good people”

or demand immeasurable altruism and kindness in a

harmonious relationship with the CR.16 It is necessary to

demystify the notion that professionals are the main agents

of the dehumanization of care, since, on the contrary, they

are also victims of the system, which — focused on the

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DOI: 10.71861/pensarenf.v29iSup.426 / e00426

Qualitative Original Article

biomedical model and on financial, economic, rigid,

bureaucratic, and vertically hierarchical service management

— undermines relationships between care recipients and

health teams by depriving both parties of autonomy in this

care-provision dyad.17

The concept of humanism is philosophical in nature,

regarding the dignity of the human condition as life’s highest

value and defining the human being’s mission as seeking to

understand humankind and to create tools that recognize

the Other as an individual, free being with their own

potential and autonomy and with the right to happiness.18

When applied to the challenges of health care, the principles

of humanism necessarily call for realigning care objectives

beyond the classification, cure, and treatment of diseases,

and for dismantling the notion of care as merely service

delivery focused on biomedical aspects that obscure

everything that makes the CR truly a person.19 This shift in

perspective in health care provision can thus be termed

“humanization,” in the sense that it values the interaction

among the various stakeholders in care delivery (managers,

health professionals, CRs, and their families), with respect

for the dignity and autonomy of each individual through

sociability, empathy, understanding of beliefs, values,

perspectives of the Other, optimism, and a measure of

compassion for those who suffer.20 Building bonds between

health professionals and those they care for is at the core of

humanizing care, since the therapeutic relationship reflects

the valuing of the human being and the ethical and humane

attitude in approaching a person in a situation of particular

vulnerability.21 This change in the organization of the health

system as a whole will allow for dignified, ethical, and

personalized care, where dialogue and listening are as

fundamental as a stethoscope, and where improving

physical and technical conditions will always prioritize the

comfort of those who use health services.22 Humanization

of care enables the CR to share responsibility for their

health/disease trajectory, since they are the protagonist of

the care provided, the services offered, and the networks of

cooperation built around them.23 Recognizing the

uniqueness of the CR beyond physical needs is the greatest

challenge for humanizing care in the ED, since the time

required for active listening — indispensable for

understanding both speech and silence — is scarce, making

it difficult for the professional to acknowledge all

dimensions of the person seeking help.24 Creating the

conditions for this humanization of care in the emergency

context is the primary challenge to ensure respect for

privacy, dignity, ethical and moral values, and autonomy,

while improving interactions among the various actors in

care provision with the ultimate goal of reducing suffering

and making the emergency episode as minimally traumatic

as possible.25 Considering all these aspects, this study was

designed to address the research question: “What measures

can be implemented in adult emergency departments to

promote the humanization of care provided by the

multidisciplinary team?” The objectives are to define

guidelines for providing humanized care in the ED through

an integrative review of the literature and to validate the

guidelines for humanized care in the ED through an expert

panel using the Delphi methodology.

Methods

To answer the research question and meet the proposed

objectives, a simple descriptive observational study was

designed to establish a broad consensus on the

humanization of reception and care provided in EDs by

multidisciplinary teams.

Sample

To select the panel of experts that composed the sample, an

invitation email was sent to several health institutions,

committees, and professionals who met the following

inclusion criteria: interest in the study topic; being a

physician or nurse who provides (or has provided within the

last two years) care in adult EDs with at least 10 years of

professional experience; having advanced training in

Urgency and Emergency care, medical-surgical care, or

Bioethics; holding hospital management positions or

working in adult ED management (or having training in this

area); membership in patient/user committees with more

than three years of active service; membership in Ethics

Committees for the Life Sciences; being a clinical

psychologist experienced in delivering bad news; or being a

representative of the Health Regulatory Authority. These

criteria were defined to ensure that participating experts had

practical experience in ED care, ethics, and psychology.

Members of patient/user committees were invited to

provide the service-user perspective without the bias that

professionals’ operational knowledge of services might

introduce.

To screen participants who registered for the study

according to the defined inclusion criteria and to

characterize the future expert panel, respondents were asked

to complete a Microsoft Forms questionnaire presenting the

Informed Consent Form (ICF) for study participation.

Thirty participants responded to the invitation to form the

panel of experts, of whom 27 (90%) met the defined criteria.

However, after the first validation round, only 20 (67%) of

those enrolled responded, so only these participants were

considered for the expert panel. In addition to answering

sociodemographic and professional characterization

questions, participants were asked two open questions:

“What does humanizing health care mean to you?” and

“Why did you decide to pursue your profession?” These

questions were posed prior to the application of the

guidelines-validation questionnaire to learn what motivates

these professionals in their daily work and what they think

about the study topic, thereby fostering preliminary

reflection. Only physicians and nurses accepted the

invitation to participate in the study. The expert panel was

Campino, S.

Qualitative Original Article

characterized according to professional background and the

region of the country to which they belong, as shown in

Table 1:

Table 1. Professional characterization of the experts

(n = 20).

Physician

n = 5 (25%)

Years of experience

(mean)

Professional experience

13,2 years

Professional experience in ED

12,6 years

(n=)

Professional career

category

Nurse

40%

Specialist nurse

53%

Nurse manager

Health system sector

Public

100%

Private

Region

North

13%

Center

53%

Lisbon and Tagus Valley

27%

Alentejo

Algarve

Autonomous Region of the Azores

Autonomous Region of Madeira

Experts were asked to disclose their advanced training in

Urgency and Emergency care and in Bioethics. Of the 20

experts, 5 (2 physicians and 3 nurses) did not have advanced

training; among the remainder, some individuals held more

than one qualification, as described in Table 2:

Table 2. Training of the experts (total trainings: n = 24).

Level of training (n=)

% Course/training name

Included in

undergraduate

medical training

2 8% Intensive care medicine

Urgency and emergency care for adult

medical conditions

Postgraduate diploma

6 25%

Critical care (n = 2)

Critical care nursing

Urgency and emergency care

Intensive care and emergency care

Emergency and trauma

Postgraduate

specialization 4 17% Medical-surgical nursing (n = 2)

Medical-surgical nursing in the area of

critical care (n = 2)

Master’s degree 6 25%

Medical-surgical nursing — specialization

in nursing for persons in critical condition

(n = 5)

Bioethics

Prehospital care

training 6 25%

Immediate life support — nurses

Emergency medical care in the prehospital

setting

Helicopter transport

VMER (Medical Emergency and

Resuscitation Vehicle) (n = 2)

Trauma

Instruments

Following a brief preliminary search prior to the start of this

study, we identified several publications on the

humanization of care provided by nursing teams. However,

one objective of this study was to define guidelines for the

humanization of care delivered by the multidisciplinary

team, aiming to encourage all professionals to create a more

humanized care environment for those who seek EDs,

placing the person at the center of the team’s care. To

develop the guidelines and the items intended to achieve this

objective, an integrative review of the literature was

conducted because it enables the clarification and synthesis

of research findings on a topic.26 By identifying what is

already implemented in the field of humanization of care

and which studies exist, it was possible to establish items to

be implemented to improve the quality of care delivered in

EDs and to submit them for validation by the expert panel.

For this integrative review, the following inclusion criteria

were defined: all professional groups that assist people in

adult hospital emergency departments; all previously

described measures that promote individualized care

delivered by the multidisciplinary team; any documentation

produced on the humanization of health care;

documentation in Portuguese, English, and Spanish; and

any types of documents for which full-text access was

available. The databases searched according to these criteria

were EBSCOhost, SciELO, PubMed, BioMed Central, the

Virtual Health Library (Biblioteca Virtual da Saúde), and the

Portuguese Open Access Scientific Repositories. The

following Health Descriptors (DeCS and MeSH) were used

with the Boolean operator AND: “humanização da

assistência”/”humanization of assistance”/”Humanización

de la Atención”; “serviços médicos de emergência”/

“emergency care”/”Servicios Médicos de Urgencia”;

“adulto”/”adult.”

In an initial title screening, 1,934 records were selected for

abstract review, of which 146 were selected for full-text

reading. Applying the inclusion criteria above, 37 articles

were selected by the principal investigator to define the

guidelines; full analysis and reading of these documents

made it possible to extract 170 items, which, as they

emerged from the reviewed documents, required

organization into multiple levels and domains, as shown in

Table 3:

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DOI: 10.71861/pensarenf.v29iSup.426 / e00426

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Table 3. Guidelines for the humanization of care provided

by the multidisciplinary team in the emergency department.

A: STRUCTURAL LEVEL

This level lays the foundations required to deliver humanized care in

Emergency Departments (EDs), covering national policy, community health

interventions, adequacy of physical infrastructure and service support, and

hospital management.

A1: National policy domain 10,21,22

A national, cross

-cutting response across all

health institutions is essential to

address the humanization of care throughout health services.

A1.1. Develop a National Plan for Humanized Healthcare (PNHCS).

A1.2. Involve nurses, social workers, and psychologists in developing the

national plan.

A1.3. Include the PNHCS in the next National Health Plan.

A1.4. Replace the designation “user” with “care recipient (CR).”

A1.5. Streamline access to healthcare.

A1.6. Streamline the referral network.

A1.7. Streamline internal care networks.

A1.8. Implement triage and risk classification in all health institutions.

A1.9. Conduct regional studies of ED user populations and tailor responses

accordingly.

A1.10. Conduct municipal studies of resident populations and adapt

responses at the primary care level.

A1.11. Promote cooperation between regional and municipal authorities to

implement measures that promote individual and community health.

A1.12. Promote cooperation between regional and municipal authorities to

implement disease-prevention measures.

A1.13. Create effective communication channels between the public and

health institutions.

A1.14. Establish forums for dialogue between communities and health

institutions about needs and barriers.

A1.15. Create mechanisms to foster individual accountability of the CR for

their health care pathway.

A1.16. Identify the CR and a designated family member as part of the

multidisciplinary care team.

A2: Community health intervention domain 27,28

To ensure appropriate ED use, promote health literacy and public awareness

at individual and community levels. By strengthening local care delivered

through health centers and family health units, reduce ED visits for low

acuity

or non

urgent conditions and enable professionals to focus on urgent and

emergency cases.

A2.1. Empower citizens to take an active role in their health-care pathway.

A2.2. Implement individual health projects in Primary Health Care (PHC).

A2.3. Implement community health projects.

A2.4. Conduct media campaigns across communication channels to clarify

the role and scope of Emergency Departments.

A2.5. Distribute posters explaining Primary Health Care and its scope of

services.

A2.6. Conduct seasonal health promotion and disease-prevention campaigns

targeting different

age groups.

A2.7. Conduct health education campaigns explaining which urgent and

emergencies justify ED visits.

A2.8. Implement health education protocols across all care levels to define

which urgent and emergencies justify ED visits.

A2.9. Implement health education protocols across all care levels to clarify

the CR’s role in their health

-care pathway and their co-responsibility within

the care team.

A2.10. Implement triage-based health education protocols to explain

priorities for care.

A2.11. Implement caregiver support programs to strengthen caregivers’

knowledge of health promotion and of preventing acute exacerbations of

chronic conditions

A3: Infrastructure adequacy domain 29, 30, 31

The physical environment, equipment, and appearance of EDs play a central

role in promoting environmental comfort and the well

being of CRs, reducing

suffering and psychological distress, and clarifying internal service pathways.

A3.1. Allocation of financial resources for the physical redesign of EDs.

A3.2. Physical layout of EDs that is flexible and adaptable to exceptional

events, disasters, pandemics, etc.

A3.3. Regular acquisition of modern, high-quality equipment to replace items

that are inoperable and/or outdated.

A3.4. Adequate and regular maintenance of equipment.

A3.5. Regular maintenance of the service’s physical premises.

A3.6. Adequacy of triage areas to ensure calm and full privacy.

A3.7. Creation of individual changing rooms for dressing and undressing CRs

on arrival and departure.

A3.8. Adequacy of physical spaces for assessment of CRs with privacy,

comfort, and without interruptions.

A3.9. Adequacy of consultation rooms for family members/companions to

collect clinical information and to receive updates on t

he CR’s clinical

progress.

A3.10. Adequacy of physical spaces to guarantee full privacy for CRs during

procedures and clinical observation.

A3.11. Creation of a lactation room with access to a breast pump.

A3.12. Clear identification of internal routes and the various rooms of the

ED in a simplified, visible, and accessible manner.

A3.13. Provision of information about internal routes at multiple points

throughout the service.

A3.14. Adequate signage for restrooms, exits, routes, information services,

and other key areas.

A3.15. Reduction of noise (alarms, architectural interventions).

A3.16. Lighting with adjustable intensity options across different rooms.

A3.17. Service layout that allows natural light to enter, enabling staff and

users to distinguish the time of day.

A3.18. Placement of clocks in all rooms and corridors.

A3.19. Installation of air renewal/ventilation systems to ensure air quality and

odor removal.

A3.20. Creation of free access water points.

A3.21. Installation of air-conditioning systems that allow control and

maintenance of a comfortable temperature across rooms.

A3.22. Playing ambient music that promotes calm in waiting rooms.

A3.23. Provision of charging points for electronic devices.

A3.24. Provision of free-access Wi-Fi.

A3.25. Installation of televisions in waiting rooms with messages aimed at

health education, explanations of internal routes, priorities for care, and other

relevant topics.

A3.26. Broadcasting of nature films on televisions that do not require audio.

A3.27. Pleasant decoration of waiting rooms through the display of art, soft

colors, and similar measures.

A3.28. Paint waiting rooms in different ED areas according to the triage

priority color.

A3.29. Provision of equipment to allow companions to rest overnight while

accompanying a CR with a high degree of dependency.

A3.30. Allocation of rooms for delivering bad news that ensures total privacy,

without unnecessary interruptions, and in which family

members and

companions recognize a safe space to express their emotions.

A3.31. Creation of relaxation spaces for staff, properly equipped and with

comfortable furniture.

A4: Institutional and emergency departments management domain29, 32

Hospital management that promotes humanized care should foster

cooperation and participation among managers, professionals, and service

users. Middle management in EDs must ensure staff well

being and the proper

functioning of multidisciplinary teams so care is delivered by professionals who

feel valued and fulfilled in their work.

A4.1. Ensure safe staffing levels for the multidisciplinary team.

Campino, S.

Qualitative Original Article

A4.2. Conduct quarterly studies on ED access (number of visits, acuity levels,

waiting times, length of stay) to adjust staffing rosters and work schedules.

A4.3. Establish standby teams to be activated during periods of higher ED

attendance or when there is an increased number of complex patients

requiring higher staffing ratios.

A4.4. Create reinforced staffing rosters for days with expected higher ED

attendance.

A4.5. Implement strategies to reduce time to first contact.

A4.6. Refer non-urgent patients or those meeting “white wristband” criteria

to specialty outpatient clinics or PHC.

A4.7. Expedite intra- and inter-hospital referral networks.

A4.8. Organize ED specialty teams to operate in a complementary model.

A4.9. Create referral teams in the ED for the various medical specialties and

for social work.

A4.10. Define CR referral pathways to be used by physicians and nurses.

A4.11. Create care circuits centered on the CR.

A4.12. Encourage a culture of reporting problems and resolving them

through cross

-functional co-management that involves all multidisciplinary

team members and includes them in major

management decisions.

A4.13. Establish focus groups to evaluate the implementation of new care

strategies, involving health professionals, managers, and service users through

problem-based discussion.

A4.14. Create multidisciplinary working groups (health councils) to manage

work organization processes, analyze productivity, define tasks, and develop

continuous quality improvement projects.

A4.15. Address hierarchical power dynamics between professional groups.

A4.16. Promote teamwork with the shared goal of providing humanized,

high

-quality care.

A4.17. Acknowledge legitimate differences among team members, promote

unity, and develop action strategies for critical situations through team

building events.

A4.18. Define technical and humanistic criteria for admitting professionals to

provide care in EDs.

A4.19. Promote a collaborative, low-conflict professional environment.

A4.20. Motivate and recognize proactive professionals as champions and

leaders of change.

A4.21. Create a hospital humanization group.

A4.22. Define liaison roles within services for the humanization of care.

A4.23. Promote spaces for reflection and discussion to resolve conflicts and

foster attitude change.

A4.24. Establish a structured listening system at management levels to collect

concerns, receive feedback, and develop solutions, including an open

communication channel for service users.

A4.25. Implement an open-door policy allowing companions to remain with

the CR continuously, regardless of their level of dependency.

B: PROFESSIONAL LEVEL

Professionals from the various fields who work in EDs are the primary actors

in implementing measures for humanized care. Therefore, they should also be

targeted by humanization measures so they can perform their work

satisfactorily for themselves and for those they serve. In addition, it is essential

to promote initiatives that produce knowledge and provide continuing

education.

B1: Domínio da Formação dos Profissionais do Serviço de Urgência 8,11,

15,

17, 19, 21, 22, 24, 33,35,36, 37

Introducing humanized care into medical and nursing curricula is part of the

path to ensure that future health professionals are mentored and trained in

humanized practices and in holistic clinical assessment.

B1.1. Administer psychometric assessments as part of admissions to higher-

education health programs.

B1.2. Assess humanistic and interpersonal competencies of students enrolled

in health-related programs.

B1.3. Ensure medical, nursing, and healthcare assistant curricula include a

mandatory component to develop humanistic competencies, communication

skills, and holistic clinical practice.

B1.4. Establish graduate-certificate programs in humanized care.

B1.5. Foster closer links between health schools (medicine and nursing) and

care institutions to increase research and scientific production in humanized

care.

B1.6. Implement mentorship programs in medical and nursing education

focused on humanized care and on creating safe spac

es for students and

tutors to share experiences and cultivate professional bonds.

B1.7. Create internship programs within Life Sciences Ethics Committees for

medicine and nursing students.

B1.8. Develop Ethical Life Support courses for multidisciplinary teams

working in EDs (A

— Recognition; B — Care; C — Communication; D —

Management).

B1.9. Train ED professionals in communication techniques, with refresher

training every 5 years.

B1.10. Provide specific mental health training for ED professionals who are

not mental health specialists, with refresher training every 5 years.

B1.11. Train ED administrative staff in communication and in serving people

with special needs.

B1.12. Train medical and nursing teams in delivering bad news.

B1.13. Conduct practical drills for caring for people presenting to EDs after a

suicide attempt.

B1.14. Train multidisciplinary teams in family support during resuscitation.

B1.15. Provide training to all ED team members on cultural differences and

on personali

zed care for people from other cultures, religions, or belief

systems

B2: Support and professional recognition domain 4,7, 8, 10, 14, 15, 17, 19, 20,21, 22, 27,

29,

Recognition, promotion of staff satisfaction, and the health of

multidisciplinary teams enable them to provide higher

quality care and to be

more available to apply the humanized care principles.

B2.1. Establish incentive schemes that support training, capacity building, and

professional development tied to career progression.

B2.2. Promote staff satisfaction through employment stability, improved

compensation, productivity incentives, and recognition of individual and

team competencies.

B2.3. Implement initiatives to promote work-life balance.

B2.4. Implement physical and emotional support programs for ED staff.

B2.5. Require annual mental health screening of ED professionals by a

clinical psychologist to identify mental health conditions and burnout.

B2.6. Provide decompression areas outside clinical zones where staff can rest

and recover from stress.

B2.7. Promote team-building events to foster positive interprofessional

relationships, empathy, sociability, resilience, and se

lf-control in high-

pressure

or conflict situations.

B2.8. Implement multidisciplinary reflection cycles on humanized care

practices and on coordinated, collaborative work between teams, recognizing

each member’s role.

B2.9. Define performance evaluation objectives collaboratively with staff and

align them with ED care delivery.

B2.10. Promote inclusive decision-making by involving staff in developing

inclusive work methodologies aimed at a shared objective: CR well

being and

professional recognition

C: CARE LEVEL

Changes in work methods and in approaches to attending CRs and their

companions

—grounded in all previously described domains—

enable the

transition from a biomedical view of the person to a holistic perspective,

shifting the focus from disease

to the person and their needs. This approach

supports the delivery of humanized, personalized care that dignifies the

individual as a unique person with specific needs.

C1: User embracement domain 4,5,6, 8, 17, 21, 22, 27, 28, 29, 33, 34, 36, 38

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Pain, physical and mental illness, and the time CRs and their companions spend

in the waiting room before medical attention generate anxiety and tension. User

embracement throughout the ED stay addresses these situations and seeks to

reduce the suffering they cause.

C1.1. Reduce bureaucracy in ED registration.

C1.2. Privately record the reason for ED presentation (assault, fall,

pregnancy, etc.) during triage.

C1.3. Minimize or eliminate interruptions during triage.

C1.4. Provide CRs with information at triage about care available in EDs and

PHC when the assigned priority is not urgent, very urgent, or emergency.

C1.5. Flag the need for social support during triage when appropriate.

C1.6. Inform CRs and their companions about waiting times, ED workflows,

and referral pathways; answer questions and listen to their concerns and

expectations.

C1.7. Ensure transfer equipment allows safe and comfortable movement of

CRs.

C1.8. Allow continuous presence of a companion during CRs’ ED stay,

except during exposure, invasive, or diagnostic procedures, unless the CR

consents.

C1.9. Implement a culture of continuous information sharing with CRs and

their companions, with CR’s consent.

C1.10. Create a reference nurse or care-manager nurse role to follow CRs

from admission to clinical discharge, serving as a liaison between the

multidisciplinary team and CRs and their companions.

C1.11. Create a quick-reference guide on cultural practices and norms to

support respectful reception and care

for people from diverse cultural

backgrounds.

C1.12. Develop communication booklets for use by the ED for people with

cognitive, hearing, or visual impairments.

C1.13. Produce documentation in Braille (e.g., informed consent forms,

treatment instructions, etc.).

C2: Clinical assessment domain 6, 8, 22, 29, 31, 33, 39

The clinical assessment performed by the multidisciplinary team must cover

multiple components related to physical and mental health as well as

psychosocial issues.

Effective, solution-

oriented communication and active

listening are essential tools to ensure CRs feel heard and properly attended to.

C2.1. Integrate social assessment into CRs’ clinical assessment.

C2.2. Implement rapid mental health screening protocols and referral

pathways to mental health services (psychiatry or clinical psychology).

C2.3. Conduct clinical assessments in a calm, quiet environment designed to

assure CRs that the consultation is a setting for attentive, qualified listening to

their concerns, with privacy and without interruptions.

C2.4. Recognize and prioritize pain complaints as a core element of clinical

assessment.

C2.5. Establish therapeutic bonds with CRs.

C2.6. Implement ED admission protocols that include two separate clinical

assessments: a medical assessment followed by a nursing assessment.

C2.7. Use plain language when communicating with CRs.

C2.8. Minimize bodily exposure and ensure it occurs in locations that

guarantee full privacy.

C2.9. Limit the number of professionals present during exposure and physical

examinations to the minimum strictly necessary.

C2.10. Ensure nursing assessment and the development of individualized care

plans based on needs identified in the assessment

C3: Person-centered care domain 3,4,5,6,8,10,12,

14,15,19,20,22,23,24,25,27,28,29,31,33,35,39,40,41,42

Teamwork with a person

centered focus enables differences of opinion to

enrich the care process among the various professionals in the teams. The ED

should act as a starting point or a moment to revise the person’s individual

health plan, in which the person, together with professionals, establishes a

shared plan for their life

course and health/illness trajectory in coordination

with their family and PHC.

C3.1. Create a 24-hour bioethics advisory service to support professionals

and families.

C3.2. Structure the medical consultation around the CR through active

listening.

C3.3. Assess social conditions and support needs during the medical

consultation.

C3.4. Deconstruct paternalistic approaches toward the CR: introduce yourself

(e.g., “My name is X and I am Y”), smile, greet the person, adapt technical

language, show interest in what they say, and make eye contact.

C3.5. Use friendly conversation as a data-collection tool.

C3.6. Identify the person by their preferred name rather than by their

pathology during contacts and at transitions of care.

C3.7. Conduct a nursing assessment after the medical consultation according

to the person’s basic human needs and

ensure these are met (hygiene,

hydration, adequate meals, etc.).

C3.8. Create nursing consultations for low- and non-urgent situations to

assess teaching needs and to promote the person’s participation in their

individual health plan.

C3.9. Promote autonomy and independence at all times during care delivery.

C3.10. Maintain continuous negotiation of care with shared responsibility by

the person for their role, involving them in decision

-making processes and

recording their preferences, feelings, and beliefs in the clinical record.

C3.11. Explain procedures performed, their benefits and risks, and the

rationale for complementary diagnostic tests.

C3.12. Request feedback from the CR on the current therapeutic plan and

clarify any doubts.

C3.13. Continuously assess therapeutic adherence.

C3.14. Explore reasons for nonadherence at home and define strategies to

address gaps.

C3.15. Provide ongoing information to the CR about possible diagnoses,

eliminating deception and the “conspiracy of silence,

” while never

abandoning hope.

C3.16. Promote inclusion of the companion in care delivery when authorized

by the CR, avoiding situations in which family members assume guardianship

over an older adult, and maximizing the person’s autonomy when cognitively

intact.

C3.17. Assess burnout in the primary caregiver.

C3.18. Inform family members about the CR’s clinical situation whenever

possible and with prior authorization from the CR.

C3.19. Permit the presence of a family member during resuscitation if they

wish, with a designated staff member present to support them and to explain

all interventions being performed.

C3.20. Ensure the multidisciplinary team maintains continuous attention to

reducing, eliminating, and controlling acute and chronic physical a

psychological pain.

C3.21. Train volunteers to implement non-pharmacological pain-management

strategies (distraction techniques, among others) and to provide emotional

support.

C3.22. Administer analgesia for all procedural interventions, regardless of

their complexity.

C3.23. Communicate bad news to the CR and/or their family in a calm,

uninterrupted setting, allowing them space to share their feelings, doubts, and

anguish.

C3.24. Create protocols for delirium management in the ED that include

chemical restraint when appropriate, reduction of sensory stimuli, and the

presence of a companion if they are a calming influence for the CR.

C3.25. Avoid physical restraint whenever possible; if unavoidable, limit its

duration to a

defined maximum number of hours and inform the CR of its

necessity.

C3.26. Allocate people under observation according to their gender,

prioritizing care provision by same-gender staff when appropriate.

C3.27. Understand and accept a CR’s refusal of treatment, ensuring they are

informed of the risks of their decision and documenting this in the clinical

record.

Campino, S.

Qualitative Original Article

C3.28. Schedule timely medical re-evaluation appointments in PHC after an

ED episode.

C3.29. Create a nursing follow-up consultation after medical discharge from

the ED to provide education on the therapeutic regimen, address the CR’s

needs, and answer questions

C4: Death and end-of-life domain 8, 9, 12, 22, 41

Death and end

-of-life situations are common in EDs. Creating

conditions that

allow CRs and their families to experience these moments with dignity ensures

humanized care continues until the person leaves the department.

C4.1. Promote completion of advance directives among the population.

C4.2. Transfer CRs in cardiac arrest to a designated area away from other

patients and their families.

C4.3. Limit invasive interventions that cause suffering in terminally ill CRs.

C4.4. Empower CRs in the terminal phase by offering choices about end-of-

life care.

C4.5. Establish palliative care teams with a permanent on-site presence in

EDs.

C4.6. Minimize the suffering of CRs and their families by applying principles

associated with a good death.

C4.7. Encourage open discussion about death with families and among

professionals.

C4.8. Make psychological support available to families.

C4.9. Create spaces where CRs can die with dignity and be accompanied by

their loved ones.

C4.10. Provide emotional-intelligence training for professionals to help them

cope with death and

with treatment failure

Guidelines validation procedures

The Delphi methodology enables building consensus when

empirical and scientific evidence on a given topic is

dispersed, by using a panel of experts chosen according to

predefined criteria.43 As Barrios et al. note42, the Delphi

process allows anonymous participation, which reduces

social pressure on individual responses and helps achieve a

convergence of opinions that more faithfully reflects

participants’ convictions despite their diverse backgrounds

and levels of experience. The questionnaires used to validate

the guidelines were created in Microsoft Forms and divided

according to the three previously presented levels

(A: Structural; B: Professional; C: Care) to accommodate the

required number of responses and to avoid software

limitations. They were sent to the email addresses that

experts had provided in the first survey using the code

assigned as their name. The investigators had access only to

the code and the corresponding email address and,

therefore, could not identify who completed the surveys,

which ensured participants’ full anonymity because

respondents were not asked to identify themselves.

The items for validation were presented according to Table

III, and experts were asked to rate each item using the

following Likert scale:

1. Totally disagree

2. Partially disagree

3. Neither agree nor disagree

4. Partially agree

5. Totally agree

When a score of 1, 2, or 3 was assigned, experts were asked

to provide a comment justifying their disagreement or lack

of agreement with the item. The scores were then used to

compute content validity indices. Yusoff44 recommends an

item-level content validity index (I-CVI) of at least 0.78 to

consider an item valid for a panel size of nine or more.

Because a panel of 20 experts was assembled, this threshold

was adopted to define positive item validation. In the first

round, only 6 items (3.5%) failed to reach agreement; these

items were revised according to experts’ suggestions and

resent for revalidation. In the second round, 15 experts

(75% of the panel) responded to the revalidation of the

revised items; of those revised items, only 3 (50%) achieved

agreement. Consequently, the three items that failed to

obtain agreement in both rounds were removed from the

initial set. The calculations used to establish content validity

followed Yusoff44 and included: Experts in Agreement

(EA); Universal Agreement (UA); item-level content validity

index (I-CVI); and scale-level content validity index (S-CVI),

computed both by the Mean Method and by the Universal

Agreement Method.

Ethical considerations

The Ethics Committee of the School of Health of the

Polytechnic Institute of Leiria approved the study. In the

initial questionnaire, participants were asked to identify

themselves using an initialism formed from the initials of

their name (for example, SRVC), so that investigators could

link email addresses for feedback on the study’s progress

while preserving participants’ anonymity.

Results

The first Delphi validation round included the 20 selected

experts, who were numbered P1–P20 to preserve the

anonymity of their responses. The results are presented in

Table 4:

Table 4. Results of the first validation round.

A: STRUCTURAL LEVEL

A1: National policy domain

Items

Experts in

agreement

Universal agreement

I-CVI

A1.1

1.00

A1.2

1.00

A1.3

1.00

A1.4

0.60

A1.5

0.95

A1.6

0.95

A1.7

1.00

A1.8

1.00

A1.9

1.00

A1.10

1.00

A1.11

1.00

A1.12

1.00

A1.13

0.95

A1.14

0.95

A1.15

0.95

A1.16

0.90

S-CVI (mean): 0.95

S-CVI (UA): 0.56

A2: Community health intervention domain

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A2.1

1.00

A2.2

1.00

A2.3

1.00

A2.4

0.95

A2.5

0.95

A2.6

1.00

A2.7

1.00

A2.8

1.00

A2.9

1.00

A2.10

0.95

A2.11

1.00

S-CVI (mean): 0.99

S-CVI (UA): 0.73

A3: Infrastructure adequacy domain

A3.1

1.00

A3.2

1.00

A3.3

1.00

A3.4

1.00

A3.5

1.00

A3.6

1.00

A3.7

0.90

A3.8

1.00

A3.9

1.00

A3.10

1.00

A3.11

1.00

A3.12

1.00

A3.13

0.95

A3.14

1.00

A3.15

1.00

A3.16

1.00

A3.17

1.00

A3.18

1.00

A3.19

1.00

A3.20

1.00

A3.21

1.00

A3.22

0.90

A3.23

1.00

A3.24

0.95

A3.25

1.00

A3.26

0.80

A3.27

1.00

A3.28

0.80

A3.29

1.00

A3.30

1.00

A3.31

1.00

S-CVI (mean): 0.98

S-CVI (UA): 0.81

A4 – Institutional and emergency department management

domain

A4.1

1.00

A4.2

0.95

A4.3

1.00

A4.4

1.00

A4.5

1.00

A4.6

0.95

A4.7

1.00

A4.8

1.00

A4.9

1.00

A4.10

0.95

A4.11

1.00

A4.12

1.00

A4.13

1.00

A4.14

1.00

A4.15

0.90

A4.16

1.00

A4.17

1.00

A4.18

1.00

A4.19

1.00

A4.20

1.00

A4.21

0.95

A4.22

1.00

A4.23

1.00

A4.24

0.95

A4.25

0.75

S-CVI (mean): 0.98

S-CVI (UA): 0.72

B: PROFESSIONAL LEVEL

B1: Training domain for emergency department

professionals

B1.1

0.90

B1.2

1.00

B1.3

1.00

B1.4

0.95

B1.5

0.95

B1.6

0.90

B1.7

0.85

B1.8

0.95

B1.9

0.95

B1.10

0.90

B1.11

1.00

B1.12

1.00

B1.13

0.95

B1.14

0.95

B1.15

0.95

S-CVI (mean): 0.95

S-CVI (UA): 0.27

B2: Support and professional recognition domain

B2.1

1.00

B2.2

1.00

B2.3

1.00

B2.4

1.00

B2.5

1.00

B2.6

1.00

B2.7

1.00

B2.8

0.95

B2.9

1.00

B2.10

0.95

S-CVI (mean): 0.99

S-CVI (UA): 0.80

C: CARE LEVEL

C1: User embracement domain

C1.1

0.95

C1.2

0.85

C1.3

1.00

C1.4

0.90

C1.5

0.85

C1.6

1.00

C1.7

1.00

C1.8

0.80

C1.9

0.95

C1.10

0.85

C1.11

0.80

C1.12

0.80

C1.13

0.95

S-CVI (mean): 0.91

S-CVI (UA): 0.23

C2: Clinical assessment domain

C2.1

0.85

C2.2

0.95

C2.3

0.95

Campino, S.

Qualitative Original Article

C2.4

0.90

C2.5

0.75

C2.6

0.85

C2.7

0.95

C2.8

0.95

C2.9

0.95

C2.10

0.85

S-CVI (mean): 0.90

S-CVI (UA): 0.00

C3: Person-centered care domain

C3.1

0.80

C3.2

0.95

C3.3

0.85

C3.4

1.00

C3.5

0.95

C3.6

0.95

C3.7

1.00

C3.8

0.75

C3.9

1.00

C3.10

1.00

C3.11

1.00

C3.12

0.95

C3.13

0.95

C3.14

0.95

C3.15

0.95

C3.16

1.00

C3.17

0.95

C3.18

1.00

C3.19

0.65

C3.20

0.95

C3.21

0.80

C3.22

0.95

C3.23

1.00

C3.24

0.95

C3.25

0.95

C3.26

0.85

C3.27

1.00

C3.28

1.00

C3.29

0.90

S-CVI (mean): 0.93

S-CVI (UA): 0.34

C4: Death and end-of-life domain

C4.1

0.85

C4.2

0.70

C4.3

1.00

C4.4

0.95

C4.5

0.85

C4.6

1.00

C4.7

1.00

C4.8

1.00

C4.9

0.95

C4.10

0.95

S-CVI (mean): 0.93

S-CVI (UA): 0.40

In summary, the structural level submitted the largest

number of items for validation (n = 83), followed by the

care level (n = 62) and the professional level (n = 25).

The item with the lowest item-level content validity index

was A1.4 (I-CVI = 0.60), corresponding to the proposed

change of the designation “Utente” (user) to “Pessoa

Cuidada (PC)” (care recipient). A brief analysis of the

calculations shows that all domains exhibited a mean scale-

level CVI between 0.91 and 0.99, indicating a high degree of

agreement with the items presented. However, when

considering S-CVI by Universal Agreement (S-CVI/UA),

no domain reached absolute UA (1.0); values ranged from 0

(Domain C2 — Clinical assessment) to 0.81 (Domain A3 —

Infrastructure adequacy). A summary of S-CVI by domain

is shown in Figure 1:

Figure 1. Summary of S-CVI by domain.

For the second round, the six items with I-CVI < 0.78 were

identified and their content revised according to experts’

suggestions, yielding the following proposed changes:

• A1.4: Change the designation “Utente” to “Pessoa

Alvo dos Cuidados” (PAC) and standardize this

nomenclature.

• A4.25: Implement an open-door policy allowing

companions to remain continuously with the CR,

regardless of the CR’s level of dependency, except

in clinical areas with patients in critical condition

and during procedures or situations that require

bodily exposure.

• C2.5: Develop strategies to establish rapid yet

effective therapeutic bonds with the CR.

• C3.8: Schedule nursing appointments at Primary

Health Care (PHC) centers for low- and non-

urgent cases to assess educational needs and

promote the person’s participation in their

individualized health plan.

• C3.19: Permit the presence of a family member at

the start of resuscitation, if the family member so

wishes, assigning a staff member to accompany

them to a quiet area to await information from a

member of the resuscitation team after the

procedure.

• C4.2: Transfer PACs in cardiopulmonary arrest to

a designated resuscitation area away from other

CRs; if resuscitation is unsuccessful, allow family

members to be with the body to begin mourning.

Fifteen experts (75% of the panel) responded in the second

round:

Table 5. Results of the second validation round.

Items

CVI

A1.4

0,40

0.95 0.99 0.98 0.98 0.95 0.99 0.91 0.91 0.93 0.93

0.56

0.73 0.81 0.72

0.27

0.8

0.22

0.34 0.4

0,2

0,4

0,6

0,8

A1 A2 A3 A4 B1 B2 C1 C2 C3 C4

IVC-S (Média) IVC-S (AU)

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Qualitative Original Article

A4.25

0,60

C2.5

0,93

C3.8

1,00

C3.19

0,60

C4.2

1 1 1 0 1

1 0 1 1 1 1 1

1 1 13

0,87

S-CVI (mean): 0,73

S-CVI (UA): 0,17

Consequently, items A1.4, A4.25, and C3.19 were removed

from the initial set. The revised versions of items C2.5, C3.8,

and C4.2 were approved and, therefore, represent the final

versions to be implemented as guidelines.

Discussion

This research project set out to identify ways to overcome

the challenges to humanizing care in EDs and to define the

measures needed, based on existing knowledge, to humanize

the care delivered by multidisciplinary teams. The literature

review revealed that this is a concern among nurses who

conduct studies and propose measures to enhance the care

they provide, thereby contributing to the updating of the

conceptualization of Caring and the development of nursing

knowledge, which in turn reinforces their mission within

health services and improves quality.45 Driven by the

biomedical model implemented in EDs and by the

exponential growth of health technologies, the

depersonalization of care has distanced professionals from

those they care for, and vertically hierarchical service

management pressures them to produce rapid, efficient

results, hindering recognition of the person’s uniqueness

beyond their physical needs.24 Humanization of care

requires the involvement of all stakeholders — direct and

indirect — in creating conditions for personalized care

grounded in therapeutic relationships that confer dignity

and comfort to those who seek EDs 22. In response to the

research question, 170 measures were defined and

categorized into three levels (Structural, Professional, and

Care) after a full-text review of 37 articles, resulting in

measures distributed across 10 domains. In addition to the

guidelines defined, it is worth noting that concern for

humanizing care already exists as national programs in other

countries and as continuous improvement projects in

obstetric, pediatric, and psychiatric settings. The greatest

number of proposed measures is in the domain of

infrastructure adequacy (n = 31), while the fewest are in the

domains of clinical assessment, professional support and

recognition, and death and end-of-life care (n = 10).

This distribution reflects the larger number of studies

proposing changes in those areas rather than a difference in

relative need.

After being defined through the integrative literature review,

the guidelines’ content was validated in two rounds using

the Delphi methodology, which is recognized for its

efficiency in building consensus among diverse

professionals on topics where they hold relevant

professional and academic experience.43 Barrios et al.42

emphasize that appropriate expert selection reduces bias,

that opinions are principally shaped by researcher feedback

rather than by experts’ sociodemographic or professional

attributes, and that decision validity is strengthened by

submitting proposals to multiple rounds, as done here.

Because no substantive feedback was provided to

participants between rounds, we minimized the

investigator's influence on experts’ opinions. Twenty

experts were selected according to the predefined criteria

and participated in this study; in the first round, they

approved 164 proposed guidelines. After the second round

of validation of the remaining measures, now evaluated by

15 experts, three items were eliminated at the end of

the study.

When asked at the start of the study why they had chosen

to become physicians and nurses, the experts reported: a

strong community-oriented drive to help others; a passion

for caring for other people; the conviction that helping

another human being can contribute to the change they wish

to see in the world; and the experience of caring as work that

fulfills the professional and makes them feel complete as a

person—motivations rooted in family illness histories and

values received during personal development. Being part of

that change motivated all these professionals to pursue (and

to remain in) their chosen professions and to participate in

this study. For the surveyed experts, the humanization of

care entails a necessary renewal of clinical practice toward

personalization of care and liberation from a mechanistic

model of health care delivery, placing the person and their

needs at the center. Their contribution to this study enabled

the presentation of a proposal for change in EDs and

addressed the need to humanize care through

implementation of good practices and recognition of the

role professionals can play—beyond technical and scientific

competence—in improving the lives of those they care for.

The item-level content validity index calculation enables the

quantification of experts’ agreement for each proposed

measure, with values ranging from 0.60 to 1.00. An absolute

value (1.00) corresponded to Universal Agreement, which

was achieved for 89 of the items under validation (52%).

Thus, the items can be considered to have been well

approved by the panel, since only 6 (3.5%) required

reformulation and revalidation in the subsequent round.

Further evidence of high agreement is provided by the mean

scale-level content validity index, whose values across

domains ranged from 0.91 to 0.99, with an overall mean of

0.95 for all items. The domains with the highest levels of

agreement were A2 and B2; those with the lowest were C1

and C2. Achieving this broad consensus demonstrates how

the plurality of opinions among diverse experts can coincide

even when responses are provided anonymously.

Universal Agreement was never reached at the domain level

(UA = 1.00), despite 89 items attaining UA = 1. Although

consensus was reached for the 164 items validated in the

first round, no domain achieved universal agreement across

Campino, S.

Qualitative Original Article

all proposed measures. Indeed, the S-CVI (UA) calculation

shows that domain C2 had no items with UA, while A3 had

the highest mean UA (0.81). Therefore, consensus is

attainable even when experts do not fully agree on every

item. Ideally, UA would be achieved for all items, but the

diversity of opinions enriches studies of this nature because

it yields multiple perspectives on a topic while allowing the

panel to conceive and validate concepts considered

acceptable by the majority of its members.

As noted above, six items did not reach an I-CVI ≥ 0.78 and

were therefore revised and resubmitted for a second round.

In that round, 15 of the 20 experts (75%) participated, and

this decline was one of the challenges encountered during

the study. One possible explanation for the reduced

participation is the limited time available to reflect

adequately on the presented items, since all participants are

active health professionals facing daily demands on their

time and physical/mental energy. In this second round, only

50% of the revised items achieved approval despite an S-

CVI (mean) of 0.73. Interestingly, only one item reached

Universal Agreement (C3.8). This finding reflects

recognition of the importance of follow-up by Primary

Health Care nurses for care recipients who visit an ED and

are assigned a low- or non-urgent priority. Andrade and

Donelli27 propose such follow-up to provide clarification of

treatment regimens, condition-specific education, and

reassessment of needs. The need to establish care networks

among institutions through referral pathways is also

recognized at this level of agreement and UA,

as Lopes argues.

Item A1.4 failed to obtain approval in both rounds,

recording an I-CVI of 0.60 in the first round and 0.40 in the

second, even after its content was revised. Although Lopes

argues that people who seek health care should not be seen

as clients but as persons in need of help — and therefore

labelled Pessoa Cuidada or Pessoa Alvo dos Cuidados

(PAC), a nomenclature to be standardized as part of a

person-centered care policy — this item was removed.

Experts’ justifications included: the complexity of the

proposed nomenclature; doubts as to whether the change

would actually improve care delivery; the fact that the

acronym PAC is already used to denote community-

acquired pneumonia, creating confusion and

communication difficulties within teams; the term “alvo”

(target) not conveying the person’s involvement in their

care; and the concern that associating the label “cuidado”

(care) with the person could create a sense of loss of

autonomy for the CR.

Item A4.25 followed the same downward trend in I-CVI

after its content was revised, reflecting experts’ concerns

about clinical areas where patients are critically ill, privacy,

and confidentiality. In both rounds, experts emphasized that

their clinical experience revealed companions may hinder

care delivery due to unfamiliarity with service dynamics,

frequent overcrowding in EDs, companions’ refusal to

assist with hygiene and feeding tasks, inappropriate conduct,

and infection-control risks. Lemos5 advocates applying the

pediatric model of companion presence to adults in EDs to

reduce the suffering and anxiety this setting causes CR. This

view is reinforced by Rios19, who notes that companions’

presence was one of the earliest humanizing practices in

services because it did not alter organization or management

methods and can serve as support for both the CR and staff.

Freitas et al.23 corroborate these perspectives, but stress the

importance of creating spaces that can accommodate

companions, as their own discomfort can generate conflicts

with staff. Other considerations allowing companions to

remain with the CR include providing a private area where

they can receive information about their relative’s clinical

condition and recognizing older people’s need for the

presence of a trusted person as a “safe haven” in a service

whose conditions may not support the comfort they

require.28 In situations of delirium, which are common in

EDs, the presence of a family member is particularly

important to reassure the CR and to help ensure that

physical restraint is used only as a last-resort intervention.39

The difference between the two rounds in the validation of

item C3.19 was not large; nevertheless, it was eliminated like

the two previous items. Dall’Orso and Concha34 report that

professionals view the presence of family members during

resuscitation negatively, arguing that it may interfere with

procedures and that cessation of resuscitation efforts can be

misinterpreted. However, interviews by Dall’Orso and

Concha34 with family members show that, despite the heavy

emotional burden and the difficulty of managing it

individually, their presence during resuscitation was

beneficial for making sense of death, reducing anxiety, and

enabling the initiation of grieving — provided they are

supported by a professional who explains what is being

done and why. The removal of this item highlights the work

that still needs to be done with professionals to manage

these situations and encourages reflection on family

presence during resuscitation.

The Delphi methodology proved effective for gathering

consensus within a heterogeneous group of people with

different opinions, professions, and experience in ED care.

A major advantage of this method, as noted by Marques and

Freitas45, is anonymity, which reduces confrontational

debate and prevents opinion shifts due to group pressure or

perceived need to follow a single direction to facilitate item

validation; it also fosters creativity and deeper reflection on

the topics under study. Conducting the process via online

questionnaires, as in this study, increases flexibility for

experts’ participation because it enables geographically

dispersed panel members with different work schedules to

take part without the time pressure imposed by, for

example, a focus-group meeting.45 Barrios et al.42 argue that

experts’ opinions are shaped by feedback received during

the study rather than by sociodemographic factors; in this

study, only the need to revalidate the six items that failed to

reach agreement in the first round was communicated to the

experts. One limitation encountered — and a known

Pensar Enfermagem / v.29 n.Sup / Jan-Dec 202

DOI: 10.71861/pensarenf.v29iSup.426 / e00426

Qualitative Original Article

drawback of this method, as Marques and Freitas45 note —

was timing: it was necessary to send multiple reminder

emails encouraging experts to participate in the content

validation and to respond to the three questionnaires (one

corresponding to each defined level).

Conclusion

Implementing the presented guidelines requires investment

— financial, academic, managerial, and in the workforce

(including leadership commitment and staff training) — to

shift the biomedical perspective that currently governs

service operations, a perspective centered on disease

classification, treatment, and cure. The anxiety and tension

generated by an emergency episode can be reduced through

humanized care without defaulting to sedatives or

anxiolytics, and humanized approaches may also promote

greater therapeutic adherence to a shared health plan

through the involvement and shared responsibility of the

care recipient. This work can contribute to much-needed

changes in health services, specifically in emergency

departments, and to reflection on humanization by

policymakers and health professionals, prompting

individual practice changes that spread across teams and

foster a more humanizing approach. Therefore,

psychometric validation of the guidelines on a larger,

national sample of professionals is required.

Caring for others while feeling valued — combining

technical and scientific competence with empathy and

active listening — is the path to a future in which health

professionals can make small but meaningful

improvements in the lives of those they care for, “making

them human.” Let us have the courage to change and break

the vicious cycles in which a prescriptive model traps us,

rendering us cold and distant: one day it may be us who

need care and those who accompany us. Let us create a safe,

welcoming, and reassuring care environment in which trust

in professionals is complete, because we know they will

attend to us, our family members, and our friends with a

humanizing, attentive gaze that values our needs and offers

relief from physical and/or psychological suffering. We

should also consider investigating, testing, and

implementing humanizing measures across all health

professions, bearing in mind that the person is the alpha

and the omega of our health care system.

Study limitations

Only physicians and nurses responded to the invitation to

participate in this study as experts, despite the invitation

being extended to other professionals and to patient/user

committees. This is a limitation, since diverse perspectives

could have enriched the validation and revision of proposed

items from ethical, managerial, psychological, and user-

experience standpoints. A further limitation is that the study

involved a tiny fraction of health professionals providing

care in some regions of the country and is, therefore, not

nationally representative.

Author contributions

SC: Study conception and design; Data collection; Data

analysis and interpretation; Manuscript writing; Critical

revision of the manuscript; Approval of the final version of

the manuscript and assumption of responsibility for it.

MD: Study design and conception; Critical review of the

manuscript; Approval of the final version of the manuscript

and assumption of responsibility for it.

Conflict of interest

No conflict of interest was declared by the authors.

Sources of support/funding

This study did not receive any funding.

Acknowledgements

To the esteemed experts who participated in the study and

enabled the validation of more than a hundred items with

measures to be implemented in our emergency services to

humanize the care provided there: may you maintain the

resilience that characterizes the role you play in your services

and motivates you to participate in research projects to

improve clinical practices.

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