Nursing Care with a Human Approach ” : A Model for Practice with Service Excellence

Objective: Develop a model of care for clinical the practice that allows for a continuous improvement in nursing care at the Fundación Santa Fe University Hospital in de Bogotá (FSFB). Materials and methodology: This is a descriptive methodological study developed in sequential phases that included: 1) identification of the need to have a model of care for nursing practice; 2) a characterization of the context and the desired scenario; 3) a literature review; 4) a description of the model; and 5) validation of the theoretical proposal. The study was conducted in 2016. Results: The global trend in the use of nursing models in clinical practice recognizes common aspects and emphasizes relevance, methodologies and different roles in their implementation. The context and projection of excellence for nursing at the FSFB necessitated the evident orientation of a model for the practice that guides care and responds to the vocation of service centered on the experience of human health. Conclusion: The model known as "Nursing Care with a Human Approach" helps to understand and communicate the essential components of nursing at the institutional level. It also develops parameters to measure and qualify nursing practice at the FSFB on a permanent basis.

The topic: theory based practice Contribution to the discipline: A nursing professional practice model, such as the one developed in this study, allows us to reflect and focus on the practice of nursing, and to generate a collective vision and a common language to communicate developments and significant advances.This model also intends to be understandable and close to daily practice, to build identity, to have bases that allow for the generation of scientific evidence, to mobilize collective leadership by generating conditions of empowerment for nursing, and, thus, to achieve an autonomous practice that cares for the experience of people in whichever health condition they may find themselves.In that sense, this work responds to the most significant global trends in the development of the professional discipline of nursing.

Introduction
Service teaching alliances respond to the call of worldwide trends that look to qualify nursing practice (1)(2)(3)(4)(5).Recent advances in this field of nursing indicate these models are an appropriate response to the demands of the global agenda (6), and to the development of leadership required by the profession (7).They are a way of articulating the practice of nursing with the health system (8), complementing the theoretical development of other levels in the knowledge hierarchy (9,10), and responding to the highest accreditation criteria, while allowing for a link between the academy and assistance (11), generating an impact on nursing practice (12).
In the midst of the partnership between the Nursing Department at the Fundación Santa Fe University Hospital of Bogotá (FSFB) and the Faculty of Nursing and Rehabilitation at La Sabana University (Universidad de La Sabana -US), we identified the need to develop a model for practice or functional care that would allow for continuous improvement in the nursing task at the FSFB University Hospital.The idea is to respond to the challenge of excellence in service, while focused on the care user, as has occurred in other contexts (13).

Methodology
We summarized the contributions of partner institutions and those of the nursing staff currently working at the institution in order to develop a model for practice.This invaluable input was based on four decades of nursing work at the FSFB.The US contributed in the form of methodological support and validation by experts of national and international renown in the field of nursing ontology and epistemology.
This descriptive methodological study sought to document and systematize nursing information in order to generate a practice model that allows for a better understanding of nursing care in the human health experience and within a specific institutional context.The study considered the ethical and environmental aspects in each of its phases.Due to the methodological approach, it is considered a risk-free study.It was endorsed institutionally, respected the rights and credits of each of the authors consulted, and called for voluntary participation in each of its workshops and in the validation.We encouraged the rational use of resources throughout its development.
The study included five different stages: 1. Identify the need to develop a model for nursing practice In order for nursing, as a working group, to identify the need to develop a model for practice, there was an initial review and training on the characteristics and relevance of the use of nursing models in practice.To this end, we called upon each of the services provided by the institution, which together comprise an intramural and extramural practice that expresses the different roles of nursing (14).Through nursing group-work workshops at in the FSFB, advised by the US, we studied the hierarchy of knowledge and its relationship with the practice and development of nursing at the institution.The workshops were coordinated by the Nursing Department, with the participation of service coordinators, in addition to several strategic guests.

Characterization of the context and desired scenarios
We analyzed the trajectory and nursing situation at the FSFB by reviewing and examining the historical documents available in the Nursing Directorate, such as minutes and advisory reports and audits, including their vision for 2022 and their position and relationships within the framework of the mission, vision and development plan in force at the institution.
The survey was applied to 145 nurses whose profile represented the nursing staff of the FSFB.We included professionals with different experience times, different shifts, services and academic levels.Once we identified the profile of the participants, we asked whom the subjects of nursing care at the FSFB are, what is the goal of that care, in what context is it provided, and what is the role of nursing.In order to confirm what they perceived as the most important part of nursing practice at the FSFB, we asked the participants what made them most proud and what worried them that they would modify.
From this exercise, and considering each of the responses received through the surveys, we achieved a description of the fundamental concepts for nursing practice.
In a subsequent intervention, a new group of nurses from the institution participated in an exercise developed in small groups to see how these concepts were associated.This exercise produced the assumptions of care, which are the second component of the model.

Validation of the model
Experts validated the concepts and assumptions internally and externally.This was done along with a cross analysis of congratulatory and complaint letters from patients and other health professionals.Finally, we submitted the study to be reviewed by international peers with recognized experience, and the product was revised based on standards of evaluation of current nursing theory.

Results
The study made it possible to understand why the development of a model to guide the practice of nursing based on care is essential to qualify it, since it allows nursing care to be guided to fulfill its true purpose.Only by understanding the essentials of nursing care is it possible to respond to the commitment to institutional excellence.
To accomplish this, it was necessary to identify what type of care-based model for practice was required, considering that it should respond to the institutional framework of high-value service and be functional at the same time to reflect the commitment of nursing to care in service, when implemented.It was also determined that the model should allow for an indicator based on follow-up to guarantee a permanent improvement in four fields: humanization in care, risk management, knowledge management and technology management.
With respect to characterization of the context and the desired scenario, and considering the institutional mission, we accepted the institutional vision of nursing, which states: by 2022, the Nursing Department at the FSFB University Hospital will be able to lead practices in comprehensive care of the patient with family participation, which generate the best results for the recovery of health.It will be recognized nationally and internationally for the practice of nursing based on evidence, scientific input, teaching and research.It will be a source of improvement in practice innovation, assistance, teaching and an influential opinion leader on the strategic direction of the FSFB.It will lead health promotion and disease prevention programs that positively affect the quality of health in the community, and will be recognized for its participation in the generation and implementation of national health policies.
The review of experiences and global trends in the use of nursing models allowed us to conclude that every nurse has a model, a theoretical perspective or an ideal that guides her/his practice, which, by making it explicit, allows the nurse to reflect on it.However, an institutional practice model based on care requires clear agreements in accordance with the mission and vision of each institution.For an institution, having a model of practice based on nursing care is a starting point to strengthen nursing autonomy by recognizing the fundamentals of the nurse's work and qualifying them.
A theory is the set of concepts, definitions and propositions that project a systematic vision of a phenomenon, designating the relationships and interactions between the concepts with the purpose of describing, explaining, predicting or controlling said phenomenon.In the case of nursing theories, these are statements that attempt to describe, explain, predict or control nursing as a phenomenon of study (16,17).
Within the review, we accepted Fawcett's scheme of knowledge hierarchy (18) and its interpretation for the practice of nursing by Morse (19), understanding that at the highest level of abstraction is the metaparadigm of nursing or the basic agreement on what nursing is and that has to do with the care experience of human health.This metaparadigm is traversed by different philosophical conceptions of care that give different meaning to its essential components, which include the subject of care, the nurse, the context and health.The result of these conceptions with respect to the four metaparadigmatic elements are the macro theories or conceptual models of nursing.In order to bring these conceptualizations into practice, they are applied through medium-range theories, which are closer to the tangible reality handled by the nurse, with a higher level of concreteness and a more restricted scope of action.Finally, there are the micro theories of nursing, the highly specialized ones that allow us to measure specific phenomena the nurse faces in daily life.When talking about models at the last three theoretical levels, it should be noted that there are conceptual models at the macro-theoretical level, functional ones at the mid-range level, and specific models, practice guides, protocols or indicators of measurement of a specific phenomenon at the micro theoretical level (20).
The same essential elements of the metaparadigm appear at all theoretical levels of nursing.In other words, they must express how the human health experience is taken care of and respond to who is cared for and where, what is taken care of, how and by whom.
From its inception, nursing at the FSFB has had a reciprocal philosophy; it finds care in the interactive and integrative nature between the nurse and the subject of care.Nursing at the FSFB is viewed as an exchange in which the patient-nurse relationship is fundamental.The nurse herself or himself must be well in order to provide care, and when caring she/he gains knowledge and experience as a caregiver.In turn, we see the patient, the family and even the community that receives care express their gratitude in different ways.
Nursing care models allow nursing to develop an intellectual activity, and for others to comply with orders to control and respond for their performance (21).They also help to generate change through our own knowledge, and to integrate nursing into the health system, which is why the use of such models is recommended as a guide to practice (22).
Conceptual models are a general theoretical guide for the thoughts and actions of nursing, hence the term macro theory, while the functional or practice models are a theoretical guide for the thoughts and actions of nurses in their daily lives, pursuant to the guidelines of a conceptual model.Each one articulates and communicates a mental image of the order that must exist in the practice of nursing, by pointing out what their metaparadigmatic concepts are and the relationship between them (23).
In the specific case of the FSFB, it was found that a practice model based on nursing care gives the nurse a general perspective of what is important as part of nursing practice in a specific institutional context, orienting it towards what it is valuable, and affecting the nature of the intervention that is performed.This model is only useful insofar as it does not remain solely on paper.This is the only way to better understand nursing practice as a requisite and, therefore, to be able to improve it by strengthening the nurse's professional identity.The model determines processes and indicators of care in practice, supports an analysis of intangible processes that affect the results of care, and helps to determine factors that affect nursing care either positively or negatively.Moreover, it guides the evaluation and improvement of nursing care.
Once we reviewed and clarified the general theoretical aspects of the nursing exercise as a professional discipline, we then proceeded to choose the best practice model for the FSFB.This was done based on identification of what the members considered to be their ideal model.One hundred forty-five (145) professional nurses participated in this exercise and were distributed as follows: 22.8% had less than a year's experience; 29.7% had from one to five years; 15.2%, from six 6 to 10 years; 17.2%, from 11 to 20 years; and 9.0%, from 21 to 30 years of experience.In all, 6.2% of the nurses who took part did not answer this question.
Regarding the shifts the nurses work, 22.1% said they did it in the morning, 18.0% in the afternoon, 22.8% at night, 14.5% all day, 17.2% rotated schedules, and 6.2% did not answer the question.
The academic level of the nurses who participated reflects the training pattern of the FSFB.Specifically, 4.1% were students, 51.7% had an undergraduate degree, 2.8% had a postgraduate degree with no specific level, 27.6% had a specialization, 5.5% had a master's degree, 0.7%, had a doctorate, and 7.6% of the nurses did not respond to the question.
Regarding the services in which they work, it was found the nurses who took part came from all the different areas of the institution.These include emergency services, the renal unit, the intensive care unit, pulmonary rehabilitation, radiology, oncology, internal medicine, hospitalization, obstetrics and gynecology, clinical management, management, coordination and nursing management, palliative care, education, urology, the wound clinic, surgery and outpatient services.
When asked about who they recognize as the subject of nursing care at the FSFB, most of them indicated they see it as the human being (60%), followed by the person with an illness and a family or family caregiver (22.8%), the person, family or community that requires care (8.3%), the patient or the healthy or ill family (4.8%), and the healthy or ill person or family 4.1%.
The goal of care for nursing practice reflected that most people expect a better quality of life, recovery, comfort or wellbeing (95.9%).
As for the context of care that is kept in mind when caring for the subject, in order to know if it is limited to the hospital environment or transcends the daily life of the person, family or community, the participants, in general, answered that this is where the subject is and needs to be cared for (100%).
Given the definition of the role of nursing in light of the subject of care, the importance of the nursing process as a fundamental tool of that care was evident (66.2%).The respondents also highlighted education (12.41%), company (6.9%),encouragement of comfort (3.4%), and other responses (3.4%).
They identified human care and the development of human potential as the most important aspect of nursing practice at the FSFB.They also were most disturbed by the workload, which was expressed in terms of the number of patients assigned, and hoped for a more equitable distribution.This exercise showed the description of the fundamental components for nursing practice to be the following: The subject of nursing care is the human being.This subject, who can be a healthy or ill person, a family caregiver, a family and even a community, needs to be cared for.
The nurse focuses his/her work on human care, based on the nursing process that assesses, diagnoses, plans, executes and evaluates this care, considering the integrality, totality, safety and continuity required by the care subject at different times and in different scenarios.
By attending to the subject of care, the nurse comforts, educates to maintain or restore health, prevent illness or prevent complications, and accompanies the subject of care during the disease process, in recovery or at the end of life, while coordinating activities in favor of said subject with other professionals and growing in his/her their own capacity to provide care.
The goal of nursing care is to seek the healthiest condition for the subject of care, with the best possible quality of life, doing so constantly, dynamically, comfortably and while caring for the subject's well-being.This goal assumes that integrity in the identification and satisfaction of the subject's needs and expectations is maintained by preventing complications and supporting the subject so their normal condition is restored, or the subject can adapt to a new state.
The context of nursing care is the place where the nurse interacts with the subject, in person or using information and communication technologies.This includes the infrastructure of the university hospital with its different services, the home, or another context in which the subject of care is located.
The relationship between these concepts resulted in the second component of the model; that is, the assumptions of care.Here, and by way of example, we cite 12 of the 25 defined cases: 1.The nurse who gives nursing care with a human focus prioritizes the subject of care in the care she or he provides.
2. Prioritizing and involving the subject of care in the care being provided allows nursing to identify the subject's needs, appropriately use technology, and make the right decisions regarding care.
3. Application of the nursing process as part of the service makes it possible to transform care into nursing care with a human approach.
7. Giving and receiving nursing care with a human approach gratifies and generates well-being for those who participate in this interaction.
8.An adequate environment for nursing care with a human approach must be available and have sufficient physical and technological resources that help to guarantee the care subject's welfare and quality of life.
9. Nursing care with a human approach, along with the appropriate time, attitude and knowledge, reflects nursing autonomy.
10.A nurse who provides nursing care with a human approach cares for the right environment for the subject (s) of care.
11.The institutional environment must reflect respect for differences, facilitate timely attention, and promote the importance and participation of the subject in his or her own care.
12. The availability and adequate use of technology, including information and communication technologies, constitute part of the requirements for nursing care with a human approach.
As for the internal validation, the nurses found the model reflected their ideal of practice and was familiar to them.On the outside, the experts suggested an analysis of coherence with the institutional mission and vision, based on the quality parameters of the FSFB, and an analysis of the comprehensibility of the product, which also needs to be diagrammed to communicate it in a simpler way.
The other professionals indicated the model allowed them to understand aspects of nursing that they did not know beforehand and were compatible with the work developed in other areas of the institution, which places a priority on service, a user-centered practice, and the quality of care that users look for.
The opinions of the patients coincided with these approaches, especially with respect to the assessment of the human approach, which the patients perceived as being warm and personalized treatment in the midst of complex life situations that affect their health.
International nursing peers of the FSFB reviewed the name of the model, and allowed several clarifications to be made when editing this document.
Finally, the analysis of theoretical development confirmed that it meets Banum's the criteria of internal and external criticism, the theoretical description and critical reflection of Chin and Kramer, the analysis and evaluation proposed by the models and theories of Fawcett, the Parse process, and the criteria for a nursing theory in line with the mid-range practice and external analysis proposed by Whall (24).

Discusion
The pertinence of these theoretical models to guide the practice of nursing is not subject to discussion, due to an important disciplinary consensus (21,(25)(26)(27)(28).In Colombia, for example, the use of models produced changes from professionalization to professionalism, and their application has become increasingly frequent (29), thus seeking to guide excellent care, as claimed by the FSFB.
When reviewing the model that should be used for clinical practice, we found it works with similar purposes, but with a different methodological approach (30).In this case, the advances of the Nursing Department at the FSFB allowed us to conduct a reflective deductive exercise, and through it, to make the make the agreements on care explicit.
The exercise, which calls for the collective participation of institutional nursing, has starting points similar to those of successful exercises that have been reported previously at the international level (31,32).Some of them have led to an improvement in the delivery of care, with positive results for patients and service personnel (33,34).Others have been shown to empower the nursing staff (35) and to help strengthen leadership capacity (36), based on adjustments in the work schedules of nurses.They have also helped to strengthen, in a special way, the autonomy and dignity of the people who are being cared for (37).
In this case, establishment of the model known as "Nursing Care with a Human Approach," based on a care practice model (38), allows for nursing practice at the FSFB with principles of excellence, and is an important step in the approach between theory and practice in order to qualify it.Because of its very nature, which begins with the everyday reality of nursing practice to identify the theoretical guide that allows for its improvement, the next step will be to make the relationship with a conceptual human care model of nursing evident.