INTRODUCTION

The Intensive Care Unit (ICU) is a restricted hospital sector designated for the treatment of emergency cases involving critically ill patients who require continuous monitoring and care, utilizing advanced technological tools to provide life support systems⁽¹⁾.

Within this context, the Neonatal Intensive Care Unit (NICU) is specifically designed to deliver advanced life support, particularly to premature newborns who require continuous, prolonged care. It operates with a trained interprofessional team—including physicians, physical therapists, speech therapists, nutritionists, nursing technicians, and nurses—capable of addressing complex clinical demands. The nursing team, in particular, plays a pivotal role in delivering care, performing complex procedures, maintaining direct patient contact, assessing patient needs, interacting with family members, and contributing to humanized care practices⁽²⁾.

Premature newborns admitted to NICUs often present with multiple physiological limitations due to the immaturity of their organs, making adaptation to extrauterine life a significant challenge. This difficulty is compounded by constant exposure to the hospital environment, characterized by high noise levels, continuous lighting, temperature fluctuations, frequent handling, and invasive procedures. Such conditions subject neonates to considerable stress and pain, which may adversely affect treatment outcomes⁽³⁾.

From birth, premature infants in the NICU are subjected to a range of invasive and non-invasive procedures and receive nursing care that includes numerous interventions such as venous punctures, bathing, and repositioning. These routine practices are major contributors to the pain experienced by preterm infants during hospitalization⁽⁴⁾.

Persistent exposure to pain can lead to physiological alterations, including cardiovascular instability, sleep disturbances, disruption of breastfeeding, unnecessary energy expenditure, and even long-term psychological trauma⁽⁴⁾.

Another significant risk factor for premature newborns is the occurrence of healthcare-associated infections (HAIs), exacerbated by their underdeveloped immune systems, low birth weight, frequent invasive procedures, and exposure to hospital microbial flora. Cross-contamination—often due to the use of inadequately disinfected equipment such as stethoscopes and thermometers—can frequently be attributed to lapses in biosafety protocols by healthcare professionals⁽⁵⁾.

The term “humanize” refers to the process of making something more humane. In the hospital context, nursing plays a central role in this endeavor, as nurses are not only responsible for clinical care but also for ensuring the holistic well-being of patients—treating them as individuals rather than merely as clinical cases. Their role extends beyond treating illnesses to actively promoting health⁽⁶⁾.

Although there is broad consensus regarding the importance of humanized care in promoting recovery within hospital settings, several barriers to its effective implementation persist. Despite growing discourse and advocacy for humanization in healthcare, practical application remains limited due to factors such as excessive workloads, inadequate training, and insufficient technical-scientific knowledge on the subject⁽⁷⁾.

Thus, the role of nurses is indispensable in the implementation of humanized care. The nursing team is responsible not only for the direct care of neonates but also for the early identification of potential complications, the proposition of appropriate clinical interventions, and the provision of individualized support to families—particularly postpartum mothers. Given their continuous interaction with both patients and families, nurses are uniquely positioned to identify human needs and offer comfort and support. This contributes to the creation of a therapeutic environment conducive to neonatal recovery⁽⁸⁾.

In light of this context, it is essential to examine how humanization practices are currently being implemented in NICUs, with the aim of ensuring the delivery of holistic and compassionate care to hospitalized newborns and their families. The actions of the interprofessional team—particularly those of nursing professionals—exert a direct influence on neonatal clinical outcomes. Therefore, the following research question is proposed: What are the humanized care practices implemented by nursing professionals in the neonatal intensive care setting?

Accordingly, this study aims to investigate current humanized care practices in NICUs as reported in the literature and to evaluate their effectiveness in supporting the treatment and recovery of newborns.

METHOD

This is an integrative literature review, characterized by theoretical investigation and the identification of studies related to the research theme, following the established stages: formulation of the research question; selection of databases and inclusion/exclusion criteria; definition of data to be extracted; evaluation of included studies; interpretation of results; and synthesis of findings⁽⁹⁾.

The research question was constructed based on the PICo framework, where P stands for Population, I for Interest, and Co for Context⁽¹⁰⁾. In this study, P represents nursing professionals working in NICUs; I refers to humanized care practices; and Co corresponds to the neonatal intensive care unit setting. Accordingly, the research question was defined as: What are the humanized care practices performed by nursing professionals in the neonatal intensive care unit?

The literature search was conducted in July 2024 in the following databases: National Library of Medicine (PubMed) and the Virtual Health Library (BVS). Access to these databases was obtained through the CAPES Periodicals Portal via the Federated Academic Community (CAFe).

Articles were selected based on the following inclusion criteria: publications from 2011 onward—marking the implementation of the Rede Cegonha ("Stork Network") in Brazil, which initiated the promotion of humanized care practices⁽¹¹⁾; articles available in full text and free of charge; and with no language restrictions. Exclusion criteria included: literature reviews, reflective essays, editorials, opinion articles, undergraduate theses, dissertations, studies using secondary data, and studies that did not meet the aforementioned criteria.

The search and selection of studies were carried out by two researchers independently. The descriptors used were drawn from the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH), namely: “Neonatal Intensive Care Unit,” “Premature Newborns,” “Humanization of Care,” and “Nursing Care.” These were combined using the Boolean operators AND and OR to form the search strategies, as shown in Table 1.

Table I - Search strategies employed in the selected databases.

PUBMED

“Intensive Care Units, Neonatal” OR “Infant, Premature” OR “Newborn, Infant” AND “Humanization of Assistance”

Filters: full text with abstract available; period from 2011 to 2024.

BVS

"Neonatal Intensive Care Unit" OR "Premature Newborn" AND "Humanization of Care" OR "Nursing Care"
Filters: full text; open access; in Portuguese, English, and Spanish; period from 2011 to 2024.

Source: The Authors.

The results were exported to Microsoft® Excel® 2019, and a spreadsheet was created to organize and synthesize the data. The spreadsheet included: original title, journal/year/level of evidence, methodology/participants, and main findings. The classification of levels of evidence followed the hierarchy: Level I – meta-analysis of randomized controlled trials; Level II – experimental studies; Level III – quasi-experimental studies; Level IV – descriptive/non-experimental or qualitative studies; Level V – case reports/experience reports; and Level VI – expert consensus or opinion⁽¹²⁾.

The search and selection process followed the flowchart recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ⁽¹³⁾. Qualitative analysis and synthesis of the selected studies were conducted descriptively. As this is an integrative literature review, the study was not submitted to a Research Ethics Committee; however, the ideas and intellectual contributions of the authors of the included publications were preserved and duly acknowledged.

A total of 163 articles were initially identified. After applying the eligibility filters, 90 articles were excluded. Following the screening of 73 abstracts, 52 articles were excluded, leaving 21 that met the inclusion criteria. Of these, 7 were excluded for not addressing the research question, and 3 for not meeting the inclusion criteria. Thus, the final sample consisted of 11 articles (Figure 1).

Figure 1 - Flowchart of study selection. Maringá, PR, Brazil, 2024.

Source: The Authors.

RESULTS

Findings from the literature indicate that the majority of the articles (n=9) were published in national journals and in Portuguese (81.9%). Two articles sourced from PubMed (18.1%) were international and written in English. For these, since the authors do not possess fluency in the language, Google Translator—a free, virtual, real-time translation service for texts and websites—was used as an auxiliary tool.

With regard to the Qualis classification system, an important tool for academic assessment and for ranking the quality of scientific journals, most of the articles (45.4%) were published in B1-ranked journals, followed by B2 (36.4%), A2 (9.1%), and A3 (9.1%) journals.

All publications originated from the American continent (100.0%), with a predominance of Brazilian production (81.9%), followed by the United States (18.1%). Furthermore, there was a higher concentration of articles published between 2016 and 2020 (45.4%), followed by the periods 2011–2015 (36.4%) and 2021–2024 (18.2%).

In terms of methodology, 45.4% were qualitative descriptive studies, 27.2% were quantitative descriptive, 18.2% were identified as descriptive and exploratory qualitative, and 9.2% as experience reports. Among the qualitative studies, data analysis was primarily conducted using thematic analysis (n=7), whereas the quantitative studies employed simple descriptive statistics (n=3).

Regarding the level of evidence, 90.9% were classified as Level IV (studies with non-experimental designs such as descriptive, correlational, and qualitative research or case studies), and 9.1% as Level V (case reports or data obtained systematically, of verifiable quality, or program evaluation data), as described in the literature ⁽¹⁴⁾.

The studies included in this review varied in terms of their target populations, with the majority conducted with nursing professionals (nurses and technicians) working in Neonatal Intensive Care Units (n=7), followed by studies involving only mothers of hospitalized newborns in neonatal care services (n=1), and studies including both mothers and healthcare professionals (n=1). Additionally, two articles obtained their data from documentary records.

In general, the studies included in this review addressed, from various perspectives, the humanization of neonatal care. This concept refers to approaches focused on the well-being and dignity of newborns and their families during neonatal care, involving practices that promote a more welcoming and less stressful environment for infants, as well as emotional and informational support for parents. The detailed descriptions, characteristics, and synthesis of findings are presented in Table 2.

Table 2 - Presentation and synthesis of the main findings from the studies included in the review.

Title⁽ⁿ⁾

Journal / Authors

Year / Country

Method /

Participants

LoE*

Findings

Perception of the nursing team in pain management newborn⁽¹⁵⁾

Cuid Enferm

Rafael, ACM / Figueiredo, TJ/ Correa APV/ Paes LBO

2023

Brazil

Qualitative descriptive study – content analysis (Bardin)

11 NICU’s nursing team members

This study aims to understand the perception of nursing professionals regarding neonatal pain management. Three thematic categories emerged: neonatal pain management methods, humanization practices, and pain assessment perception, revealing that the nursing team has comprehensive knowledge and techniques concerning pain management in newborns.

Humanization of neonatal care in the optics of nursing professionals⁽¹⁶⁾

Rev enferm UFPE

Costa, JVS/ Sanfelice, CFO / Carmona EV

2019

Brazil

Descriptive, exploratory, and qualitative study – thematic content analysis

1 nurse and 21 nursing technicians (NICU)

This study aims to identify the nursing team's perception regarding humanized care in the NICU. Results highlight the need for educational activities to enhance understanding and implementation of a humanized approach in neonatal care.

Knowledge of the nursing team on premature newborn pain⁽¹⁷⁾

Rev enferm UFPE

Marcondes C / Costa, AMD / Chagas, EK / Coelho, JBA

2017

Brazil

Descriptive, exploratory, and qualitative study – thematic content analysis

2 nurses and 5 nursing technicians (NICU)

This research aims to identify the nursing team's knowledge on pain in premature newborns. Findings show that pain is often identified empirically, indicating the need for implementing the Nursing Care Systematization (SAE) to enable more effective pain interventions.

Share applicability recommended by kangaroo method⁽¹⁸⁾

J. res.: fundam. Care

Stelmak, AP / Freire MHS

2017

Brazil

Quantitative descriptive study – simple descriptive statistics

37 nursing professionals

This study seeks to identify the prevalence of actions recommended by the Kangaroo Method (KM) in neonatal care. The most frequently applied practices were welcoming, tactile stimulation, breastfeeding, and environmental control (97% each). Less frequent actions included diaper changing in lateral position (83%) and swaddled bathing (58%).

Use of Peripherally Inserted Central Catheters in Neonatology⁽¹⁹⁾

Revista Baiana de Enfermagem

Jantsch, LB / Neves, ET / Arrué, AM / Kegler, JJ / Oliveira, CR

2014

Brazil

Quantitative descriptive documentary study – simple descriptive statistics

58 PICC follow-up forms in newborn

This article aimed to characterize the use of PICCs in a NICU. Indications included IV hydration and parenteral nutrition. The most commonly used vein was the saphenous vein, with an average catheter use of 11.7 days. The study concluded that the PICC should be incorporated into neonatal intensive care as a technology for humanized care.

Technology Applied for newborn care in nursing⁽²⁰⁾

Revista Baiana de Enfermagem

Fialho, FA / Dias, IMAV / Silva, LR / Santos, RS / Salvador M

2011

Brazil

Qualitative descriptive study – categorical analysis

8 NICU’s nurses

This research aims to identify care technologies used in NICUs. Findings highlight two complementary trends in neonatal care evolution: the advancement of hard technologies and of soft technologies. While both are essential, the latter still poses a challenge in neonatal nursing practice.

Nursing Team and Promotion of Humanized Care in Neonatal Units⁽²¹⁾

Rev Rene

Ferreira, JHP / Amaral, JJF / Lopes, MMCO

2016

Brazil

Qualitative descriptive study – thematic analysis

14 nurses and 20 nursing technicians (NICU)

This study aims to understand the nursing team’s knowledge and actions related to humanized care in a Neonatal Intensive Care Unit. The team demonstrated technical-scientific knowledge, humanized skills and attitudes that contributed to the newborn’s recovery, minimized stress factors in the NICU environment, and promoted family bonding during the care process.

Effect of "quiet time" to reduce noise at the neonatal intensive care unit⁽²²⁾

Esc Anna Nery

Santos, BR et al.

2015

Brazil

Quantitative descriptive study – descriptive statistics

261 hours of noise recording

This study aims to identify and compare sound pressure levels (SPLs) inside NICU incubators with and without the “nap time” intervention. Results emphasize the need to improve the acoustic environment in both the micro and macro contexts around the neonate, which function as interconnected systems.

Importance of humanized welcome to the mothers when visiting the child in a neonatal intensive care unit: experience report⁽²³⁾

Rev enferm UFPE

Lopes, IO / Brito, MR

2015

Brazil

Descriptive observational study – experience report

Mothers of patients and NICU’s professionals

This study describes the experience of a nursing undergraduate during clinical practice in a NICU. The actions taken revealed the importance of including mothers as integral to the child’s recovery, encouraging professionals to adopt a new perspective on family participation in care.

Nurses’ Reflections on Benefits and Challenges of Implementing Family-Centered Care in Pediatric Intensive Care Units ⁽²⁴⁾

Am J Crit Care.

Coats, H et al.

2018

USA

Qualitative descriptive study – content analysis

10 NICU’s nurses

This article explores nurses' perceptions of the benefits and challenges of providing family-centered care, highlighting a "balancing act" involving policies on visitation and bedside presence, and physical transformations in the NICU from open wards to individual private rooms.

Mothers' Experiences in the NICU Before Family-Centered Care and in NICUs Where It Is the Standard of Care ⁽²⁵⁾

Adv Neonatal Care.

Neu, M et al.

2020

USA

Qualitative descriptive study – interative coding and thematic clustering

14 mães de bebês prematuros de uma UTIN

This study compares the experiences of mothers in NICUs where family-centered care is standard to those from two decades prior. Suggestions included added comforts in private rooms, NICU areas for social interaction among mothers, and early information about transportation upon discharge. Improved recognition and support for socially isolated mothers was identified as a critical emotional support need.

LoE*: Level of Evidence.

Source: The Authors.

DISCUSSION

To ensure the quality of care and the safety of newborns (NBs), healthcare professionals must be well-prepared to implement humanization practices in Neonatal Intensive Care Units (NICUs). The findings presented enabled a synthesis of the main humanized care practices provided in neonatology.

Regarding the comprehensiveness of care, the implementation of the Kangaroo Method is particularly noteworthy, as it is of paramount importance for promoting family involvement in inpatient care. This method especially encourages skin-to-skin contact through the kangaroo position. Such methods can significantly improve the clinical condition of newborns, particularly premature infants, by strengthening familial bonds, reducing stress and pain, and stabilizing heart rate and oxygenation⁽¹⁸⁾.

In terms of care procedures, the use of the Peripherally Inserted Central Catheter (PICC) is highlighted. This device is primarily used in premature infants who remain hospitalized for extended periods and require constant intravenous therapy. Therefore, its use is considered humanized care, as it ensures a secure access route, avoids the creation of new peripheral accesses, and aids in pain management. However, this device must be handled correctly to preserve the catheter's duration and prevent potential infections⁽¹⁹⁾.

Regarding pain management in newborns, nursing professionals are key allies as they employ non-pharmacological methods to assist in this process. Among the care measures, the following stand out: position changes, reduction of noise and light, skin-to-skin contact, breastfeeding, immersion baths, non-nutritive sucking, and oral glucose. These methods are most frequently used in controlling pain during painful procedures. In addition to promoting comfort, these practices help prevent complications such as neonatal stress and pressure ulcers ⁽¹⁵⁾.

Concerning pain identification, another finding highlights visible signs in newborns, such as crying, facial expressions, and bodily changes, as the primary indicators of discomfort when exposed to painful stimuli. They may also exhibit changes in heart rate and respiratory frequency. Therefore, healthcare professionals must be attentive to these signs since newborns are unable to verbally communicate pain and can intervene by implementing measures to alleviate it. Massages are mentioned as one of the most effective methods for relieving colic, applied before medication administration. Thus, regardless of the method, the care provided by the multidisciplinary team must focus on humanization and respect, always aiming to minimize the trauma that may occur during the hospitalization period ⁽¹⁷⁾.

Therefore, humanized care has become fundamental in patient assistance, and nursing plays a pivotal role in welcoming and implementing measures that promote humanization. Among these measures, effective communication is identified as the safest and most efficient method during the provision of care. Furthermore, the reduction of stress-inducing stimuli, such as light and noise, is considered a strategy capable of minimizing stress and pain experienced by the neonate ⁽²⁷⁾.

Regarding noise and light emission, the literature suggests that high sound pressure levels contribute to the disruption of newborns' sleep patterns, leading to alterations in thermoregulation and hormone release, which impair immunity. Additionally, they cause irritability, crying, and agitation, factors that contribute to increased intracranial pressure. As a result, scientific evidence describes the "sleep time" as a way to minimize these complications. This involves reducing light and noise during four periods of the day, each lasting one hour (morning, afternoon, and twice at night), to create a calm and welcoming environment that promotes newborns' rest. The study demonstrates the need for professional team contribution regarding noise emission, as actions such as avoiding speaking in loud tones and not slamming doors help create a more acoustically pleasant environment⁽²²⁾.

The inclusion of humanized methods emphasizes that treatment goes beyond medical care, addressing emotional and social needs as well. Implementing strategies to minimize pain and promote a relaxing environment can help reduce neonatal stress, as well as engage parents in the care of their children, fostering communication between nursing professionals and the family, strengthening familial bonds, and providing good emotional support. Care goes beyond what is prescribed, and family inclusion, particularly that of mothers, is crucial in building humanized care⁽¹⁶⁾.

Maternal inclusion has numerous advantages for both newborns and mothers. According to a study published by the “Universidade Federal do Recôncavo da Bahia (UFRB)”, inclusion strengthens the bond between mother and baby, allowing the mother to follow her child's clinical development and encouraging breastfeeding. Skin-to-skin contact fosters closeness, as touch enables them to recognize each other’s presence and contributes to the clinical progress of these children, allowing mothers to identify their children's individual characteristics⁽²³⁾.

Family inclusion brings some challenges to the nursing team during the provision of care to newborns. A North American study points out that the multidisciplinary team faces difficulties in managing the presence of mothers, who tend to ask many questions related to their child's condition. Such inquiries are considered “distracting” for the nursing team, as they must divide their time and attention between providing care and addressing family demands. These questions, in turn, tend to lead to new service requests, which directly impact the nursing team, interrupting their work and potentially compromising its effectiveness. On the other hand, for parents, it is important to have the support of a care team nearby, as these professionals address their concerns and reassure them that their children are receiving proper treatment^(25-26).

Although challenging, family inclusion, recommended by the Kangaroo Method, is potentially beneficial to newborns. Through this contact, particularly with mothers, newborns begin to recognize their familial bonds and show clinical improvements that favor and accelerate their recovery⁽²⁶⁾.

Humanization strategies do not require high-cost materials; they are easy to understand and accessible, thereby providing benefits to newborns and their development. Given that nursing professionals have direct contact with newborns and their families, they must implement humanized care strategies daily, promoting the recovery of newborns while focusing on respect and ethics toward the infants and their families. Therefore, they must ensure a welcoming environment, addressing the anxieties and fears experienced by family members, aiming for the recovery and well-being of the newborns.

FINAL CONSIDERATIONS

Skin-to-skin contact and family inclusion in inpatient care have been positively described in the literature, as they not only strengthen family bonds but also contribute to reducing stress and pain, while stabilizing heart rate and oxygenation. Other findings include pain management strategies that go beyond pharmacological interventions, such as massage, repositioning, immersion baths, and the creation of welcoming environments with soft lighting and reduced noise levels. The use of Peripherally Inserted Central Catheters (PICCs) was also mentioned as a humanization strategy, as it provides a secure and long-term venous access route.

Moreover, effective communication between the multidisciplinary team and the family is essential for the effectiveness of care delivery. It facilitates the identification of the newborns’ individual needs and enables the inclusion of mothers in the care process, as the proximity of parents and their active participation in decision-making enhances both emotional support and the physical health of the mother and the infant.

Finally, neonatal humanization emerges as a means to overcome the traditional curative and assistance-based care model, by embracing practices that foster inclusion and consideration of differences within the care management process. This model seeks to recognize and value the biopsychosocial context of those involved in the care process—emphasizing the physical and emotional well-being of the newborn and the family, as well as the importance of welcoming attitudes, respect, and comfort-oriented practices.

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Authorship criteria (authors' contributions)

1 Study design and planning; data collection, analysis, and interpretation; writing 2 Study design and planning; data collection, analysis, and interpretation; writing 3 Study design and planning; data collection, analysis, and interpretation; writing 4 Data collection, analysis, and interpretation; critical review 5 Data collection, analysis, and interpretation; critical review 6 Writing and critical review; final approval of published version 7 Critical review, final approval of published version

Declaration of conflict of interests:

nothing to declare

Funding and Acknowledgements:

the research did not receive any type of funding.

Scientific Editor: Ítalo Arão Pereira Ribeiro. Orcid: https://orcid.org/0000-0003-0778-1447

Rev Enferm Atual In Derme 2025;99(supl.1): e025062

Atribuição CCBY