FormalPara Key Points for Decision Makers

Respect for patient’s dignity, uniqueness, individuality, and humanity, as well as adequate working conditions and sufficient human and material resources are the most discussed key elements of humanization of care according to the different areas explored (i.e., relational, organizational, and structural, respectively).

The key elements identified are expected to help patients, caregivers, healthcare providers, and institutions in implementing humanized care.

Future studies fully examining implementation strategies of humanized care and quantitatively testing their effectiveness are warranted.

1 Introduction

In recent decades, there has been a progressive increase in the use of technology in the prevention, diagnosis, treatment, and rehabilitation of disease [1]. The aim is generally to increase the quality, efficiency, and safety of care. Further, there has been an increase in specialization and subspecialization in medical settings in order to provide greater expertise in treating specific, complex diseases and conditions [2].

Although these medical developments have improved some elements of the care of patients, such as safety, effectiveness, and efficiency [3], they come with new problems. The automatization and standardization of care and the fragmentation of work and care pathways, often linked to time and staff rationing, can lead to a dehumanization and depersonalization of care [1]. There is a tendency to treat the patient as a ‘group of symptoms’ rather than a human with individual needs [4]. This can negatively affect the doctor–patient relationship, and undermine patients’ and caregivers’ trust in the healthcare system [5, 6]. Further, healthcare providers are mainly evaluated on the basis of their professional performance [7] and are often not seen as a valuable resource but as a risk in healthcare [8]. As a consequence, healthcare providers may experience stress, burnout, and compassion fatigue [7].

To overcome this counter-productive approach to healthcare, the concept of ‘humanization of care’ has been introduced into the scientific literature [9]. This is still a vague concept, overlapping with existing approaches to healthcare such as patient-centered care [3, 10, 11] and person-focused care [12]. Introduced by Balint in 1969 [10], patient-centered care has been developed as an alternative to the traditional, paternalistic, disease-centered model [10, 13]. Instead of focusing primarily on symptoms during the clinical encounter, the physician shows compassion and empathy towards the patient, respects her/his individual values, needs and preferences, and involves the patient in the decision-making process [3, 11, 14]. While patient-centered care is mainly visit- and episode-oriented [12], person-focused care adopts a more holistic perspective, considering the patient as a person with a unique personal history, and treating symptoms and diseases in the context of the course of life [12].

Humanization of care embraces these principles but also considers the other stakeholders involved in the process of care (i.e., patients, patients’ caregivers, healthcare providers, policy makers) and their interactions [15,16,17]. This approach aims to humanize the overall healthcare system by focusing on the relational as well as organizational and structural aspects of healthcare, involving all medical tasks and procedures [16, 17] (see Fig. 1).

Fig. 1
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Development from patient-centered care to person-focused care to humanization of care

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Patient-centered and person-focused care have been widely acknowledged in the literature, whereas the ‘humanization of care’ still lacks conceptual clarity and well-defined dimensions. Consequently, its implementation in clinical practice has received less study.

Todres et al. [18] introduced a theory-driven, philosophically based framework for humanizing healthcare. Following the existential-phenomenological theory, the authors define eight forms of humanization and dehumanization of care, including insiderness/objectification, agency/passivity, and uniqueness/homogenization.

Attempts to review the concept of humanization of care have been made in some clinical areas, such as in critical and pediatric care [19, 20]. However, to date, there has not been a comprehensive review including different settings of care and capturing the voices of different stakeholders. Thus, this systematic review aimed to clarify the concept of humanization of care and identify its key elements by exploring its main features and barriers to and strategies for its implementation according to different stakeholders’ (i.e., healthcare providers, patients, and patients’ caregivers) perspectives.

2 Methods

2.1 Search Strategy and Selection Criteria

We conducted a systematic search of five electronic databases (Web of Science, PubMed, MEDLINE, PsycInfo, Cumulative Index of Nursing and Allied Health Literature [CINAHL]) using the search terms humanization/humanisation of care, and dehumanization/dehumanisation of care up to 31 December 2017. To detect additional studies, we searched three databases of gray literature (PsycEXTRA, OpenSIGLE database, Grey Literature Project). A detailed record of the search strategy applied in the electronic and gray literature databases is provided in Electronic Supplementary Material [ESM] Online Resource 1 and 2.

Articles were included if (i) stakeholders’/participants’ (i.e., healthcare providers, patients, or patients’ caregivers) understanding of the concept of humanization/dehumanization of care and/or its role in the process of care were reported and (ii) papers were published in English, Italian, or German. The following types of articles were excluded: editorials, general discussion papers, commentaries, letters, book chapters, and reviews.

The search and selection process have been recorded according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement by Moher et al. [21]

2.2 Data Extraction

Two reviewers (IMB and GT) independently screened titles and abstracts of the records for inclusion using the reference management software Mendeley® (Mendeley Ltd, London, UK). The full texts of the records considered eligible by either one of the two reviewers were then independently evaluated. In cases of disagreement, the appropriateness of the inclusion/exclusion was debated, and the selection performed in consensus. If necessary, a third reviewer (FM) was involved.

Two investigators (IMB and FM) independently collected study characteristics (i.e., publication year, country, study design, setting, type of participants, sample size) and results, extracted from the ‘Results’, ‘Findings’, or ‘Results & Discussion’ sections in the texts and the abstracts of the included studies, using a data collection form. In case of discrepancies, the two investigators reassessed the respective articles together.

2.3 Quality Assessment

Two appraisers (IMB and FM) independently assessed the quality of the included studies using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research [22], a standardized rating tool based on ten criteria, such as congruity between the stated philosophical perspective and the research methodology, locating the researcher culturally or theoretically, and representation of participants and their voices. The criteria can be rated as yes (i.e., met), no (i.e., unmet), unclear, and not applicable. Cases of dissent were solved through discussion.

2.4 Data Synthesis

We performed a thematic synthesis based on Thomas and Harden [23] with the aim of organizing and summarizing the results of the included studies. Using this method, we identified descriptive themes from which we subsequently derived key elements (see Fig. 2). Two investigators (IMB and FM) performed all steps independently. They resolved any disagreement by consensus and/or by involving a third investigator (MR).

Fig. 2
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Example of the applied thematic synthesis (based on three text sections)

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A description of the three stages of the thematic synthesis process is given in Sects. 2.4.1 and 2.4.2.

2.4.1 First and Second Stage: Text Coding and Developing Descriptive Themes

We performed free line-by-line coding of the findings of the included studies, by extracting distinct text sections and coding each of them regarding their meaning and content.

Related codes were then clustered in order to develop descriptive themes. Each descriptive theme was identified as a main feature, barrier, or implementation strategy.

2.4.2 Third Stage: Generating Key Elements

We grouped the descriptive themes (i.e., main feature, barrier, implementation strategy) that portrayed highly similar content into newly generated key elements. We then assigned each key element to the relational, organizational, or structural area.

Absolute numbers and frequencies of the occurrence of key elements (i.e., overall and subdivided into healthcare providers’ and patients’/patients’ caregivers’ perspective) across the primary studies are reported.

3 Results

A total of 1327 records were retrieved from the selected databases and additional sources (1324 and three, respectively). After screening for title and/or abstract, 54 full-text articles were assessed for eligibility: 34 studies were then excluded (see ESM Online Resource 3) and 20 [4, 16, 17, 24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40] included (see Fig. 3).

Fig. 3
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Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart

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3.1 Quality Assessment

The quality of the included studies varied. All primary studies met more than half of the quality criteria, but only one study [16] met all. All studies received ethical approval by an appropriate body and demonstrated congruity between the stated philosophical perspective and the research methodology as well as between the research methodology and the research questions or objectives. The representation of the participants and their voices [26, 28], the link between the research methodology and the data collection methods [29], as well as the relationship of the conclusions to analysis or interpretation of the data [39] remained unclear for only few studies. Several articles did not clearly locate the researchers culturally or theoretically [4, 30, 32, 40] and did not draw clear connections between research methodology and data collection methods [29] and data representation and analysis [28,29,30, 32, 33, 35, 38, 40].

Just two studies [4, 16] explicitly addressed the influence of the researcher on the research, and vice versa. A detailed overview of the appraisers’ judgments of each included study can be found in ESM Online Resource 4.

3.2 Study Characteristics

The included studies were published between 2007 and 2016 (see Table 1) and were mostly conducted in Brazil (n = 16, 80%), as well as in four other countries (Colombia, Canada, Japan, and Australia). A qualitative design was applied in most studies (n = 18, 90%), whereas a mixed-method approach was used only twice. Sample sizes ranged from four [17, 24] to 70 participants [29]. Thirteen studies focused on the point of view of healthcare providers (e.g., physicians, nursing professionals, midwives), four on the perspective of patients and their caregivers (e.g., family, partner), one on the patient’s perspective, and two on both healthcare providers’ and patients’ point of view. Different medical settings (e.g., mental health, obstetrics/gynecology) were investigated.

Table 1 Characteristics of included studies
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3.3 Thematic Synthesis

Overall, using a thematic synthesis approach, 357 descriptive themes, defined as main features, barriers or implementation strategies, emerged. Since numerous descriptive themes were very similar to each other, we generated only 30 key elements (e.g., regarding the key element empathy towards the patient, the descriptive theme put oneself in the patient’s shoes was identified seven times).

Specifically, we assigned 17 key elements to the relational (e.g., relational bonding), ten to the organizational (e.g., vertical and horizontal communication), and three to the structural area (e.g., adequate physical structure) and calculated the frequencies with which these key elements were discussed by the different stakeholders (patients, patients’ caregivers, healthcare providers) (see Table 2).

Table 2 Frequencies of key elements (relational, organizational, structural area) discussed by the different stakeholders
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Table 3 provides examples of the descriptive themes (i.e., main features, barriers, implementation strategies) representing each key element. However, for some key elements, main features, barriers, or implementation strategies did not emerge. For instance, regarding the key element psychological support for healthcare providers, participants just mentioned its lack without reporting any strategies to tackle this issue.

Table 3 Key elements and examples of the related descriptive themes (i.e., main feature, barrier, or implementation strategy) in the relational, organizational, and structural area
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3.3.1 Relational Area

The relational area includes all key elements and related descriptive themes focusing on the aspects of humanization of care that may directly influence the personal relationship between healthcare providers and patients and their caregivers.

The following key elements were mentioned in more than half of all papers (see Table 2): respect for patient’s dignity, uniqueness, individuality and humanity (90%), empathy towards the patients (70%), relationship bonding (65%), holistic approach (55%), respect for patient’s autonomy and patient involvement (55%), and verbal and non-verbal communication (50%). Other key elements, such as healthcare provider’s personal characteristics (15%), fair-mindedness/equity towards patients (10%), and psychological support for healthcare providers (10%) were mentioned only in a few studies.

Participants noted that dehumanizing behavior, such as ‘othering’ (i.e., treating the patient as subhuman) [27] can undermine the patient’s dignity, uniqueness, individuality, and humanity. On the contrary, strategies such as referring to the patient by his/her name [36] can help the patient to feel respected and be seen as an individual.

3.3.2 Organizational Area

The organizational area includes all key elements and related descriptive themes linked to the work environment (e.g., workload) and the organizational and administrative practices of healthcare institutions (e.g., visiting hours).

While the key elements adequate working conditions, adequate training, and team work were mentioned in more than one-third of all papers (50%, 40%, and 40%, respectively), other key elements, such as vertical and horizontal communication, pleasant hospital stay, and adequate priority assessment were covered much less often (15%, 15%, and 10%, respectively) (see Table 2).

While the fragmentation of the work process [31] was seen as a barrier, the efficient use of time [29] was considered as a strategy to improve the working conditions.

3.3.3 Structural Area

The structural area encompasses all key elements and the associated descriptive themes that focus on the structure of healthcare institutions (e.g., hospital design) and the work environment (e.g., material resources) regarding humanization of care.

Two of the three key elements in this area were mentioned in more than one-third of the included studies: human and material resources (45%) and adequate physical structure (35%). The third key element (pleasant hospital stay) was mentioned only twice (10%) (see Table 2).

It has been often reported (e.g., Cassiano et al. [17], Chernicharo et al. [29]) that sufficient human and material resources are required for providing humanized care. Nevertheless, in many healthcare institutions there was a lack of material resources [29] and health professionals [24, 31, 33, 34]. Including volunteers in the routine hospital practice [26] was considered a strategy to overcome this obstacle.

3.3.4 Stakeholders’ Perspectives

Comparing the studies focusing either on the patients’ and patients’ caregivers’ perspective (n = 5) or on healthcare providers’ perspective (n = 13) alone, it emerged that when patients and patients’ caregivers were assessed, the key elements psychological support for healthcare providers (relational area), vertical and horizontal communication, adequate priority assessment (organizational area), and pleasant environment (structural area) were not discussed. Some other key elements, such as holistic approach (20% vs. 69%), adequate working conditions (20% vs. 62%), and human and material resources (20% vs. 54%) were mentioned notably less often, and some were mentioned more, such as commitment (60% vs. 23%), patience (60% vs. 15%), healthcare provider’s competence (80% vs. 8%), healthcare provider’s personal characteristics (40% vs. 8%), appropriate medical treatment (60% vs. 8%), facilitated access to healthcare (60% vs. 8%), and pleasant hospital stay (40% vs. 8%) (see Table 2). However, some key elements were discussed by patients and patients’ caregivers as well as by healthcare providers to a similarly small (e.g., fairmindedness/equity, organizational support for the patient and patient’s caregivers) or great extent (e.g., respect for patients’ dignity, uniqueness, individuality, and humanity, empathy towards the patient, relationship bonding).

Further, regarding the two studies investigating both patients and healthcare providers, it was found that several key elements of the relational, organizational, as well as structural area (e.g., empathy towards the patient, relationship bonding, facilitated access to healthcare, pleasant environment) were not mentioned at all.

4 Discussion

To our knowledge, this is the first systematic review examining the concept of humanization of care from the perspective of the involved stakeholders and aiming to create a shared understanding about what delivering humanized care means and how it can be implemented. Our analysis revealed that gaps between the expectations of all the protagonists involved in the process of care and routine clinical practice still exist.

4.1 Relational Area

The relational area turned out to be the one most explored and discussed, which demonstrates the importance of relationships in humanized care.

The key elements relationship bonding, discussed in two-thirds of the included studies, and relational support for the patient and patient’s caregivers reflect the need for a genuine relationship between healthcare providers, patients, and caregivers. This highlights that it is not sufficient to simply treat the disease or the symptoms. As mentioned by the participants, being attentive/interested/concerned towards the patient and sensitive verbal/non-verbal communication are important means for establishing such a connection, as previously demonstrated [41,42,43]. According to the National Patient Safety Foundation’s (NPSF) Lucian Leape Institute, “the experience of trust and partnership is itself valuable, satisfying, and fulfilling to patients, families, clinicians, and staff alike” (p. 6) [44].

Besides relationship bonding, empathy towards the patient and respect for patient’s dignity, uniqueness, individuality, and humanity were also highly discussed by the large majority of stakeholders in the included studies (70% and 90%, respectively) as elements of humanization of care. In agreement with such evidence, several authors have already linked empathy to an improved therapeutic relationship [45] and to higher patient satisfaction [45,46,47]. According to our results, the key element respect for patient’s dignity, uniqueness, individuality, and humanity points to the understanding that every patient is a unique person with their own values, expectations, and life experiences that have shaped the patient’s identity and relational style and which might have been shattered by the disease. A severe disease might also reduce the patient’s perceptions of dignity due to a loss of functionality and reduced control over their body and daily activities [48, 49]. Healthcare providers can promote patients’ dignity by developing a deep understanding of how conditions of the disease affect the patient’s life, emphatically acknowledging patient’s suffering, and, at the same time, trying to emphasize the characteristics less affected by the disease. A study by Beach et al. [50] showed that being treated with dignity is linked to higher patient satisfaction and therapy adherence.

Closely related is the key element holistic approach, which was mainly mentioned by healthcare providers who might have been more familiar with this medical concept than patients and their caregivers. The concept refers to the need to take into account all the biopsychosocial and spiritual dimensions of the patient, disease, and care, and to see the patient as a biopsychosocial being. Such an approach recognizes that the mind has a strong impact on the body and that we need to ensure a form of care that addresses both body and mind in order to be effective [51]. As early as 1996, the World Health Organization (WHO) Study Group saw integrated care, in which all the components of a health system play a complementary role to ensure patients’ well-being, as a way to approach health holistically and to foster personalized services [52, 53].

Further, showing respect for patient’s autonomy and patient involvement and meeting patient’s needs/demands were mentioned in half of the included studies (55% and 45%, respectively) as a means for humanizing healthcare. Thus, as an example, excluding women from decision-making processes in their own care [25] or ignoring women’s needs [40] can represent barriers to the humanization of care. Overwhelming evidence indicates that engaging patients in their own care and thus taking patients’ preferences and needs seriously improves patient satisfaction, empowerment, quality of life, and treatment outcomes [54,55,56]. Transparency regarding the treatment was considered, more so by patients and their caregivers than by healthcare providers, to be another key element. Consequently, not being willing to answer patients’ questions [39] can impede humanized care. A complete understanding of one’s own medical condition and treatment options gives the patient the feeling of autonomy, of being respected, and of being seen as an equal partner. As highlighted by the NPSF’s Lucian Leape Institute [57], greater transparency is linked to higher patient satisfaction, better health outcomes, lower costs, and also fewer medical errors.

Healthcare provider’s personal characteristics and healthcare provider’s competence were rarely mentioned in studies exploring the healthcare providers’ perspective, probably because they did not question themselves. On the contrary, almost all studies analyzing the patients’ viewpoint reported competence as an aspect of humanized care. Psychological preparation to understand the patient was reported as one strategy to convey such competence. Thus, professional competence should be understood not only in terms of technical but also non-technical skills. Equipping healthcare providers with such psychosocial abilities should become an integral aim of medical education.

Moreover, according to our findings, healthcare providers should follow moral and ethical principles, be fair-minded and treat all patients equally (fair-mindedness/equity), and show patience and commitment to their jobs. However, being committed, patient, and empathic towards patients is challenging when experiencing distress or even burnout [58, 59] due to seemingly overwhelming work demands and time constraints. Healthcare providers may then rush through patient encounters while experiencing a loss of enthusiasm, dedication, and meaning [60]. Given these circumstances, it is surprising that only two studies [25, 35] pointed out that healthcare organizations do not provide sufficient psychological support for healthcare providers. Healthcare staff will only be able to truly care for patients and deliver humanized care if their own human needs are also addressed.

4.2 Organizational Area

Adequate working conditions was the most discussed key element in the organizational area. According especially to the opinion of healthcare providers, fragmentation of the work process, lack of time, intense routine at work, excessive demands on healthcare providers, excessive bureaucratic activities, and additional activities out of professionals’ scope impose significant barriers to achieving humanized care. When organizations are able to overcome these barriers, establish proper working conditions, and thus demonstrate that healthcare providers’ well-being is of great importance, healthcare providers will experience higher levels of job satisfaction, be less susceptible to burnout, and provide better care [61].

Although less frequently reported, adequate training opportunities for healthcare providers, effective interdisciplinary team work as well as proper vertical and horizontal communication in the institution were listed, especially by healthcare providers, as organizational requirements for providing humanized care. However, as pointed out by the participants of the included studies, several barriers to these key elements continue to exist in healthcare institutions, such as a still widespread traditional approach to medical education and training [33], a strict hospital hierarchy [25], and lack of cooperation from the management [17].

In contrast, regarding patient care itself, mostly patients and their caregivers called for appropriate medical treatment tailored to patients’ needs and facilitated access to healthcare to ensure humanized care. Open and easy access to primary care has also been demonstrated to play a significant role in reducing, for instance, healthcare inequalities, mortality, morbidity, and costs [62]. Healthcare organizations should also guarantee continuity of care by avoiding, for example, frequent changes of healthcare professionals [26] and provide organizational support for the patients and their caregivers. Further, a pleasant hospital stay, without, for instance, interruptions to sleep [26] or long intervals between lunch and dinner [39], was valued by patients and their caregivers, as already shown in the literature [63]. Two studies also highlighted the importance of adequate priority assessment of medical care (i.e., to find a compromise between ensuring effective care and life-saving treatment, such as in intensive care situations [4], and delivering humanized care), as also discussed by Todres et al. [18, 64].

4.3 Structural Area

Due to economic imperatives and increased demands (e.g., the aging population, an increase in chronic diseases), healthcare systems have been struggling lately with a critical shortage of healthcare personnel and lack of material resources [65,66,67], which were considered in the included studies as barriers to humanized care. According to the American Association of Colleges of Nursing, insufficient staffing leads to increased stress levels among nurses, reduced job satisfaction, and dropouts [61]. Meaningful personal relationships with patients have become challenging tasks carried out under immense time pressure [61]. Thus, to give healthcare providers the chance to spend time directly engaging with patients and caring for them, healthcare institutions must provide sufficient human and material resources.

Healthcare settings, not lacking in space [35] and with an adequate physical structure and pleasant environment were also considered to be structural aspects of humanized care. Indeed, factors such as floor and room layouts and lighting have been shown to positively influence health outcomes [68,69,70].

4.4 Limitations

A number of limitations may have influenced our results. All primary studies applied qualitative or quantitative–qualitative methods and had small sample sizes, thus limiting data rigidity and replicability, and reducing the generalizability of the findings. However, by using qualitative approaches, such as focus groups and interviews, each of the included studies was able to provide an insight into healthcare practices and the ‘lived experience’ of patients and healthcare providers in the field of humanization of care [71, 72].

Intrinsic limitations associated with the applied methodology of our study have to be considered as well. First, despite extensively searching published and gray literature in the medical field, we may have nevertheless missed relevant studies in the field of humanities which could have impacted our results. It is also likely that our applied search terms “humanization/humanisation of care” and “dehumanization/dehumanisation of care” did not capture studies that investigated elements of humanized care (e.g., liberal visitation policies in pediatric care) but did not specifically use the terms “humanization” and “dehumanization”. Further, because of our restriction to include only studies published in English, German, or Italian, we may have missed otherwise eligible studies that could have contributed to a broader geographical and cultural scope of the findings.

Moreover, the methodological steps of the thematic analysis can be prone to subjectivity. To limit this potential bias, two reviewers performed all steps independently and resolved any disagreement in consensus and/or by involving a third reviewer. One might argue that summarizing and synthesizing the results of the primary studies, conducted in different medical settings with participants from various backgrounds, could lead to a decontextualization of the findings [23]. Following Thomas and Harden [23], we therefore tried to preserve context by providing detailed characteristics (e.g., study design, setting, type of participants) and quality assessment for each study. Further, we consistently examined whether the results that emerged from our synthesis could be translated into other medical settings without loss of meaning [23].

Lastly, the generalizability of our findings is hampered by the fact that most of the research was conducted in Brazil. This geographical predominance is not surprising given the fact that since the introduction of the Brazilian National Policy of Humanization of Care and Management in 2003, Brazil has devoted great effort to establishing humanized care, specifically in medical settings that deal with very fragile patients (e.g., newborn/infants or oncological patients) or where risk of dehumanization is high (e.g., extensive use of technology in intensive care) [73, 74].

4.5 Future Studies

Although we were able to extract numerous key elements of humanization and point out similarities and differences between patients’ and professionals’ perspectives, we identified only a few implementation strategies, which were often insufficient to add actionable information. Thus, further research around humanization of care is warranted.

Future studies need to fully examine specific practices of humanized care and test their effectiveness quantitatively by examining psychosocial and health outcomes. Moreover, to examine how the concept of humanization of care might be shaped by the culture we live in, research on humanization of care should be increased in many countries, thus providing a global perspective. To ensure that future literature reviews on humanization of care are able to capture all potentially eligible studies from around the world and thus to provide an even clearer picture of the key elements of humanized care, the search criteria of this study might be expanded. Indeed, the literature search could be extended to other scientific areas, language restrictions might be omitted, and the search strategy could include more terms. The key elements identified by our study may even serve as additional search terms. Future research aiming to identify an even more articulated structure composed of additional sub-constructs within the relational, organizational, and structural area could be beneficial for formalizing a model of humanization of care and for assessing model-consistent interventions to improve outcomes.

5 Conclusions

By synthesizing and thematically analyzing the different perspectives of patients, caregivers, and healthcare providers, our systematic review contributes to a better understanding of the concept of humanization of care. An empathetic and respectful approach to patients, sufficient human and material resources in healthcare institutions, and a balanced workload for healthcare providers are important prerequisites for establishing meaningful, mutually beneficial relationships with patients and delivering humanized care. The key elements proposed here can be considered as preliminary guidance that can help patients, caregivers, healthcare providers, and healthcare institutions in this endeavor.