Care in psychiatric hospital under the perspective of a nursing team Atención en hospital psiquiátrico bajo la perspectiva de enfermería del equipo

O presente estudo teve como objetivo descrever a percepção da equipe de enfermagem acerca do cuidado no hospital psiquiátrico. A pesquisa teve abordagem qualitativa, do tipo exploratória, com uso do grupo focal, com cinco participantes, em agosto de 2011, no município de Niterói, RJ, Brasil. A partir da análise dos dados, emergiram cinco categorias: escuta sensível; disponibilidade pessoal; projetos terapêuticos; fator humano da equipe; tensão “psiquiatria tradicional x paradigma psicossocial”. Concluiu-se que, apesar dos sujeitos da pesquisa atuarem ainda no modelo hospitalar, foi possível que trouxessem percepção do cuidado de forma humana e integral. Mas, esta percepção sobre o cuidado possuía fragilidade, pois não se evidenciaram as bases científicas da enfermagem. Recomenda-se que o profissional da equipe de enfermagem invista em seu papel no processo de cuidar no contexto da Reforma Psiquiátrica, em busca de uma abordagem centrada no sujeito e no seu modo de existir. Descritores: Hospitais Psiquiátricos; Cuidados de Enfermagem; Enfermagem Psiquiátrica; Saúde Mental; Autoanálise.


Introduction
The changes in the area of assistance to Mental Health occurred in Brazil from the 80s and they were guided under the perspective of the Psychiatrist Reform, which brought the need of reorganization of the services and the creation of new ways of therapeutic assistance, among them the assistance rendered by the nursing professional is included.
The transformation of the psychiatry has been taking place in the last decades, bringing along with it requirements, once their professionals look for better education and updating in order to follow all the process of change, therefore the psychiatric nursing and his health professionals are part of this context (1) .
The process of transformation of the practices in Mental Health as well as the effectiveness of the presupposition of the Movement of Anti-Mental Institution Fight imply changes of theoretical, juridical and socio-cultural scopes, permeating the area of the construction of policies and models of attention.We intend not only to build new assistential practices in Mental Health but also to produce transformations regarding the social position given to madness, to the different citizen, questioning the culture which stigmatizes and marginalizes specific social groups.
The action of nursing still consists in: care with the food (following the food using a spoon to avoid that the silverware is transformed in knives, i.e.); care with the sleep; care with hygiene; watching aggressive, suicidal, manipulative, depressive, anxious, sociopaths, psychopaths, sexually deviated and amoral attitudes; and forwarding the patients to the patio, a few hours a week.In an environment with such characteristics, the patient becomes a deposit of pathologies to be observed, diagnosed, controlled, documented and latter on sent to medical care to healed (2) .
In this context, we notice the importance of change of concept and attitude of the nursing professionals regarding the psychic disorder.In order for this to happen, it is necessary that these nursing professionals obtain new conceptions and therefore become able to provide the assistance based on the principles of citizenship, ethics, humanization and complete assistance (3) .
Facing the previous considerations, the present study is aimed at describing the perception of the nursing team regarding the care in the psychiatric hospital.

Method
This is a study of qualitative approach, exploratory type.The scenario was a psychiatric hospital in the county of Niterói, Rio de Janeiro, Brazil.The population of the study was made up by nursing professionals who participate in the permanent education at the Psychiatric Hospital which happens weekly, here it is known as an educational group.The group is a 'set of people linked among themselves for periods of time and space and articulated by their mutual internal representation, which proposes a task explicitly or implicitly, which is the reason of its purpose' (4:253) .
The educative group does not have a fixed number of participants, varying weekly.However, approximately 15 nursing professionals attend the permanent education every week, from those, five are daily nurses, five are daily technicians and five are technicians on duty.Of those, only five accepted to participate in the study composing the focus group: three nurses and two nursing technicians.
The technique used for the data collection was the focus group, made in August 2011 by one of the authors with the help of two assistants for the registry of verbal and non-verbal information.
In the focus group we consider what belongs to order of verticality and what belongs to horizontality.
Each participant speaks from his verticality, that is, from his experiences.But, as the individual history is built in the core of experienced interrelations, the report, the opinions, the positioning are constructs that are being delineated in the relations with the other (s).Therefore they report to their groups of origin, the manifestations of the previous and contemporaneous history.So, the subjects are also spokesman of the horizontality in which they are inscribed and the debate itself in the focus group is one of these constructions (5) .
In the focus groups, open questions in order to provide individual verbal answers were raised and the discussion were potentialized among the participants.For such, the starting point was a reflection concerning the situation of the psychiatric hospital itself.The central question was: 'What words would you use to describe the care in psychiatric nursing and the Mental Health care?'This moment was recorded in MP3 and later on, transcript.
The practice of care being performed, when discussed within the group, favored the construction of the meaning of care for these subjects.The group interview was chosen because, from the joint analysis, it was possible to re-signify spaces, to think alternatives of confrontation collectively, rediscover potentialities, associate experiences, search identification, provide visibility to the frailties in order to overcome them, unveiling blocking, process of alienation, reinvigorate energies, links, organizational potential and recognize spaces of belonging.
The starting point was the concrete reality of the subject and their social practices in the pursuit to overcome the apparent situation through new points of view.Therefore, the focus group and the later analysis of the data collected trailed the same path in the pursuit of provocations, reflections and conclusions which actually establish a confrontation with the reality of the nursing in Mental Health, dialectically reflecting on the speeches presented in the focus group.
For the analysis of the research, the analysis of content was used, concerning a set of techniques of analysis of communication which aims at obtaining results through systematic procedure and objective of description of the contents of the messages.The different phases of the analysis of contents are organized around three chronological poles: the preanalysis; the exploration of the material; the treatment of the results, the inference and the interpretation.The pre-analysis, phase of the organization, has the objective to make the initial ideas operational and systematize them.The phase of exploration of the material consists essentially in operations of codification, decomposition or enumeration.In the phase of treatment of the results obtained and interpretation, the gross results are treated in a way that they can be significant and valid (6) .
With this, the present study used the analysis of contents through the theme categorization, which presupposes the formation in the classes, categories to data grouping and so, transmits more visibly its meaning.Categories of analysis were generated from the elements which were more frequent in the transcript of the focus group.
A study was approved by Committee of Ethics and Research of the University Hospital Antônio Pedro of the UFF, under register CAAE 0130.0.258.000-10.The identity for the interviewees was kept in secret, complying with resolution 196/96 of the National Council of Health.The participants are identified as P n (ex: P 1 = participant 1).

Results
From the analysis of the data, the following categories emerged: offering sensitive listening; the need of personal availability; the construction of individualized therapeutical projects; human issues of the team; 'Traditional Psychiatry vs. Psychosocial Paradigm' tension.

Offering sensitive listening
According to the nursing team, the care in psychiatry nursing requires a qualified listening.They consider that the sensitive listening must be a behavior to be followed in its practice.I think that the listening is essential (P 2 ).Both for the patient as well as for the team itself.To provide opportunity and listening (P 5 ).That famous behavior which we always prescribe and must be effective, which is the sensitive listening in order to favor the therapeutical link (P 3 ).
They report that it is very important what the bearer of the disease says, once through his speech they can sign something serious, from intensification of the symptoms or of the anguish, up to suicide.I also think that we have to pay a lot of attention to what they say.
Sometimes there in his speech (the patient´s) he brings something very serious.Even concerning suicide.Sometimes he is already signalizing something and we don't always understand or do not pay attention to it.What also happens is the fact that we don't have so much time to pay that attention, to be there, paying a lot of attention to what they are signalizing (P 5 ).

The need of personal availability
The educative group points to a personal availability by part of the nursing team as a starting point in order to reach the subject so that, from then on, take care of the bearer of the psychic suffering.I think that also availability.Not Just being there involved with the routine but also want to understand, to be available (P 1 ).And also to show himself available as well.You can´t listen if you not there available.This is essential, especially in the psychiatry… (P 3 ).

The construction of individualized therapeutic projects
Another aspect pointed as relevant for the psychiatric nursing team is the construction of the individualized therapeutic project.It explains that in all the areas of health the individualization of care is necessary, but in Mental Health it becomes even more indispensible to emphasize the specificities of each one, considering the observation and the assistance in the routine of the patient, once it is primordial that the nursing team guarantees the continuity of the foreseen actions in the therapeutic project and in the routine of works foreseen for each patient.You should observe too, follow the routine of the patient, I think it's essential, thus providing continuity to the therapeutic project concerning the questions which emerge in his routine (P 2 ).Considering the specificities of each one for you to come up with some result, some therapeutical project.Another word to describe care is 'individualized'.In all the areas we need the individual treatment.And in psychiatry, more than ever, this has to be really present... (P 3 ).
However, it is necessary to know how to leave aside the idea of excessive demand from the patients, the notion that his psychic suffering, so avoiding the attribution of a pejorative sense due to the fact that this patient demands a lot of attention from the team.
And you must leave aside this excessive demand, from the policomplaint patient that we sometimes even play with the psychic suffering (P 1 ).

The human issue of the nursing team
Another outstanding aspect in the statements analyzed is regarding the vocation to take care in Mental Health.It is necessary to enjoy what you are doing, because otherwise, in a short while, the health professional gives up, due to the great demand of the bearer of psychic suffering.It is considered very important to have the human side of the health professional, because, without that, it is not possible to take care of this bearer.The nursing team must work with the bearer of mental suffering using devices to reach reciprocal complicity and sympathy.I will talk about the human side of the team there.I think you have to really enjoy it because otherwise in a short time you give up everything, you get sick of it.We know how it is to work with psychiatric patients.It's really a lot of demand.The professional has this human side, because if not we don't treat the patient as well as he deserves (P 4 ).[Listening]   Both the patient as well as the team (P 5 ).

'Traditional Psychiatry vs. Psychosocial Paradigm' tension
According to the nursing team, there is a resistance from some people in accepting the 'new'.They explain the new as follows: the therapeutical assistance, the fact that the psychologists are closer to the patients and the nursing team, nursing professionals and other areas with renovated ideas concerning the care among the citizens, aspects which touch the guidelines themselves of the Psychiatric Reform.I think it is important to state that there is a little resistance from the older people.I notice this day by day.I think that the older employees don't care about this new thing (P 5 ).The therapeutic assistants, the fact that the psychologists are closer to the patients and the nursing team [proposals related to the Reform].I see a big resistance from the old employees receiving the new ones.Some new guys arrive, with new ideas, but many times I listen to the old people saying 'why all of that with the psychiatric patient?What a joke!' That's why I think that the hospital should call the people that say these things to attend courses, to defend this idea more, for the Reform itself.I don't see this going ahead with the old employees (P 2 ).

Discussion
The categories show that the perception of the educative group concerning the care in psychiatric nursing and Mental Health are related to the notion of 'operators', who are people able to reconstruct the history of the life of the users beyond the diagnosis and symptoms, active workers in the process of reelaboration of the suffering and reinvention of life (7) .The 'operator' turns to the quality of the care and to the creation of strategies of modification of the reality of the users.The care in Mental Health must be most welcome and responsible for the whole attention of the individual and collective health (7) .
The perception of the participants leads to the reflection that care is above all an exercise of human beings and an art of observing, knowing and doing.For that, that is why it is not a technical action to be studied and developed such as arm work (8) and for this to be so perceived by the nursing team, it is necessary to assure moments of reflection in the day by day experiences of the team.
The category 'offering sensitive listening' reinforces the studies which show that the integrity of Mental Health aims at presenting different answers from those oriented by the biomedical model, which has the disease as the focus of intervention.So, the care presupposes the capacity of listening and the availability to choose an interact with the subjects that demand attention in health (9) .
But, the interviewees repeated what had happened in a previous study (10) , in which the nursing professionals highlighted their personal involvement as reference of the care to the psychotic patient, showing the interaction as an instrument of the assistance in Mental Health, but without bringing a theoretical appropriation of the method of therapeutic interpersonal relation.
One of the biggest mistakes in nursing was to believe that the administration of the hospital environment and the bureaucratic control of the institutional forms would make the nursing professionals indispensible in care.The greatest consequence was to use most of the working time with administrative activities and consequent distancing of the patient, a fact which leads to the lack of recognition of the nurse by part of the clientele and by the other professionals (11) .
When thinking about the human and sensitive care to the bearer of psychic disorder under the perspective of citizenship, the discussion of care to be offered within the psychiatric hospital becomes delicate.It is believed that efforts from by part of whole society for a true change on the look of madness are necessary in the pursuit of experiences and tolerance so that the bearer of psychic suffering can occupy collective areas, and that the socialization itself can be a device to promote therapeutic approach in the psychotic crisis.But while this doesn´t occur, the psychiatric hospitalization show to be a therapeutical clinical instrument which is still prescribed in cases in which the protection of life of the sick patient is required or the protection of life of others, it must be used when there is a rupture in the assistance of other instruments of the net.The decision of hospitalization must be taken in a selective way, specifically in necessary cases, in an attempt to avoid the chronification of the patient and of the disease (12) .
When mentioning the human factor and the personal availability of the nursing professionals, the perception of the health team, the perception of the nursing team finds correspondence in the literature that the care rendered is within each one of the members of the nursing team, being influenced through the wishes, needs and satisfaction of the subjects who take care of the patient, inevitably considering the satisfaction of a set of needs of the users of SUS (Unified Health System) (13) .
There is a lot to be done and transformed in the practice of Mental Health, requiring the commitment of the several social segments in the construction of a net of attention which provides assistance to the new order of precepts and emotional demands (14) .
Under this variation, the category 'the construction of individualized therapeutic project' confirms the literature, where the matter of the integrality in the mental health is approached as something which values the contact and the acceptance of the patient going through psychic suffering.Therefore, in a psychosocial way, the importance to the patient is attributed, considering him as the main participant in the treatment.This subject is seen as a being inserted in a family and social group, so he must also be considered as an agent of the changes pursuit and included in the treatment (9) .
The therapeutical project must consider the singular history of the users, offering answers able to re-dimension his situation of life.Through dialog and mutual understanding, between the several interventions and the interaction of the professionals of different areas, contributing for the performance of more integrated practices, which lead to really transforming actions (15) .
When mentioning the resistance that some professionals still have in adhering to new ways of care in Mental Health, it is reflected that the health professional sometimes resist in participating in permanent education, and they also resist to the proposal of interdisciplinary work and to the care endowed with the listening.Working together with other professionals -not from the nursing area -and taking care of the patient considering him as a citizen of requirements to which the services of Psychiatric Reform are helpful.And such requirements (the 'new') finds resistance facing the instituted knowledge (the 'old') regarding the difficulty of team work, concerning taking care of the bearer of psychic suffering each day renovating the look, the touch and the listening.
As to the resistance in working through interdisciplinarity, it is known that the uncontrolled search of the professional identity of the psychiatric nurse generates difficulties for the interaction of the same with the other members of the technical team of Mental Health (16) .
Concerning the mentioned difficulty of some employees in taking care under the perspective of integrality, it is observed that many times the range of administrative and bureaucratic activities makes the human sensibility reduced and the professional forgets to touch, talk, listen to or, even look at the human being he should be taking care of (17) .
Psychiatric Reform has been happening in Brazil for several years and has the deinstitutionalization as one of its main pillars (18) .The deinstitutionalization is considered as the deconstruction of knowledge and psychiatric practices, a perspective which fundaments the movement of the psychiatric reform and the Brazilian Mental Health policy, inspired in the proposal of the democratic Italian psychiatry.This version of the deinstitutionalization is characterized by the epistemological critic of the psychiatric medical knowledge, in which the sense of citizenship overtakes the sense of universal value to question the concept to mental health itself which establishes limits to the rights of the citizens (7) .
Under this perspective, the movement of Brazilian Psychiatry Reform pursuits the deconstruction of the health institution reality -going beyond of 'fall of the health institution walls' in the physical sense.So, it is possible to make transformations in a whole culture that sustains violence, discrimination and imprisonment of madness.
In this context, the professionals face the challenge to build another type of care from individual therapeutic projects, considering aspects beyond the disease, many times not valued in the courses and universities (14) .
The first step would be to renounce the pursuit of the cure and have as aim the existence-suffering.Health then becomes to be understood no more from welfare parameters defined by biomedical principles, but as a production of life possible and meaningful, for the subjects in his singularities in the different spaces of sociability and sympathy which surround them.
The overcoming of the common sense of exclusion, labeling and infantilization/tutorship consists in a challenge due to the cultural universe of these professionals, to his individual and collective unconsciousness.
Nursing must articulate productive practices of care which are according to the proposal of the Psychiatric Reform, trying to daily redo the ways to see and recognize the demands concerning health and the life of the bearer with a psychic disorder.
It is possible and necessary that the nursing team is committed in the technologies of care which promote the increase of the levels of autonomy and the capacity to make their own choices, which potentializes the capacity of the user to generate his own life providing him support to face the existential suffering in a less iatrogenic and painful possible way, in the pursuit of better level of quality of life.

Conclusion
The psychiatric nursing, as social practice linked to the other practices of health, must be understood as an element which participates and has active voice within the transdisciplinary work of the team of Mental Health.But, in order to enhance the senses of care which sometimes are reduced to questions of sanitation, food, administration of medicine and surveillance and control of the patients, collective efforts are necessary.It is necessary that the elements involved in this problem are able to reflect on their day by day experiences, conceptualizing and consequently transforming it.
The results described in those categories show that, although the subjects of the research take care of the bearers of the psychic suffering still within the hospital, it was possible to bring their perception of care in a human and integral way, relating studies that show that psychiatric nursing is still merely normative.
The perception of the educative group on the care of nursing in Mental Health confirms the proposal of the social commitment of nursing.It is understood that this commitment goes through the other ones experiences in the exchange during the care and fulfilling his tasks and his condition of citizen consciously, in the investment that is made in the construction of a common domain between the caregiver and the patient being taken care of.
However, the vision that the participants bring on the care has frailties, once it is based more on the common sense, without providing evidence for the scientific basis of nursing.Besides that, it should be highlighted that according to the data of the research, a care which is centered on the demands of the users, does not exclude valuing and humanization of the nursing team itself, once this internal availability of the health professional directly interferes in the care provided.
The reconstruction of a service centered not only on the user, but in everything surrounding him -having the auto-analysis and the auto-management of the professionals as the fundamental basis -is not something unreachable.It is necessary to have a commitment with the change in the way to manage and lead the way of care in Mental Health, making every one responsible for such care.It is also necessary to have a set of subjects committed and sensitized with the matters of Mental Health and who actively participate in the continuous dialogical educational processes of the reforming of the proposals and practices.
The findings in this study allowed the comprehension on the perception of the psychiatric nursing care and Mental Health under the perspective of the nursing professionals who participated in the permanent education in a psychiatric hospital.Such findings can be guidelines of educative processes for the nursing team.
It is recommended that the health professional of a nursing team invest in this role as a facilitator of the process of taking care in the context of Psychiatry Reform, in the search of an approach centered on the subject and on his way of living, with the support of multi-professional team thus making the transformation of the reality possible.
The psychiatric nursing must have as its north the development of care as social practice, approaching the bearer according to what the study revealed, through the internal availability, inter-team appointments for the construction of the individualized therapeutical project, providing assistance to these bearers in their day by day experiences and in their lives, respecting them in their specificities, their peculiarities, choices and betting -although provisory -in watching them taking part in a social life.
The limitations of the study refer to the singularity of the group of professionals participant in the study, whose findings cannot be generalized.However, the knowledge here produced can be used for the development of other studies which deepen the theme proposed in other scenarios.

Collaborations
Tavares CMM contributed for the conception of the work, data analysis, writing of the article and final approval of the version to be published.Cortez EA contributed for the conception of the work, writing of the article and final approval of the version to be published.Muniz MP contributed for the conception of the work, data collection, data analysis, writing of the article and final approval of the version to be published.