PSYCHIATRIC CARE PROVIDED BY NURSING TECHNICIANS

Objective: to investigate nursing care practices of people with mental disorders. Method: qualitative, descriptive study, with data production through participant observation of the care provided by 12 Nursing technicians. The observations were recorded in a field diary and submitted to the Content Analysis technique, in the Thematic Analysis modality. Results: the medicalization of care was emphasized and non-medication interventions focused on hygiene, feeding and sleep. In this sense, these professionals transferred to the family member / companion part of their responsibilities such as patient observation, meal offerings, bathing, bed organization and follow-up for the examinations. The most empathic behavior occurred at hospital discharge when the patient and the companion's belongings were discussed and organized to lead them to the door. Conclusion: the theme is relevant and the results indicate the importance of the qualification of Nursing technicians to care for people with mental disorders. It is necessary that these professionals integrate skills related to technical skills, which corresponds to the main practical implication of the results of this research. Descriptors: Nursing; Psychiatry; Hospitalization; Assistance; Hospitals, General; Medicalization. RESUMO Objetivo: investigar as práticas assistenciais dos técnicos de Enfermagem às pessoas com transtornos mentais. Método: estudo qualitativo, descritivo, com produção de dados por meio da observação participante dos cuidados prestados por 12 técnicos de Enfermagem. As observações foram registradas em um diário de campo e submetidas à técnica de Análise de Conteúdo, na modalidade Análise Temática. Resultados: destacou-se a medicalização do cuidado e as intervenções não medicamentosas centraram-se na higienização, alimentação e sono. Nesse sentido, esses profissionais transferiram ao familiar/acompanhante parte de suas responsabilidades como a observação do paciente, a oferta das refeições, a condução para o banho, a organização do leito e o acompanhamento para a realização dos exames. A conduta mais empática ocorria na alta hospitalar quando se dialogava e organizava os pertences do paciente e do acompanhante para conduzilos à portaria. Conclusão: o tema é relevante e os resultados sinalizam a importância da qualificação dos técnicos de Enfermagem para cuidarem de pessoas com transtornos mentais. Faz-se necessário que esses profissionais integrem habilidades relacionais às habilidades técnicas, o que corresponde à principal implicação prática dos resultados desta investigação. Descritores: Enfermagem; Psiquiatria; Hospitalização; Assistência; Hospitais gerais; Medicalização. RESUMEN Objetivo: investigar las prácticas asistenciales de los técnicos de Enfermería a las personas con trastornos mentales. Método: estudio cualitativo, descriptivo, con producción de datos por medio de la observación participante de los cuidados prestados por 12 técnicos de Enfermería. Las observaciones fueron registradas en un diario de campo y sometidas a la técnica de Análisis de Contenido, en la modalidad Análisis Temático. Resultados: se destacó la medicalización del cuidado y las intervenciones no medicamentosas se centraron en la higienización, alimentación y sueño. En este sentido, estos profesionales transfirieron al familiar / acompañante parte de sus responsabilidades, como la observación del paciente, la oferta de las comidas, la conducción para el baño, la organización del lecho y el acompañamiento para la realización de los exámenes. La conducta más empática ocurría en el alta hospitalaria, cuando se dialogaba y organizaban las pertenencias del paciente y del acompañante para conducirlos a la portería. Conclusión: el tema es relevante y los resultados señalan la importancia de la calificación de los técnicos de Enfermería para cuidar de personas con trastornos mentales. Se hace necesario que estos profesionales integren habilidades relacionales a las habilidades técnicas, lo que corresponde a la principal implicación práctica de los resultados de esa investigación. Descriptores: Enfermería; Psiquiatría; Hospitalización; Asistencia; Hospitales Generales; Medicalización. Master, Universidade of Uberaba/UNIUBE. Uberaba (MG), Brasil. E-mail: aldo.matos@uniube.br ORCID iD: https://orcid.org/0000-0001-8924-5116; PhD., Universidade of Uberaba/UNIUBE. Uberaba (MG), Brasil. E-mail: mrcna13@yahoo.com.br ORCID iD: https://orcid.org/0000-0003-4794-4255; Studentss nursing, Universidade of Uberaba/UNIUBE. Uberaba (MG), Brasil. E-mail: mariana.souto_@hotmail.com ORCID iD: https://orcid.org/0000-00019019-5021; E-mail: moises_augusto22@yahoo.com.br ORCID iD: https://orcid.org/0000-0002-3300-3078 ORIGINAL ARTICLE Matos A, Moll MF, Souto MO et al. Psychiatric care provided by nursing... English/Portuguese J Nurs UFPE on line., Recife, 12(3):618-25, Mar., 2018 619 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i3a25080p618-625-2018 Madness has never gone unnoticed throughout human history, but it has not always aroused fear, repulsion, or pity. In Ancient Greece, fools were considered to be favored, for it was believed that in their delusions they had the ability to communicate with the gods. A complex historical-cultural construction changed its locus and stigmatized it. At the end of the eighteenth century, there is the historical reference of the pathologization of madness, which has been characterized and studied from the point of view of science. Once characterized as pathology, madness became the responsibility of the State. However, in the scenario where Cartesian thought prevailed, madness was perceived as a process of "unreason", and then there was no place for the mad in the rational society. Far from promoting the understanding of mental illnesses, this rationalist and Cartesian insight dragged the madmen into the Great Internationalization movement, coming from the sixteenth and seventeenth centuries, when general hospitals had the function of sheltering the poor and unemployed. Then begins the nineteenth century with a general hospital designed to house the poor and the crazy. Later, still following the Cartesian logic of the separation of body and mind, the diseases of the body remained in the medical-biological-scientific space of the general hospital and the madmen were destined for asylums. In Brazil, the first normative provision on mental illness was decree 1,132 / 1903, which had as objectives to unify the care policy to the alienated and to stimulate the construction of specialized hospitals in the member states. Since the modern age, patients with mental illness are stigmatized in different countries and remain on the fringes of both society and health services themselves. The word that best represents mental illness is stigma. ...] stigma involves not so much a set of concrete individuals that can be divided into two stacks, stigmatized and normal, as a two-part social process in which each individual participates in both, at least in some connections and at some stages of life. The normal and the stigmatized are not people, but perspectives that are generated in social situations during the mixed contacts, by virtue of unmet norms that probably act on the encounter. On the contrary, to strip mental illness of a stigmatizing character and allow the person with mental disorder (re) to find its place in society, actions converged that generated the movement of the Psychiatric Reform within another major movement the Reformation

Madness has never gone unnoticed throughout human history, but it has not always aroused fear, repulsion, or pity.In Ancient Greece, fools were considered to be favored, for it was believed that in their delusions they had the ability to communicate with the gods.A complex historical-cultural construction changed its locus and stigmatized it.
At the end of the eighteenth century, there is the historical reference of the pathologization of madness, which has been characterized and studied from the point of view of science.Once characterized as pathology, madness became the responsibility of the State. 1 However, in the scenario where Cartesian thought prevailed, madness was perceived as a process of "unreason", and then there was no place for the mad in the rational society.Far from promoting the understanding of mental illnesses, this rationalist and Cartesian insight dragged the madmen into the Great Internationalization movement, coming from the sixteenth and seventeenth centuries, when general hospitals had the function of sheltering the poor and unemployed.Then begins the nineteenth century with a general hospital designed to house the poor and the crazy.Later, still following the Cartesian logic of the separation of body and mind, the diseases of the body remained in the medical-biological-scientific space of the general hospital and the madmen were destined for asylums.
In Brazil, the first normative provision on mental illness was decree 1,132 / 1903, which had as objectives to unify the care policy to the alienated and to stimulate the construction of specialized hospitals in the member states. 2 Since the modern age, patients with mental illness are stigmatized in different countries and remain on the fringes of both society and health services themselves.The word that best represents mental illness is stigma.
...] stigma involves not so much a set of concrete individuals that can be divided into two stacks, stigmatized and normal, as a two-part social process in which each individual participates in both, at least in some connections and at some stages of life.The normal and the stigmatized are not people, but perspectives that are generated in social situations during the mixed contacts, by virtue of unmet norms that probably act on the encounter. 3 the contrary, to strip mental illness of a stigmatizing character and allow the person with mental disorder (re) to find its place in society, actions converged that generated the movement of the Psychiatric Reform within another major movement -the Reformation Sanitary.
Born in the academic world in the second half of the 1970s, in the midst of a military regime, the Sanitary Reform movement sought to guarantee the provision of quality health services to all Brazilian citizens through the construction of an efficient health service and democratic, which became official with the Constitution of 1988, and the creation of the Unified Health System (UHS). 4 In order to do so, it is essential to review the organization of health services and implement new healthcare practices and, in this same period, assistance in psychiatry was the target of the Psychiatric Reform that embraced the anti-asylum fight.In Belo Horizonte, in 1979, the III Mineiro Congress of Psychiatry proposed alternatives in psychiatric care. 5nce then, new services are being structured to ensure continu i ty of care and to promote the citizenship of the person with mental disorder.In view of this new approach, a new assistance network is being proposed and new social alliances and collective life projects are established through direct communication among people as an essential practice. 6wever, this process did not definitively break with the stigmatization of people with mental disorders, since hospitalization in the psychiatric hospital reinforces stigma both in society and in health services and professionals.In response to this question, the Ministry of Health published Portaria No. 148, dated January 31, 2012, which creates a Reference Hospital Service as a point of attention for the Psychosocial Care Network component, 7 to guarantee the minimum conditions of care, such as the provision of bed and care by multiprofessional staff and, therefore, to alleviate the stigma imposed on people who go to psychiatric hospitals.This question lies in the technicalassistance dimension of the Psychiatric Reform in which not only the new assistance models, the constitution of territorial health networks, interdisciplinarity and intersectoriality, but also the new role of technicians -all the health professionals who are graduates or those with a mid-level education. 8This point, at the end of the chain of attention or intentions in the care of the hospitalized person, is crucial when one considers that stigma is established within the construction of social identity .A new role requires re-meaning your practice for yourself.One element that evidences the internalization of this new proposal of attention is the relationship between the caregiver and the person with mental disorder that is established in the communication during the care actions.The role of the therapeutic relationship in the recovery of the person in psychiatric treatment requires a humanistic approach and that the caregiver is not guided only by diagnostic labels and allows the patient to approach. 9en considering this reality, it is noticed that the nursing care offered to people hospitalized in psychiatric beds of general hospitals needs to be investigated.Fear, frustration, and impotence predominate among nursing professionals' feelings about people with mental disorders, 10 which comes from the historical stigma placed on this subject, from being unpredictable and difficult to socialize, and located in the medical clinic of a general hospital. 11To investigate nursing assistants' care practices for people with mental disorders.
A qualitative and descriptive study developed in a medium-sized city in the interior of Minas Gerais with approximately 300 thousand inhabitants.The scenario of this investigation is classified as a general hospital of medium and high complexity providing care to the macro-region of the South Triangle that has, since 2014, six psychiatric beds equally divided for people of the feminine and masculine genera that are located in the medical clinic.
The study was carried out through participant observation, which totaled 107 hours, between March and August of 2016, recording the observations in a field diary.During this period of observation, the care provided by the Nursing technicians to those who were hospitalized in the psychiatric beds was emphasized.
Twelve of the fifteen Nursing technicians participated in the study and the inclusion criteria were: working in the hospital's medical clinic; care for people with mental disorders who were hospitalized in psychiatric beds, and agree to participate in the study.These professionals were identified in the descriptions by the letters NT(Nursing technician) with sequential numbers.For that, ethical procedures were respected and participant observation was initiated with the support of opinion 447.029 issued after the analysis of the Research Ethics Committee of Uberaba University.Also complying with the ethical determinations, the Term of Free and Informed Consent was signed by the persons in charge of the persons hospitalized in the psychiatric beds and it was requested the signature of the assent by these persons.
The data recorded in the field diary were analyzed through Content Analysis, in the Thematic Analysis modality, when the contents that converged to similar meanings and grouped in thematic units were identified. 12l the nursing technicians who worked in the medical clinic with psychiatric beds were invited to participate in this research, totaling 15 professionals.Of these, 12 accepted to participate: 11 (91.66%)women being ten (83.33%) married and one (8.33%)single.
During the data collection, in different shifts, attendances were realized realized by six technicians of Nursing.From the observations, two units of meaning emanated: the medicalization of care and non-medicare care.

 Care medicalizaton
The routine established in the hospital services regarding the administration of medication is followed by the team of nursing technicians of the hospital that constituted the scenario of this study and this emphasizes the investigation of the following information in the medical prescription: route, dose, schedule, name of the medicine, pharmaceutical form and registration.In addition to this analysis, practitioners should provide guidance to the hospitalized person and his / her family / caregivers on the names and objectives of the medications being administered, which does not occur during the administration of medications to persons hospitalized for psychiatric disorders or necessities due to drug use.
Faced with questions, the answers tended to be evasive and with little information, as explained below: The lady will take these medications that the doctor prescribed the same as the lady takes at home.(T3) In general, this communication of the Nursing technicians was fast and not very informative.However, a Nursing technique reported to a hospitalized gentleman who presented himself insecure and anxious at the time of receiving his medication the following: The medication serves not to be anxious, to make the head less confused and to have a calm and fearless day.(T5) This information made the mentioned gentleman accept the medication without difficulties and expressed more confidence in the professional.This professional has always shown patience in answering questions about medication, which seemed to provide a welcoming environment for both the hospitalized person and his or her companion.

METHOD
It should be noted that one of the standards of this service is the continuous presence of a companion / family member with people hospitalized in the psychiatric beds to promote greater patient safety and also to provide more qualified care.However, the presence of this companion / family member can not exclude the monitoring of the Nursing technicians to ensure the patient's care, safety and needs assessment.
In this sense, it was evidenced that they were the companions / relatives who informed the technicians about the situations of agitation.From this information, the professional was already preparing the medication -which, for the moments of crisis, was always the same -and administered without asking the nurse responsible for the shift or the doctor on call the evaluation of the patient.Faced with this reality, it was evident that the practices of the nursing technicians were specific (focused on the medication schedules) and the predictors of crisis were not evidenced by these professionals who, when informed about them, only sought to minimize them to keep the routine of the shift.
In view of the above, it is noticed that Nursing technicians perform, as a priority, the administration of the prescribed drugs and do not fulfill all the attributions inherent to this practice, and the monitoring of the hospitalized persons was in charge of the companions / relatives.Both situations do not guarantee an integral care of the patient's needs, since the companions / families do not possess technical knowledge, adding to this, their emotional involvement with the hospitalized person.The affective / family ties may reflect in a positive or negative way since, in situations of previous crises, aggression or hostility may have occurred.However, hospitalized people need care of another nature to meet their needs for recovery, and therefore, in the following theme, non-medicare care.

 Non-medicated care
Non-medicated care was restricted to meeting basic hygiene, food and sleep needs, as well as referral for additional examinations in the hospital's own premises and accompanying the patient and his / her companion / family member to the caretaker's office at the time of hospital discharge.
Among hygiene care, we prioritized the corporal hygiene and the maintenance of the clean and organized bed.But to exercise this care, five Nursing technicians handed the clean clothes to the companion / family member, who was held responsible for the patient's bath, which occurred without professional supervision.Regarding the cleaning and organization of the bed, it was evidenced that the family member or the hospitalized person tended to perform this procedure, once the Nursing technician left the bedding together with the clean clothes to be used after the bath and returned only at the end of the shift or when triggered by the family.
In feeding care, five technicians focused on the investigation of patient acceptance of diets.Most of the time, meals were delivered to the wards at the times stipulated by the institution and the diet supply or supervision of the intake was performed by the relative / companion.Specifically, one of the Nursing techniques was careful to offer the diet for those hospitalized who had difficulty feeding themselves in situations where the companions were absent.During this offer, he sought to interact with the patients by questioning the quality of the food and talking about other subjects that the patient himself wanted, which seemed to provide tranquility for the hospitalized person.
Sleeping care was expressed by complaints of insomnia, which occurred only in some shifts, since sleep medications were always present among nocturnal medications.
The referral for complementary examsmainly imaging -occurred through information about where the examination would take place and the patient was followed by the family.In cases where the family was absent, this professional would take him to the area where the examination would be held and leave him waiting until the person in charge of the examination called him.This situation can be illustrated by the following account: The patient was informed by the Nursing technique that he should perform an examination and that soon he would get it.At 1:45 pm, the professional arrives at the room and accompanies the patient to the examination room.He was left in the industry being asked to only wait sitting down that someone would call him soon. of the examination.An industry professional looks at the patient's reaction and informs that he is the next to come in and take the exam.After the completion, about 50 minutes without any follow-up, the patient returns alone to the room being himself that goes to the Nursing station to inform that he returned the examination. 13ced with situations of resistance of the hospitalized person to perform examinations, the Nursing technician triggered the doctor who visited the patient to talk and convince him about the goal and the need to take the exam.After this dialogue, acceptance of the examination was common and the person was taken to the sector where it would be held.

After tiring of waiting and without having any professional of the sector of origin or of the local sector near, the patient raises anxious to return to the infirmary claiming that it is not called for the accomplishment
Finally, the participation of nursing technicians at hospital discharge was expressive, because, at that moment, this professional sought to dialogue and contribute in the organization of the patient's belongings and his companion and lead them to the portaria.
It was also noticed that among nonmedicated care, that only one nursing technique sought to establish therapeutic communication with these subjects and the other nursing technicians did not value the needs arising from the mental disorder and performed interventions identical to those offered to people hospitalized for clinical intercurrences (hygiene, feeding, sleep, exams).
A first look at the findings points to a distance between the desire of the Nursing technicians who act in the scenario of this investigation and the reality.One can analyze this question in two aspects: those of legalorganizational nature and those related to the practice of care by the technicians.
From a legal-organizational point of view, there is a legal basis in Ordinance 148, dated January 31, 2012, 7 which allocates hospital beds for people with mental disorders and the financial incentive for their implementation.However, in order for the general hospital to be integrated, in fact, into the psychosocial care network, it must prioritize the multidimensionality of the human being as the focus of care.14The organizational issue, therefore, goes beyond the creation of mental health beds because requires that managers, professionals and caregivers know and value the proposal of psychosocial care.
In this sense, it is important to address the relevance of transposing the model focused on the disease and the medicalization of care, which reflect the stigma of madness even in a general hospital.Based on this premise, the findings of this investigation were analyzed.
When analyzing the medical care provided by the nursing technicians, it was evidenced the absence of therapeutic communication that generated a distance between the professional and the person assisted, which is demonstrated by the evasive answers when, when receiving the medication, the person questioned to the professional for the medication.These findings also occurred in a study that showed that care is technical and without specificity for mental health needs.8 It was also pointed out that occasional actions were taken by the technicians observed, which was restricted to the medication administration, at times established by the institution, and the transfer to the companion / family member of the responsibility to observe the evolution of the hospitalized person.This reality may be related to the organizational ideology that establishes, to professionals, the function of controlling the organic or psychic instability (depending on the reason for hospitalization) through medicalization and attention to the basic needs of food, hygiene and sleep.This reality may also be related to the feelings of fear and insecurity or the lack of training of the nursing technicians in the face of the care to be offered specifically to people with mental disorders hospitalized in the general hospital.15-6However, among the observations, a Nursing technique posed the patient's doubts so that he understood and managed to establish a relationship of trust on the part of the hospitalized person, who accepted the patient better.treatment.In this context, the study states that, in the context of psychiatric nursing, care must transcend technical aspects and reach psychological and emotional needs.17 Regarding non-medicated care, the perceived behavior regarding the medicalization of care was reproduced, that is, the lack of therapeutic communication and the responsibility of the companion / family member for activities that would fit the technicians.
The transfer of responsibilities to the companion was evidenced in the situations of the baths, the bed organization and the diet supply.In this sense, it was noticed that the guidelines on bathing, when they happened, were directed to the companion instead of the person hospitalized itself, which can be interpreted as an attitude of the technician in avoiding to interact with that person.In this sense, it is emphasized that nursing is really Again, the same Nursing technique, which sought to resolve doubts about the medication administered, stood out by offering help to people hospitalized for psychic intercurrences that had difficulties to feed themselves.During this procedure, she took the opportunity to establish an empathic interaction and this seemed to reassure these people.Studies recommend that the Nursing team should promote warm environment, built through a trust relationship between staff, hospitalized person and family, 19th that seems to be being valued by this professional.However, it is pointed out that this is not a frequent behavior and, to insert it in the Nursing formation, it is important that the curricular grade of the technical and undergraduate courses in Nursing value the therapeutic communication in a transversal way to prepare professionals suitable for the use of this "technology" of care.20 The evaluation of sleep care was compromised by the constant prescription of hypnotics.Still, in some workplaces, technicians were observed raising complaints about insomnia, however, without any special attention to the patient's needs in mental suffering, suggesting only routine compliance or, perhaps, data collection that allow the psychiatrist to evaluate the adequacy the hypnotic and the respective dosage prescribed.
Although a Nursing technique has assumed an empathic attitude towards people hospitalized, these findings construct an image of insufficient attention to the person with mental disorder hospitalized in general hospital.Despite the specific causes in Brazil, these results are similar to those of investigations carried out in the United Kingdom and the United States, which point out that the care of patients with psychiatric comorbidities is worse than those who do not have mental disorders.21 In general, when reflecting on the care provided by the nursing technicians to the people hospitalized in the psychiatric beds of a general hospital, the medicalization of the care and, on the other hand, a distancing, revealed by the little observation of these patients associated with the transfer of responsibilities to the companion / family member.
The medicalization of care reveals a difficulty in seeing needs of a multidimensional nature of the human being, which is a minimum condition for the practice of the psychosocial model.14And the distance and lack of observation make it impossible for the Nursing technician to perceive elements of nonverbal communication which interfere with care and the humanization of care in psychiatry.22 It is added that caring without valuing all the needs of the person with mental disorder increases the risk of rehospitalization. 23though, during the hospitalizations observed, technicians generally did not attend to the psychosocial needs of those who were hospitalized due to psychiatric disorders, at the time of hospital discharge all participants communicated with these persons and performed their duties, which raised the following question: would there be a fear of caring in moments of crisis or would it be a relief for those who did not feel prepared to take care of these people?Recent studies have found that the lack of preparation of nursing professionals is recognized by them and also constitutes a factor of insecurity when assisting people with mental disorders hospitalized in the general hospital.16Added to this are the fact that these people are seen as different of the others that are hospitalized for clinical intercurrences, and also, the mental disorder raises negative feelings.16   Thus, the findings made it clear that care for the mentally ill person hospitalized in the medical clinic provided by the nursing technicians of a general hospital does not prioritize the proposals of the new model of mental health care that emphasizes meeting the multidimensional needs of the person with mental disorder.
It was evidenced that the thematic is relevant, since it is little explored in the scientific environment and the assistance provided by the Nursing technicians was restricted to the administration of the medications, according to the schedules and the prescribed doses, and the basic needs of hygiene, feeding and sleep.
In this sense, there are practical implications that need to be valued to qualify Nursing technicians for a worthy assistance, such as: educational interventions that address the citizenship of the person with a mental disorder assured by the right to equality; the implementation of CONCLUSION