Nursing practices in a psychological care center

Objective: To analyze the practices developed by nursing professionals in a Psychosocial Care Center (CAPS). Method: A qualitative and evaluative research based on the Fourth Generation Assessment and conducted in a CAPS II of Santa Catarina State in 2014. For data collection, semi-structured interviews, field observation, and data recycling group were used with workers. Constant Comparative Method was used for data analysis. Results: Practices aimed at the subject and their clinical, social, prevention, treatment and articulation with the health network were identified. Medication care is a specificity of nursing that aims to promote autonomy and social reintegration. There is a need for greater articulation between the nursing and pharmacy staff, as well as creating spaces for users to talk about medication. Conclusion: Nursing practices are focused on biopsychosocial care, aiming to deconstruct care models focused on the disease and symptoms. Descriptors: Psychiatric Nursing; Nursing Process; Mental Health; Mental Health Services; Health Services Evaluation.


INTRODUCTION
With the changes introduced by the Psychiatric Reform in workers' practices since the 1970s, nursing was provoked to replace itself. Nursing moved from a context where it was immersed in the asylum, with fragmented and disease-focused practices and symptom identification in order to discuss and improve interdisciplinary relationship skills and develop knowledge in the psychosocial care field (1) .
Among the main changes incorporated by the Psychiatric Reform, there is network care formation and articulation. Within the Psychosocial Care Network (RAPS -Rede de Atenção Psicossocial) strategy, there is the direct involvement of primary, specialized, urgent and emergency care services, hospital care, transitional residential services, and deinstitutionalization and psychosocial rehabilitation strategies. In the case of specialized services, Psychosocial Care Centers (CAPS -Centros de Atenção Psicossocial) stand out for playing a strategic role as network and mental health policy articulators in the territories, representing meaningful advances in psychosocial care (2) .
Nursing is a fundamental pillar, since in all RAPS components, presence of nurses is recommended. Moreover, international and Brazilian psychiatric nursing is recognized as a significant profession, as it improves access and quality in public mental health, having good insertion capacity in multidisciplinary teams. This ability in these cases also brings major challenges to their professional practice (3)(4) .
For mental health services users, presence of nurses in the therapeutic process is of paramount importance. They are inserted in groups, activities and individual care, playing a role of communicator and intermediator in family relationships and, especially, in the supportive interpersonal relationship during treatment. Users recognize nursing as a profession with the ability to provide guidance pertinent to the moment of suffering and anguish. There is an expectation in creating links with these professionals (5) .
Studies also show that nursing teams work from the perspective of developing expanded and integrative care, including family and social context aspects. They are professionals prepared to make connections between mental health and health promotion. They focus on mental well-being, symptom analysis, diagnostic follow-up, medication administration, and other factors related to human life dimensions, helping to improve quality of life and prevent physical illness (4,6) .
Nursing plays a comprehensive role, with active participation in care and autonomous profession performance (6) . Nursing professionals have the mission, in the psychosocial care model, to establish more democratic relationships with users and to develop therapeutic proposals that are committed to the Psychiatric Reform guidelines that focus on humanized care, the individual and their biopsychosocial aspects, not focusing on diagnostic framing only.
However, such aspects are considered a challenge, since studies show that health professionals in general have difficulties to include themselves in this new model. This happens due to the academic formation still very focused on the biomedical model and away from the Psychiatric Reform guidelines. Regarding the mental health nursing performance, practice development with biological focus and bureaucratic activities is identified due to comprehensive care (7)(8) .
There is also a difficulty in understanding the role of nursing in the psychosocial care field, especially regarding skills and competences to work in this area. This lack of clarity has been identified as an obstacle to the elaboration of therapeutic projects and comprehensiveness of actions, thus limiting mental health nursing care contributions in these new equipment (7) . Therefore, this study is justified by the need to improve understanding of the role and practical activities developed by mental health nursing services. It can contribute to qualify interdisciplinary actions that make up the Singular Therapeutic Project (PTS -Projeto Terapêutico Singular), improve team relationships, user satisfaction with care, and offer greater possibilities for social reintegration.
The evaluation's theoretical-methodological framework adopted in this study, including a myriad of human, political, social, cultural, and contextual elements, becomes a strategic tool for discussing and building new mental health practices in-site and in Brazil (9) . Considering the need to build innovative practices and psychosocial care in spaces where nursing is inserted and has its protagonism, this study presents the following research question: what are the practices developed by nursing professionals in CAPS?

OBJECTIVE
To analyze the practices developed by nursing professionals in a CAPS.

Ethical aspects
This study was approved by the Research Ethics Committee (REC) of the Nursing School of Universidade Federal de Pelotas (UFPel) in 2011, according to Opinion 176. In 2014, the research underwent a new appraisal for the data recycling stage, being approved by the UFPel Medicine School's REC, with the Certificate of Presentation for Ethical Consideration (Certificado de Apresentação para Apreciação) 32922114.80000.5317. Ethical aspects were assured to participants in accordance with Resolution 466/2012 of the Brazilian National Health Board (Conselho Nacional de Saúde) (10) . All participants signed the Free and Informed Consent Term. In order to guarantee participant anonymity in the use and storage of information, speeches were identified with the letter "W" for workers; "FD" for field diary records and "DRG" for Data Recycling Groups.

Type of study
This is an evaluative and qualitative approach study based on the Fourth Generation Assessment's theoretical and methodological framework, which is characterized as a constructive and responsive assessment with focus on the needs, claims and concerns of stakeholders. This evaluative approach occurs from the daily constructions and part of subjects that propose the evaluation, within the perspective of a hermeneutic-dialectic process of interaction and negotiation between researcher and stakeholders. Stakeholder is represented by people involved and/ or affected by evaluation (9) .

Study setting
The study was conducted in a CAPS II of a large city in Santa Catarina State. The setting choice was intentional due to its prominence in the work process evaluation in relation to the other CAPS studied in the CAPSUL research. Among the potentialities of the service, attention was drawn to the organization in reference mini-teams, joint planning of actions, work process organization and daily discussion of cases in the space of team and mini-team meetings. Service has become a useful field for evaluating nursing practices in the mental health field.

Data source
Data from the CAPS of Southern Brazil survey (CAPSUL -CAPS da Região Sul do Brasil) were analyzed in two stages: the first stage conducted in June 2011, in which semi-structured interviews were conducted with 14 CAPS professionals and three field diaries from participant observation, totaling 168 hours. These data were collected by three researchers, two professors and one master's student.
The second stage took place in April 2014 and was characterized as Data Recycling phase. It is a step foreseen in the Fourth Generation Assessment, allowing the researcher to delve into the information, issues and concerns of previous evaluation processes (9) . This step took place for a period of two weeks in the field. In the first week, field observations were made, totaling 100 hours of observation; In the second week, a Data Recycling Group (DRG) was held, introducing issues identified in the first step in 2011 regarding work process and observations from the first week of the Data Recycling step. Data from this second stage were collected by two graduate students and one master's student.
Interviews of the first stage were conducted individually, being recorded and applied in a private room. Professionals interviewed were four occupational therapists, two psychologists, two nurses, two social workers, three nursing technicians and one pharmacist. Interviews were guided by the hermeneutic-dialectic circle application. The circle works as follows: the first respondent is submitted to an open-ended question related to the topic of study and pertaining to the interview script. The researcher was aware of the central themes highlighted by participants, their conceptions, values, ideas, concerns, finally, positive and negative aspects that were formulated in the answer. Soon after, the interview was followed by a second participant who, after asking his questions, was invited to comment on the themes arising from the first interview analysis. From the second interview analysis, information emerged not only about his considerations, but also critical to the demands and constructions of the previous interview. The process was repeated with the addition of new informants, allowing each participant to talk about their questions and comment on them in previous interviews (9) .
Participant observation, carried out in 2011 and 2014, was based on a previously established observation roadmap, initially aimed at the environment of researchers in the service, identification of agreements, conflicts. Throughout the process, there was a greater focus on the observation roadmap, interspersed with preliminary data analysis periods (9) . Participant observation was carried out with the team in the following activities: team meetings, case discussions, therapeutic workshops, matriculation meetings and home visits. Data were recorded in field diaries prepared individually by the researchers.
DRG lasted approximately two hours and was attended by 17 workers, the same participants in the first stage of CAPSUL research, except one nurse, one nursing technician, one social worker and one occupational therapist. They took on the roles of first-stage professionals, as well as other professionals added to the team, including a psychologist and two nursing technicians. The group was led by a researcher, while the other two performed field diary entries. The issues introduced in the group for deepening and understanding were: practices that promote or hinder CAPS users from discharging; best practices developed in CAPS in the context of psychosocial care, such as matrix; PTS and embracement; work organization in reference teams and mini-teams. The multimedia projector and notebook were used to present the issues introduced in the group. DRG was recorded on audio and later transcribed.
The inclusion criteria of study participants were being a service worker, not being on vacation or on leave during the data collection period. These inclusion criteria were used in the first and second stage of the research.

Collection and organization of data
Evaluation was developed based on the 12 steps of the Fourth Generation Assessment (9) : 1) contact with the field to present and discuss the research proposal, which was held during the CAPS team meeting, when workers agreed to participate; 2) organization, regarding logistics and entry into the field to conduct participant observation, in order to know the reality and context of the service using a previously established observation roadmap; 3) participants were identified and all those professionals working in the service who were directly linked to CAPS user care and who were not on vacation or on leave at the time of data collection were invited; 4) development and joint constructions, in which interviews were conducted through the hermeneutic-dialectic circle; 5) expansion of joint constructions, with the introduction of new information from field observation data and other materials, such as the therapeutic project of the service, minutes of team meetings and medical records; 6) separation of unresolved issues; 7) prioritization of unresolved issues; 8) gathering information to increase clarity; 9) preparation of the negotiating agenda; 10) negotiation execution, in which the interviewees, at the time of the team meeting, participated in a negotiation group, where they had access to the information obtained in the data collection for discussion, debate and clarification about the buildings, having the opportunity to modify them, to reach a possible agreement; 11) dissemination of results in print and electronic form (via email) of the final research report; 12) Data Recycling.
of Nursing practices in a psychological care center Santos EO, Eslabão AD, Kantorski LP, Pinho LB.

Data analysis
The Constant Comparative Method was used in the data analysis. This method advocates that data collection and analysis be parallel processes, one directed to the other. The method has two distinct steps: The first is the identification of the information units, which serve for the definition of categories, being obtained through the collected empirical material. The second is categorization, whose purpose is to aggregate all units that are related to the same content into provisional categories, aiming at the internal consistency of the categories (10) . The results were classified into thematic categories, one of which referred to nursing attributions in the field of mental health. Within this category, two subcategories were organized, which will be presented in this article: Nursing and biopsychosocial care; Nursing specificities: administration and medication care.

Nursing and biopsychosocial care
It was identified that nursing plays a biopsychosocial care, directing its practices to clinical, social, prevention and treatment issues. Biopsychosocial care of the CAPS nursing staff showed up in different spaces, inside and outside the specialized service, through care with personal hygiene, care, group activities, attention to medication and activities in the territory, such as home visits and networking with primary care, general hospital, and the Brazilian Emergency Care Unit (SAMU -Serviço de Atendimento Móvel de Urgência).
In prevention activities, nursing, investigating clinical situations such as systemic arterial hypertension, diabetes mellitus, heart disease, routine examinations, and in the necessary cases, directs users to referral services, such as primary care. [ Nursing is a care team and contributes to interdisciplinary work through its technical knowledge in the construction of PTS of users inserted in CAPS. The nurse also takes on the role of articulator of the health network, integrating processes of monitoring the user through the network and in the discharge plan of users inserted in other specialized services. The nursing work in the network appeared articulated to the General Hospital and SAMU.

Nursing specificities: administration and medication care
Nursing, as part of a multidisciplinary team, has the specificity of taking care of drug therapy. The activities of verification of correct medication, administration, evaluation of use, effectiveness and guidance for the user and family are part of the nurse's duties in mental health. User autonomy in medication care requires nursing to use strategies for the user and family to take advantage of this activity, developing skills and safety for administering medications at home. These attributions are considered an important condition for the discharge process of CAPS users, maintaining adherence to drug treatment and avoiding return to specialized service and readmissions. In medication care, CAPS nursing, psychiatric doctor and pharmacist work together, highlighting the joint work between nursing and pharmacy. There is a need for greater communication between these two areas in order to avoid errors in medication administration and to strengthen guidance and information to users: The pharmacist asked if Haldol Decanoate was prescribed yesterday. It was not administered. It gives a discussion because the nursing technician says there was no communication, the nursing did not know. The nurse said this was spoken at the meeting yesterday and was not seen in the afternoon. (FD3)

Pharmacist works closely together and in cooperation with nursing, dispensing medication daily to intensive users, seeking to facilitate the understanding of therapy, exemplifying at what times they should take. (FD1)
According to the nurse, "a pharmacy run by a pharmacist is fundamental", that would not know how the service would work without this device. (FD2) Professionals identify that although administration is a specificity of nursing, medication care is the responsibility of all staff. Nevertheless, it is necessary to get closer to the user in order to know questions about their medication, the particularities regarding the use, supervision and guidance. It also highlights the need to strengthen the role of nursing in this process and, in addition, create, in the service, more spaces for users to talk about medication, contributing to their autonomy process:

DISCUSSION
The Psychiatric Reform process and the change in the mental health care paradigm have enabled many advances, including the reformulation of the work process of nursing teams. If before nursing had a limited role in personal hygiene and food, in measuring vital signs and restraint, with the new model of mental health care, nursing now acts as an important and active part of a multidisciplinary team and with autonomous exercise of the profession. Nursing requires differentiated ways of caring, with the transformation of power relations between professionals and users and the development of competences and skills that promote attitudes of expanded care (6) .
From this perspective, the results of the present study allow us to identify that nursing is inserted in different spaces of care in CAPS, developing practices to meet physical and social needs, extending their work outside the service in the territory of life through visits. and articulation with the other services of the health network. The prevention of clinical diseases is also recognized as a nursing practice in CAPS, ensuring greater possibilities for comprehensive care.
However, it is evident that the nursing staff of this study still suffers from the reductionist attributions of their knowledge, such as hygiene and medication care. In W10's speech, it is possible to notice that the conduction of support groups and therapeutic workshops by the nursing staff is still fragile, even though they are extremely important activities within the CAPS.
Thus, it is understood that the Psychiatric Reform process is slow, but must be continuous to enable spaces that substitute for the asylum do not reproduce reductionist care practices. It is observed that there are care movements of this nursing team that aim to broaden its role, such as the availability to be acting in collective care spaces and therapeutic groups.
Another important fact is the performance of nursing in the multidisciplinary team, as highlighted by W01, contributing with their technical knowledge and helping other service professionals, which enables the construction of strategies that integrate PTS. In another study (11) , nursing also appears as a fundamental profession to compose the multidisciplinary team, aggregating different knowledge and contributing to the work of the service.
It is understood that there are different ways to do in the proposed mental health model, being necessary to identify the similarities and intersection points. The specificities of nursing appear differently in the construction of PTS. Intersections with other professionals enrich the spaces of collective construction and care from the perspective of integrality (11) . In the present study, it is also noticed that the nursing team contributes to multidisciplinary work through their specific knowledge, which is important in mental health care.
Considering the important role that nursing develops, it is necessary to advance in the process of training of nurses, to equip them for competencies and skills required in this new care setting proposed by the Psychiatric Reform and the logic of care network, from the territory of life of users and their families (12) .

Nursing practices in a psychological care center
Santos EO, Eslabão AD, Kantorski LP, Pinho LB.
It is understood that there needs to be changes in the academic curriculum bases with greater workload of mental health disciplines, as well as a training exclusively focused on the process of Psychiatric Reform. In the spaces of work in mental health, it is necessary to form and guarantee continuous spaces for ongoing formation and case discussions, because much is learned from the practice of daily life. In this study, W03 identified an important space for PTS construction, which is the case discussion in the mini-team. It is understood that this space must be maintained and strengthened by the professionals of this service.
In this study, the nursing staff appears as an important articulation agent of the health services network. Hospital, SAMU and primary care appear as connected network services, as a result of CAPS nursing practice, as seen in D03, W3 and W5's fragment. However, there is a need to expand this articulation with other RAPS services and with services from other sectors, given the complexity of the health needs of each user and their family.
It was pointed out in a study that the articulation, integration and implementation of RAPS are needs in care for users and family members of mental health, as well as the inclusion of users in the labor market (13) . However, there is little articulation between CAPS and other RAPS devices, and one of the reasons is that workers are unaware of all available care points in formal and informal care networks (14) .
Connection flows are operated by workers inserted in mental health networks, being these protagonists in care, sharing and articulating among themselves means of care that may result in comprehensive care and allowing users to access different levels of complexity, such as: according to user's therapeutic design (15) .
In the psychosocial logic of care, professionals are called to go beyond their technical knowledge, using all physical and relational spaces for exchanges of learning, knowledge and construction of new meanings (16) . There is a good articulation between the members of the multidisciplinary team, but there is a need for closer ties with other workers that make up the mental health care network.
Thus, nursing, as a category strongly inserted in the mental health network, needs to expand its articulation beyond those services linked to its technical knowledge. It must also immerse itself in the numerous RAPS devices, community spaces and other sectors such as education, work, social work, justice and leisure. Thus, it is up to nursing to strengthen its role as network articulator, identifying the functioning of services, other sectors and the user's territory of life and the dynamics of connections needed to care.
Another outstanding practice was medication care for the person in psychological distress, being observed in the speeches and research records as a specificity of nursing. Nursing was identified as a central element in the responsibility for administration, but also for having a broader understanding of good use and adherence practices, using strategies for the user and family member to take care of this therapy at home.
Medication is one of the nursing workplaces that underwent a reformulation within the psychosocial care paradigm. Leaving only its psycho-educational side, nursing has developed new relational skills to provide, in its encounter with the user, possibilities for negotiation, sharing of guidelines and care, in order to contribute to increased adherence and rational medication use (17)(18) .
In contrast to the proposal of psychosocial care, there is a growing process of medicalization, so that any sign or symptom is synonymous with medication use, and problems are not treated in their complexities and particularities. Among the consequences in Brazil and in the world, there is a significant increase in the consumption of psychotropic drugs, both in quantity and duration of use, with little question (19)(20)(21) .
The results show an important concern of the nursing staff and other service members with the correct medication use, as it is an important pillar of treatment. In fact, medication is very important in treatment, but far from being the main one, which makes nursing a unique profession in the analysis, administration and monitoring of this process.
Medication use does not determine the work model, since the model occurs from the purpose and the relationship established with the subject, which reflects the way the medication is used (22) . Medication care is also considered one of the features of CAPS discharge process, when users are continuously monitored in primary care. This discharge has been considered a marker in the process of psychosocial rehabilitation, as it allows the user to advance their trajectories in the network in an autonomous and citizen manner (23) .
Given this, it is clear that the nursing team under study is concerned about the discharge process developing actions that aim to promote autonomy to the user and family to take care of drug therapy. In the discharge process, nursing can act both in promoting strategies so that the user and family feel safe and organized to administer medication in the territory, as well as in building partnerships with other points in the network, linking users to primary care teams and providing support for those teams in the territory.
In this study, it is identified that the nursing work in medication care is involved with the practices of the pharmaceutical professional, and one of the highlighted aspects that needs improvement is the communication between the two areas to avoid medication errors. A study conducted at CAPS in Minas Gerais State found that most services had occurrences related to medication errors and doses use above the recommended or dispensing error, representing risks to the quality of care and user safety (24) .
Better articulation between nursing and pharmacy may represent an alternative to overcome problems related to psychiatric medication use. Among these problems are medication errors, access to information and understanding of drug therapy, which increases the user's appropriation for their treatment. In addition, this articulation is fundamental to ensure better patient safety, reinforcing a care that involves medication use and better therapeutic effectiveness.
Participants also stressed the need for more space for users to talk about medication. In some ways, spaces for users to talk about their medications are still insufficient in mental health services. Users feel inadequate about the medications they use, the side effects, and consider the availability of mental health professionals to answer their questions, criticisms, or dissatisfaction regarding drug treatment (21) . The importance of creating and strengthening the sharing spaces between users and professionals about the of Nursing practices in a psychological care center Santos EO, Eslabão AD, Kantorski LP, Pinho LB.
experiences of medication use is emphasized, with clarification and negotiation of this therapy, so that the user feels heard in their aspirations about medication and also participant in this decision-making process. Therefore, in the present study, it was identified that medication is one of the care resources that make up the PTS and, when used, needs to be evaluated and negotiated jointly between professionals and users. Medication care, as nursing duties in psychosocial care, should be part of a broad proposal for rehabilitation, so that the person feels appropriate in relation to their treatment and has greater autonomy in self-care.

Study limitations
The study is characterized by the perception of professionals, requiring further research that includes the view of users and their families regarding nursing practices in CAPS.

Contributions to nursing, health or public policy
Contributions of the study can be highlighted in expanding the still shy role of nursing teams within CAPS, with their technical knowledge and an expanded look at users' life needs. Another important and innovative contribution is care regarding medication use in mental health, being used as an adjunct in the treatment and not as the main method. There is a concern to share this care for the entire team and, especially, to use strategies that promote user and family autonomy in self-administration of drug therapy. The research has implications for teaching, as it demonstrated the need to strengthen the curricular basis of nursing education for the proposed new model of mental health care, as well as the need for continuing education. New research evaluating the role of nursing in CAPS and RAPS is suggested, considering the importance of these professionals in the network and mental health care.

CONCLUSION
In the present study, it was possible to highlight the importance of the work of the nursing team in mental health care within the CAPS, and as a member of a multidisciplinary team. It was identified that nursing develops practices of its core knowledge, such as prevention of clinical diseases and medication care, which is very important for the user. However, there was a need to expand the actions of these workers to other activities in the psychosocial field, such as therapeutic groups and articulation with other care sectors.
Regarding medication, as a specificity of the nursing staff, workers perceive it as an important care method that makes up the PTS. Its use, in addition to symptom control, has been used as another therapeutic resource in the user's autonomy, self-care and social reintegration processes. It was also identified the need for greater articulation between nursing and pharmacists in order to avoid medication errors and strengthen care practices focused on drug therapy. In addition, it is emphasized that more service spaces are needed to listen to users about the issues surrounding their drug therapy.

FUNDING
A special thanks to CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico -Brazilian National Council for Scientific and Technological Development for financial support in CAPSUL research, and Graduate scholarship grant.