Nursing care provided to persons deprived of liberty in the hospital environment

Objectives: To describe the nursing care provided to people deprived of liberty (PDL) in the hospital environment. Methods: An exploratory-descriptive study with a qualitative approach, conducted with 38 nursing professionals in three regional hospitals located in the Northeast of Brazil, between March and July of 2016. Content analysis was performed on the data. Results: Two categories emerged from the analysis: nursing care provided to people deprived of liberty in the hospital setting and self-evaluation of nursing care provided to PDL. Final considerations: The nursing care delivered to people deprived of liberty in the hospital environment is limited to technical procedures, revealing a fragmented work process that falls short of the standards of public policies. We found that structural deficiency, particularly regarding safety in the hospital environment, associated with lack of professional training to deal with this clientele, make nursing care difficult in this context. RESUMO


INTRODUCTION
Interpersonal care is the oldest practice in the history of mankind, whose purpose is to ensure the continuity of life by guaranteeing human vital functions. Thus, care practices, such as the provision of food or substances for curative purposes to cope with diseases, have a cultural character, transmitted from generation to generation. However, beginning in the nineteenth century, care practices to prevent or cure diseases underwent a process of professionalization, coming to be considered an attribute of health professionals, especially those of nursing (1)(2) .
Nursing care is considered one of the pillars of health practices, necessary for the promotion, prevention, treatment and rehabilitation of individuals and the community (3)(4) . Therefore, it is expected that, in assisting users, nursing professionals base their practices on scientific knowledge, but also consider humanization as the essence of technical and ethical action in health practices (5) .
As regards health care for persons deprived of liberty (PDL), we highlight the recommendations of the Brazilian Penal Execution Act (LEP) (6) , which deals with the right to health of people in prison settings, with guarantee of curative and preventive actions, comprising medical, pharmaceutical and dental care. In addition, LEP determines referral of prisoners to establishments in the health care network, in situations where the prison health facility cannot be effective.
Also within the scope of the legislation on care to PDL, the Ministry of Justice, in partnership with the Ministry of Health, instituted the National Health Plan of the Penitentiary System (PNSSP), through Interministerial Ordinance No. 1,777, dated September 9, 2003, aiming to promote integral attention to the population confined in male and female prisons, including the psychiatric facilities (7) . In 2014, with the purpose of expanding the health actions of the Unified Health System (SUS) for the liberty-deprived population, the Ministry of Health launched the National Policy for Comprehensive Health Care for Persons Deprived of Liberty in the Prison System (PNAISP) (8) .
However, it is noteworthy that despite the legal apparatus, prison health care in Brazil faces quantitative difficulties, with low percentage of prison units with health teams in place, as well as qualitative difficulties, mainly with unskilled professionals and fragmented network care (9)(10) .
In addition to the above-mentioned difficulties, and to social vulnerability prior to imprisonment, we note aspects that enhance illness processes, such as overcrowding, sanitation, insufficient food and exposure to stress and violence, with hospital treatment often needed because health promotion and protection actions have proved quite ineffective in this context (11)(12) .
The need to train the nursing team's skills and competencies to attend to PDL justifies this study. Denying the importance of the topic, and sweeping health analyses of the prison system under the carpet can mean acceleration of system depletion and worsening of the situation. Therefore, discussing the topic may be the beginning of a transformation process that starts in the academy and extends its reflections to the social context.

OBJECTIVES
Describe the nursing care provided to persons deprived of liberty in the hospital environment.

Ethical aspects
The data presented here is part of the thesis developed in the Associate Graduate Nursing Program of Universidade Estadual de Pernambuco (UPE) and in Universidade Estadual da Paraíba (UEPB), entitled "Hospital care for convicts: Nursing practices and health policies".
After a favorable opinion from the Departments of Penitentiary Administration and Hospital Institutions involved in the study, the project was approved by the Research Ethics Committee of UBB and is compliant with Resolution 466/2012 (13) . In order to safeguard the confidentiality of the research subjects, as well as the institutions visited, an alphanumeric code identification system was adopted, with hospitals identified by letters of the Greek alphabet (α, β, y), Nurses by "N" and Nursing Technicians by "NT", followed by the number indicating the interview completion order.

Study design
This is a descriptive, exploratory research with a qualitative approach, a design that is suitable to capture subjective experiences of certain events (14) .

Study scenario
The study was carried out in the medical and surgical wards of three public hospitals located in the northeastern regions of Brazil, namely: Paraíba, Pernambuco and Rio Grande do Norte. These institutions are references for urgency and emergency care and are intended to SUS users, including liberty-deprived persons.
Of the three institutions surveyed, only one had a specific ward for PDL, which was separated by bars from the other hospital spaces. In the other institutions visited, inmates shared the same wards with other patients according to one single criterion: diagnosis/medical treatment. In the three hospitals, the nursing team followed a monthly timetable in the sectors, but the number of patients attended by each nursing technician was set by the professional nurse at the beginning of the work shift.
It should be added that PDL were accompanied by security agents (military police officers), who kept guard outside the ward throughout the hospitalization period and accompanied the nursing professional during care. In addition, some inmates were handcuffed to beds because they were considered as highly dangerous.

Data source
Survey participants were nurse team members who met the following inclusion criteria: be nurses or nursing technicians who worked in the Medical and Surgical Wards of said hospitals and who had been attending to PDL for at least six months. Professionals who were on vacation or medical leave during the collection period were excluded. After considering the theoretical saturation of statements (15) , 38 professionals participated in the study: 17 nurses and 21 nursing technicians.
of Nursing care provided to persons deprived of liberty in the hospital environment Silva PBA, Barbosa ML, Oliveira LV, Costa GMC.

Data collection
Data production occurred from March to July, 2016, from semistructured audio-recorded interviews held in private rooms at the respective institutions and based on the following guiding questions: How does the nursing care provided to persons deprived of liberty occur in this institution? How do you evaluate the care (assistance) delivered by the nursing professionals?
The research subjects were identified in loco, who were invited to participate in the study after being explained about the aims of the research. Those meeting the previously established inclusion criteria were interviewed at the nursing units of each institution at their convenience. Interviews were audio taped and fully transcribed immediately after completion, so as not to lose relevant information for data analysis.

Data analysis
Data analysis was concomitant to collection and used the content analysis technique proposed by Bardin (16) , completing three phases as recommended: pre-analysis, to get a first impression of the data collected, which in turn is subdivided into four stages, namely: floating reading , choice of documents, hypotheses, objectives, and construction of indicators; the exploratory phase, in which the material was codified into categories by means of clippings of the records; and the third and last phase, in which the data were treated through critical and reflexive evaluation.

RESULTS
The following categories emerged from data analysis: nursing care provided to PDL in hospitals and self-assessment of the nursing care delivered to PDL, which will be described below, with the emerging concepts, through participants' statements.

Category I -Nursing care provided to persons deprived of liberty in the hospital setting
The care provided by the nursing team to liberty-deprived persons in the hospital setting is limited to meeting this clientele's basic needs, namely: bath, dressings, food and medicalization, to guarantee the prompt recovery, as demonstrated by the following statements: The distinction in the care provided to PDL and other patients emerges in some statements and indicates that the patient's dangerousness directly affects the practices developed by the nursing team. In general, we have a certain care, a certain caution about materials when we are going to do some procedure. Try to keep, say, a scalpel, out of reach if it is some kind of invasive procedure, after all it can be used against us. This is not a concern in the other wards. When I'm in the inmates' ward, I take it as a punishment. Being on duty is hell. (β E3) Some interviewees claim that they organize and deliver care without distinction, regardless of whether the subject has broken the law, as in the following statements: The interviewees signaled the lack of hospital structure, with emphasis on the professionals' safety as a factor that interferes with the care provided:

DISCUSSION
The results of this research allowed to identify aspects about the nursing care provided to PDL, which is limited to technical procedures, demonstrating a fragmented work process that falls short of the current standards advocated by public policies.
It is known that the Flexnerian paradigm, influential and still present in the health area, is characterized by a technicist, biologistic perspective, focused on curative actions by the nursing team, to the detriment of a holistic and humanized practice (17)(18)(19) . In this context, the care practice developed in hospitals demonstrates that nursing professionals have exercised their care practices only in search of cure, with care restricted to performing procedures, mechanized, fragmented work, absence of communication with patients, absence of clinical evaluation, and vague progresses.
The reality identified in this research contradicts not only PNAISP recommendations as to the completeness of care to PDL, but what is recommended for good nursing care, i.e., the intersection between social, technical, managerial and scientific skills (8,(18)(19) .
Nursing professionals should guide their practices according to quality standards and ethical principles, understanding that health care accountability is not restricted to the technical act of offer, but also involves commitment with the quality of life of the assisted individual (20) .
As provided in PNAISP, care should be comprehensive and promote qualified and humanized attention (7) . For doing so, it is coherent that the professional's caring actions with the freedom-deprived patient should be marked by commitment, equity, effectiveness, dignity, competence and responsibility.
Another relevant aspect for the quality of nursing care to PDL concerns the availability of trained human resources and the implementation of the Nursing Care Systematization (SAE) in the hospital context (21) .
The complexity of the nurse's practice is recognized, of the care that permeates this practice and of the doing as daily action in the care of individuals in the hospital environment. Such complexity is compounded by the discomfort mentioned by professionals in caring for PDL and the recognized inadequate number of professionals to guarantee nursing care. These aspects demonstrate the need for a fruitful debate on hospital care for prisoners and the role of nurses.
The interviews have shown services with compromised care, absence of specific qualification for the care of PDL, deficiency in the training courses, with curricula that do not teach skills and abilities to attend to PDL in the hospital environment, as well as lack of initiatives and updating of hospital institutions about the increasing demands in the work process.
Nursing professionals who work in direct care, even if occasional, recognize difficulties in the task of caring for inmates as triggers of feelings of guilt, sadness, anxiety, anger and powerlessness, similar to those experienced by nursing professionals who care for terminally ill patients (22) .
It is thus inferred that nursing professionals do not feel emotionally and behaviorally prepared to fully care for this group of subjects. Besides the stress of the nursing work process, the professional must know how to deal with the emotional stress related to the patient's condition of prisoner. These copings can compromise workers' quality of care and psychological structure (22) .
In the studied scenario, the non-establishment of interpersonal relations has repercussions on comprehensive care, humanization and preservation of ethical issues that permeate the professional practice (23) . According to the literature, communication is the basis of the therapeutic relationship. However, in the hospitals studied, the constant fear in relation to PDL and family, the imminent coexistence with confrontations between them and security agents, and the fear of causing dissatisfaction with an unmet request, cause the professionals to avoid establishing a relationship.
The subjects of this research have assessed their practices negatively due to the complete absence of bonds, breach of confidentiality -since professionals perform the service only in the presence of a security guard -, and the naturalization of bed restraints. Like the professionals in the study of Kuhn, Lazzari and Jung (24) , some members of the nursing team seem to adopt mechanization, detachment, rationalization and depersonalization of care, depriving subjects of any other meaning.
For this reason, the training of skills and competencies should be stimulated for the care of PDL in the hospital environment, so that the stigma about those who break criminal law, safety rules, inadequate psychological preparation, fear, and shortage of professionals do not compromise the service, from the modification of the work process and non-limitation of health actions.
The important role of continuing education to mobilize the potential of nursing workers is evidenced, since, by rescuing a conception aimed at the development of these professionals, it allows of Nursing care provided to persons deprived of liberty in the hospital environment Silva PBA, Barbosa ML, Oliveira LV, Costa GMC.
a permanent improvement of the quality of health care and the constitution of critical, ethical and humanistic technical practices (25) . The National Policy on Permanent Education in Health, instituted by Administrative Rule GM/MS 198/04, aimed to constitute a teaching-learning network in the exercise of work in the SUS for the training and development of workers, based on the health needs of users/ population, while emphasizing the interdisciplinarity of the health team, focused the practice as a source of knowledge and placed the professional to act actively in the educational process (25) .
We have seen that the care delivered by the nursing team changes according to the users and is related to the type of crime committed and the establishment of empathy with the subject, which consequently affects the quality of care. In a study on health care work with convicted patients, the social condition of lawbreaker was shown to be present at all times, creating a conflicting relationship, because if the patient's condition is undeniable, but momentary, the transgression may be a relapse, a fact that arouses an antagonistic feeling in the professionals, between the patient and the "criminal" (26) .
In this study, despite several difficulties in establishing a positive interaction, it was possible to identify some of the interviewees' statements that construe the individual situation of the convicted patient as that of any human being, abstracting the inmate condition at the time of care.
All care and attitudes in exercise by the nursing professional should aim at preserving respect, valuing life, quality of life, and human dignity; and all this regardless of who is being provided nursing care (27) .
In addition, PDL have lost their right to come and go, but maintain all other fundamental rights protected and guaranteed by the State, including health care, from the PNAISP guidelines regarding the SUS, namely: integrality, intersectoriality, decentralization, hierarchy, and humanization (7) .
However, we found that some nursing professionals of the services surveyed face some difficulties in carrying out their patient care activities. The interviews have shown a concern with the physical integrity and safety of health care workers.
For the interviewees, the lack of partnership and harmony with the security agents is a complicating factor for performing their job. Increased interaction would favor the sense of protection and thus benefit the care of patients in seclusion in the hospital environment.
Care delivery is thus contingent on the overt presence of the security service, under the aegis of security first and then any other needs of PDL, including health care (28) . Therefore, it is understood that the nursing team should base their practice in the care of PDL on biosafety recommendations, but should also maintain ethical conduct and guarantee the right to health and human dignity, respecting the principles that govern their professional practice. After all, caring is essential for the human life of healthcare professionals and users in need of care.
This demonstrates the urgent need to establish moments of evaluation of the service provided in order to reach forms of collective action from the perspective of the interdisciplinary look and action, necessary for understanding the complexity of health care.

Limitations of the study
Collection of data limited to medical and surgical clinics are considered as limitations of this study, and the results obtained cannot be generalized.

Contributions to the field of nursing, health or public policy
It is expected that the results of this study, in revealing the nursing professionals' evaluation of their practices, can contribute to the implementation of continuing education initiatives and, therefore, changes in the work process and qualification of care. Finally, we suggest that further studies should be carried out, widening the scope and including the identification of organizational and legal barriers that interfere with the care delivered to PDL.

FINAL CONSIDERATIONS
The nursing care provided to PDL in hospital settings is limited to technical procedures, demonstrating a fragmented work process that falls short of the standards advocated by current public policies. Structural deficiency was identified, especially with regard to safety in the hospital environment, which, coupled with the lack of training of professionals to deal with this clientele, hinder effective nursing care in this context.
We conclude on the necessity of including issues related to prison health in the curricular components and student training activities of technical and university nursing courses, geared towards guaranteeing the training of skills and competencies for a comprehensive and humane professional approach to this clientele. In addition, we point out the importance of continuing education initiatives for nursing professionals about the health care of liberty-deprived persons.

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Nursing care provided to persons deprived of liberty in the hospital environment