NURSING AGENTS’ PERCEPTIONS ON THEIR WORK IN MENTAL HEALTH WITH PSYCHOTIC PATIENTS IN A PSYCHOSOCIAL COMMUNITY CENTER

This study aimed to analyze nursing workers’ concepts on the purpose, object and tools used to provide care to psychotic patients in a Psychosocial Community Center – III, Brazil. This qualitative, descriptive and exploratory study used document research, participant observation and interviews. Results reveal diverse concepts regarding the purposes and characteristics of the object, linked to the knowledge each concept is based on. We observed that the first is inspired on Care, Psychosocial Rehabilitation and Psychoanalysis; the second re-signifies principles of Rehabilitation and recovers aspects of moral treatment, and the third translates the idea of professional core and field. We conclude that there is a need for investments in the production of a conceptual corpus and practices that permit changing workers’ position on the production of services at CAPS.


The consolidation of the Brazilian Psychiatric
Reform that took place in the 1990s permitted the organization of a network of services, which is currently formalized as the core instrument of the work process technology in Psychosocial Community Centers (CAPS) (1) . It reconnected the work process of nursing agents in these services. This reformulation made nurses assume responsibilities in case management and made mid-level workers participate more in psychosocial rehabilitation (2)(3) ,  (4) .
The consolidation of these propositions also resulted from efforts along the 1990s, in which modes of teamwork organization were tested in the first substitute services, one of which was theoretically formalized as reference teams (5) . This model proposes that a health team becomes responsible for a population and establishes therapeutic bonds with it.
Multidisciplinary issues can be resolved through the establishment of each professional's core activities and field. The first comprises interventions that can be shared by the entire team regardless of specific education of members and the second comprises actions related to each professional category and which require specific formal education. It would favor the expanded clinic and permit the elaboration of individualized therapeutic projects (5) .
The theoretical assumption of this study is that, under this rationale, the work developed by nursing agents would require each professional to resignify the purpose, object and tools of the work assigned to nursing staff in psychiatric facilities and to invest in the construction of other tools, appropriate for the work process established in Psychosocial Care services, contributing to a psychiatric nursing clinic (7) . Therapeutic Services (HBTS) (8) under its responsibility, in addition to practices adopted by these workers in the management of situations that involve mental health care, explanations they produce about it and effects it generates.
Concepts produced by nursing agents on the purpose and characteristics of the object of work delivered at CAPS are emphasized in this article.
These concepts were apprehended from the way they defined their inclusion in the work process.

METHOD
This qualitative (9) , descriptive and exploratory research aimed to apprehend representations produced by nurses, nursing technicians and auxiliaries working at a CAPS about care delivered to psychotic individuals, which is the main clientele of this service, in order to characterize it. To theoretically apprehend the work signified by nursing agents, we adopted the concept of technological organization of work in health (1) as the theoretical framework. It can be captured at three levels: the elaboration of their purposes, characteristics of their object of work, and connections between tools used and actions they produce on the object (10) .
The case study was chosen as a research strategy because it permits apprehending the components of a given experience in its particularity. in in-service training activities offered when they joined the institution. We opt to work with intentional sampling by variety of types because, to define the size of the sample in qualitative studies, one has to include a sufficient number of participants so as to favor "a certain repetition of information", and not ignore unique information whose explicative potential has to be taken into account (7) .
Data analysis followed steps recommended for qualitative designs, which consist in ordination of data, classification, data summary and interpretation (9) , based on the researcher's experience, literature and theoretical framework.

RESULTS AND DISCUSSION
The characterization of the work developed by the nursing agents at CAPS was based on the participants' discourse, where they exposed their practice with psychotic individuals attended at different moments in the work process. It permitted apprehending diverse concepts on the purpose, characteristics of the object of work in mental health and its tools (10) . They reveal the coexistence of different and sometimes contradictory concepts regarding psychic suffering, which the clinic is based on, and of therapeutic approaches and technological models existent in the service at the time.
When CAPS became CAPS type III, the whole team revised its mission and the agreed purposes of work were defined as: CAPS will make priority use of Interviewees basically problematize it in three axes.
The first is a concept that refers to the notion of autonomy (11)(12)  The idea that the purpose of the work in a Psychosocial Community Center is to encourage people to do something by themselves might be linked to the way they conceive treatment and cure, elaborated by Psychosocial care (6,11) and by Psychosocial Rehabilitation (12)(13) . But, perhaps, it might also be a representation produced as from the Psychoanalysis in the institution, which used to base clinical supervision in the service (8) .
In this perspective, we observe that knowledge in Psychosocial Care and Psychosocial Rehabilitation supports the concept of characteristics of the object of work elaborated by the interviewee, but not exclusively in her discourse, of the user as someone who has had too many losses. However, given that it is not clear which losses she refers to, one can assume that social and subjective losses occupy the same hierarchical position in workers' view.
Thus, we assume that the term encouraging, chosen by the interviewee to express her view of the purpose of work at CAPS, is linked to the concept of social subject, who can "generate norms, orders for his(er) life, according to diverse experienced situations" (11) Or yet, this is about situating mental suffering as issue wont to encouragement, that is, to the presence or absence of social, legal or institutional support from someone who encourages, who favors one to overcome losses. The relevance given to this way of apprehending and re-signifying institutional discourse is because this was the way agents tended to direct their actions and whose discussion cannot be detailed here. The idea that rehabilitating and overcoming crisis means assuming a pedagogical position and that the purpose of the work is to re-educate, aiming to normalize the user, that is, to adapt him(er) to a norm established in the outer world, contrary to what some formulators of Psychosocial Rehabilitation in Brazil (11)(12) advocate, is also present in other discourses. This way of making someone think in a direction that coincides with the professional's thinking is put as a model to be followed by patients, in other words, the parameter which they have to aim for.
One can say it is a re-signification of psychosocial rehabilitation models that pass from a behavioral to a psycho-educative perspective, criticized (11)(12)(13) by the adaptative and, at the same time, reductionist potential of seeing the human being.
It is noteworthy that, in addition to the pedagogical nature attributed to rehabilitation, nursing agents also preserve a childish concept of their object of work, similar to that existent in moral treatment.
This was the first knowledge that supported the organization of a psychiatric hospital as a therapeutic instrument, for which the participation of nurses was essential. They used persuasion as a way to obtain the cooperation of patients and keep order (14) . In the remainder of the participants' discourse regarding their work routine, the re-signification given to rehabilitation that refers to concepts that used to permeate nursing work based on moral treatment also stands out, illustrated in the following.  to that individual, as its funders proposed (11)(12) . As some authors admonish (15) , the consequence of this break is to return to the prescriptive and normalizing pedagogical nature of psychiatric practices, which are expected to be overcome, to the detriment of rehabilitation as proposed by its idealizers. The concept of this interviewee shows that, as opposed to expectations, living with two perspectives of care delivery, which could be considered incompatible or contradictory in mental health care, is possible if we take into account knowledge that based its construction. It is noteworthy how the idea of core activities and field is re-signified so as to preserve the way they put into operation work tools listed as nursing core activities, without connecting them to the idea of singularization of care, at the same time as the idea of unpredictability, uncertainty is incorporated, or at least mentioned, and also the importance of considering each case as a particularity as these tools are put into operation, identified as the professional's field. Care in this context is conceived as welcoming with warranties (7) and its object is the human being conceived as a biopsychosocial being or in a predominantly biological dimension. This is not a work that implies the production of services oriented by clinical knowledge (2,7) , which means that taking care of hygiene