“WE EVEN FORGET THAT WE’RE NURSES”: IDENTITY PERSPECTIVES OF NURSES IN PSYCHOSOCIAL CARE CENTERS^*

ABSTRACT

Objective:

To analyze the interface between the nurse’s professional identity and her work process in mental health.

Method:

An exploratory, qualitative study was conducted in six Psychosocial Care Centers in Salvador - Brazil. The data was collected between June and August 2022 through interviews with ten nurses and was subjected to thematic analysis.

Results:

the thematic analysis resulted in one category: Identity conflicts and ambiguities, with the themes “Core know-how and the identity of the ‘traditional nurse’” and “Field know-how and the vagueness of identity contours”.

Conclusion:

The results point to the need for more in-depth research into the nurse’s know-how, which includes the fulfillment of her private activities that are congruent with the production of care in the field of psychosocial care.

KEYWORDS:
Mental Health Care; Nurses; Role of the Nursing Professional; Mental Health Services; Work.

RESUMO

Objetivo:

analisar a interface da identidade profissional da enfermeira com seu processo de trabalho no campo da saúde mental.

Método:

estudo exploratório de abordagem qualitativa, realizado em seis Centros de Atenção Psicossocial no Município de Salvador - Brasil. Os dados foram coletados entre os meses de junho e agosto de 2022 por meio de entrevistas realizadas com 10 enfermeiras e foram submetidos à análise temática.

Resultados:

a análise temática resultou em uma categoria: Conflitos e ambiguidades identitárias, com os temas “O saber-fazer do núcleo e a identidade da “enfermeira tradicional”” e “O saber-fazer do campo e a imprecisão de contornos identitários”.

Conclusão:

os resultados apontam para a necessidade de aprofundamento de investigações acerca de um saber-fazer próprio da enfermeira que inclua o cumprimento de suas atividades privativas e congruentes com a produção do cuidado no campo da atenção psicossocial.

DESCRITORES:
Assistência à; Saúde Mental; Enfermeiras e Enfermeiros; Papel do Profissional de Enfermagem; Serviços de Saúde Mental; Trabalho.

RESUMEN

Objetivo:

analizar la interfaz entre la identidad profesional de la enfermera y su proceso de trabajo en el ámbito de la salud mental.

Método:

estudio exploratorio con enfoque cualitativo, realizado en seis Centros de Atención Psicosocial de la ciudad de Salvador - Brasil. Los datos se recopilaron entre junio y agosto de 2022 mediante entrevistas a 10 enfermeras y se sometieron a un análisis temático.

Resultados:

el análisis temático dio como resultado una categoría: Conflictos de identidad y ambigüedades, con los temas “Los conocimientos básicos y la identidad de la “enfermera tradicional”” y “El saber hacer del campo y la imprecisión de contornos de identidad”.

Conclusión:

Los resultados apuntan a la necesidad de investigar más a fondo el saber hacer de la enfermera, que incluye la realización de sus actividades privadas congruentes con la producción de cuidados en el ámbito de la atención psicosocial.

DESCRIPTORES:
Cuidados de salud mental; Enfermeras; Papel del profesional de enfermería; Servicios de salud mental; Trabajo.

HIGHLIGHTS

1. Mental health nurses experience identity conflicts at work.

2. The homogenization of professional roles pressures nurses.

3. A fragile understanding of the know-how of the psychosocial clinic.

4. A nursing process based on theories strengthens professional identity.

HIGHLIGHTS

1. Mental health nurses experience identity conflicts at work.

2. The homogenization of professional roles pressures nurses.

3. A fragile understanding of the know-how of the psychosocial clinic.

4. A nursing process based on theories strengthens professional identity.

INTRODUCTION

Professional identity has been the subject of research in different areas of knowledge and theoretical currents, with an emphasis on studies in the field of sociology. Among the multiple conceptualizations and theoretical references about professional identity, it can be understood as a complex phenomenon, the product of socialization mechanisms, in which the biographical characteristics of the worker, the organizational context, and their training paths play a fundamental role in its constitution¹.

In this way, nurses’ professional identity is (re)produced based on the elements through which they identify themselves and are identified throughout the various socialization processes in their personal and professional trajectories. Therefore, these elements originate from their biographical history, training paths, and daily work experiences, always crossed by the political, social, and cultural transformations surrounding them. They guide the consolidation of nursing as a discipline and social practice².

We must consider the impact of global changes in communication systems and in the systems and models of health practices themselves, which end up producing changes in the work processes of nurses, requiring them to improve and adapt to the new demands regarding the scope of their work and the skills to be developed in their various practice scenarios. In this way, the changing nature of their work tends to produce attempts to adjust to the new realities that shape the professional identity of nurses³.

In this sense, it is worth highlighting the transformations in the Mental Health Nursing field since the Brazilian Psychiatric Reform movement. The diversification of work processes resulting from this new political-assistance configuration of the mental health field has challenged nurses to revise their object, previously the sick body under the condition of psychiatric pathology, and to re-signify the purpose of care, which is now centered on the singularity of the subject’s experience. To this end, it is essential to expand their working tools and technologies and be part of interdisciplinary teams, especially in CAPS⁴.

Although the theme of the professional identity of nurses in their various practice settings has been gaining prominence in the scientific literature in recent ^decades5, the production of Brazilian studies on the identity of working nurses in the field of mental health is still scarce. The available literature suggests that their role is still poorly understood or even made invisible by other professional categories, service users, and workers, which compromises the construction of their professional identity and diminishes the social and professional value of their work⁶-⁹.

Inconsistencies related to nurses’ professional identity tend to compromise the quality of care they provide and user satisfaction with the care they receive. Feelings of frustration and underutilization of their professional skills can be present, contributing to lower job satisfaction, a greater likelihood of occupational illnesses, and abandonment of the profession⁹.

Considering the complex ways in which professional identity, work processes, and daily working life shape each other and the need to deepen the discussion on identity implications for nurses in the face of new work processes in the field of mental health, this study aimed to analyze the interface between nurses’ professional identity and their work process in the field of mental health.

METHOD

This qualitative exploratory study was conducted with nurses working in six type II Psychosocial Care Centers (CAPS) in Salvador-BA. The inclusion criteria included professionals working in direct care in CAPS for over a year. The exclusion criteria were professionals on vacation or other leave provided for by labor legislation who could not be contacted. The Consolidated Criteria for Reporting Qualitative Research (COREQ)¹⁰ was used to construct and describe the research.

Data was collected between June and August 2022 through semi-structured interviews. The interviews were carried out individually in a private room, on dates, times, and places scheduled according to the availability of each participant. In compliance with the biosafety measures recommended to reduce the risk of contagion and transmission of the SARS-COV-2 virus, a remote interview has been made available to professionals who prefer it. Thus, all the interviews were conducted in the participants’ work environment, according to their preference, considering their comfort and privacy, and lasted an average of one hour.

Applying the semi-structured script made it possible to collect data through dialog based on the following guiding question: How do you perceive your professional identity and the relationship between this identity and your work at CAPS? At the same time as transcribing the interviews, data saturation was carried out, a criterion used to define the number of participants¹¹.

The data collected from the interviews was analyzed using the thematic content analysis method proposed by Minayo¹², which consisted of the following stages: Pre-analysis, where the material was read to recognize the units of meaning pertinent to the objective of the study; Exploration of the material, where we sought to identify the nuclei of meaning, which facilitated the aggregation of these units of context into sub-themes and themes, within the thematic category; and Treatment of the results obtained, a phase in which the raw results underwent an interpretative synthesis, to relate the themes found to the questions, research objectives and literature on the themes. The data was processed using NVivo® 11, which coded the materials according to similarities and correspondence with the study’s objectives.

The Ethics and Research with Human Beings Committee of the State University of Feira de Santana authorized the research under opinion No. 2,998,614. The names of the interviewees were replaced by alphanumeric codes, consisting of the letter E, followed by the numerical identification corresponding to the sequence in which the interviews were conducted.

RESULTS

The study was carried out with 10 participants, nine of whom were female. Because the sample was mostly women, we used the term nurses and the female gender to refer to all the participants in this study. About their educational backgrounds, seven of the participants were graduates of public universities, six of whom had been nurses for more than ten years, three for between six and ten years, and only one for less than five years. All the interviewees had postgraduate degrees in lato sensu specialization, but none of them were in the area of mental health. However, the majority (six) had worked in CAPS for over five years.

The results presented refer to the Conflicts and ambiguities of the identity category, which grouped the themes: “Core know-how and the identity of the ‘traditional nurse’”; and “Field know-how and the vagueness of identity contours”. The recording units pertinent to each subcategory show the participants’ reflections on how they define their professional identity to the work processes they carry out in the CAPS. The concept of an identity articulated around the competencies relating to two distinct and central professional roles in the CAPS was highlighted: the reference technician and the nurse.

Core know-how and the identity of the “traditional nurse”

The figure of the nurse, confined to her professional core, is represented by the participants through actions centered essentially on the management of the nursing service, attention to the clinical demands of users, situations of psychic crisis, and care related to the use of psychotropic drugs.

There are some specific things about the technical side, about working in the nursing procedure room, but the work of a CAPS nurse is very different from that of a hospital nurse. (N1)

On the administration side, the health guidance side is more focused on the nursing side. But, in general, we do the same job: to welcome and guide users, right? So, being a nurse at CAPS means covering more of the health field. Nursing is more focused on the health area, users who have comorbidities, and we have to advise them to go to the basic health unit and take care of themselves. (N3)

The exclusive role [of nursing] here in the unit is more focused on this part of medication care, medication control. We’re the ones who act in crises, right? Here, when the patient goes into crisis, everyone runs away. It’s just nursing. (N10)

The distinction made in Participant N1’s speech lies in the coexistence of the figure of the reference technician, who represents an important element of group identification, given that all the professionals on the team carry out this function. Supported by the concept of an expanded form of care beyond their core duties, the participants seek to align themselves with this new professional position they have taken on in the CAPS, which produces deviations from the representation they have of the “traditional nurse”, often associated with the work carried out in hospitals.

Field know-how and the vagueness of identity contours

So, we act as nurses. I mean, we act as nurses but as technicians, right? It’s a multi-professional team where we do some things specific to nursing; others are activities we work on together with the team. [...] So we do activities with colleagues different from being a nurse, but not from being a CAPS professional, you know […]. Sometimes, we even forget that we’re nurses than traditional nurses. (N1)

That’s my identity. I see myself as a nurse, but also, because of the specific issues we have in the work process, as a mental health technician. And then, as a mental health technician, this view needs to be much broader. (N5)

The CAPS nurse works more as a mental health technician; he’s here to be a reference technician. […]. It’s a very broad job. Nurses are not restricted to nursing. (N6)

It can be seen, however, that the work processes of the professionals interviewed, centered on the attributions of reference techniques based on the expanded clinic and the discussion of interdisciplinary work dynamics, tend to produce a perception of homogeneity and standardization of professional roles among the team. This perception is expressed by the understanding that all the workers who make it up have the same duties.

It’s because here we are struggling with the question of the field and the core. There are specific nursing issues and broader issues that we deal with as mental health technicians. So, there are moments that blend. (N5)

But we’re just like any other reference technician. […] We have a mixed role when I see it with the other professionals. (N10)

The nurse’s professional identity is still being recognized, considering the changes that have taken place in the field of mental health policies. According to participant N6, the paths to this recognition also start from discussing the performance of nurses’ private activities in the organization of the CAPS teams’ work processes, such as the Nursing Process.

We build our identity according to the work environment and public mental health policies, right? Related to psychosocial care. It’s a difficult process where you work with the issue of the nursing profession in psychosocial care. […] Nurses are still in the process of being recognized in psychosocial care. […] Sometimes, it’s difficult to understand on the part of the population and even for the professional trying to build their identity in psychosocial care. […] building a nursing identity goes through these conflicts. I also see that mental health and psychosocial care coordinators sometimes resist systematizing nursing care in the workplace. (N6)

DISCUSSION

The scenario of paradigmatic disputes in the mental health field, marked by the coexistence of the asylum and psychosocial models expressed by divergent policies over the years, is revealed in this study as an important determinant of the context of the participant’s identity constitution. In this context, they build their professional career based on movements to preserve traditional and historical identity references, to the extent that they are pressured to break away from these references in the face of the different ways of caring proposed by the psychosocial model in mental health¹³.

Contemporary changes in the world of work in a globalized society must also be considered, as well as their effects or impacts on health work processes, including organizational and managerial changes incorporated by health services, which contextualize the production of professional identities for their workers. These changes have demanded the management of more flexible production processes, highlighting the emergence of a new multi-skilled and multi-functional worker or even the flexible specialization of the collective worker¹⁴.

Thus, in the nurses’ discourse, daily work experience is marked by the perception of homogeneity of professional roles, and the reference technician device, recommended for the collective management of users’ care processes in the CAPS, refers to the tendency of polyvalence and multifunctionality of a health worker “capable of handling everything”¹⁵. This situation requires nurses to reorganize their practice in CAPS to deal with the diversity of duties in this role.

This practice reduced to a flexibilization and dilution of the various types of knowledge and specificities, ends up collaborating with the neoliberal project that advances the logic of the productive restructuring of health services¹⁴. As a result, the participants’ speeches show the conception of a faded identity in the face of the growing demand to perform multiple tasks of varying natures, as participant E1 states when she says that sometimes she forgets that she is a nurse, based on a comparison with references she recognizes that represent the figure of the “traditional nurse”.

In this sense, the nurse figure, when represented in terms of her professional core, is portrayed by the participants as based on practices with a biological focus regarding hygiene, self-care, prevention of clinical comorbidities, and care with medication¹⁶. This finding points to the persistence of the representation of the professional core of nursing based on care practices secondary to biomedical knowledge as an element that characterizes the work of nurses and the recognition of their professional identity. It should also be noted that the nursing team’s responsibility in the face of users’ crises still refers to the identity inclinations of the professional figure who orders the asylum space and docilizes bodies, historically linked to their insertion in the psychiatric nursing¹⁷.

Comprehensiveness is understood in the statements to mean expanding or even deviating from the nurse’s traditional practice. From the place of reference techniques, the participants in this study appropriate this sense of broadening the ways of working. However, this expansion of their work, coupled with a fragile understanding of their competencies and attributions as core professionals in line with the logic of care based on the psychosocial care model, has repercussions on the definition of their professional identity. Their work tends to be carried out among the multi-professional team without clarity about their place of work¹⁸.

It is possible to state that although technical reference figures and nurses appear to coexist in the discourses without canceling each other out, this duality is not free from presenting conflicts to the workers. These conflicts may arise from the tension generated by the tendency to distance themselves from models that still support the relationship of self-recognition of these professionals (identity references inherited from the historical-social construction of the nursing field) and which are opposed to the care logic of the psychosocial care model, associated with the nurses’ lack of clarity about the bases of their knowledge that anchor their work in this scenario of practices¹⁹. Thus, there remains a strong identification with the role of reference techniques, from which they seek to be characterized and recognized professionally.

It is important to emphasize that the homogeneity characteristic of the process of collective construction of care through the device of the reference technician and the integration of knowledge and shared decision-making in the team does not necessarily imply the loss of the identity of the professionals. It is considered here that the management of work through the technical reference device in mental health based on the interdisciplinary logic of care does not exclude the specific responsibilities and interventions of each profession²⁰.

Since these professionals show difficulties in situating their place and the theoretical and practical references of their field of knowledge in substitutive mental health services, they reinforce the theoretical and practical dependence on other health professions, accentuating a historical identity crisis in nursing. Studies on nursing theories and nurse autonomy in the face of the delimitation of their private activities, such as the systematization of care through the Nursing Process (NP) anchored in nursing theories, have been pointed out in the literature as essential to diluting this identity crisis¹⁸,²¹-²³.

In this sense, the National Guidelines for Mental Health Nursing Care²⁴ list the nursing theories applicable to mental health PE, such as the theories of Joyce Travelbee, Hildegard Peplau, and Imogene King. However, despite the existence of nursing theories that guide mental health care, it can be seen that nursing professionals still subordinate their work to the knowledge of other professionals in the team²⁵. Regarding the implementation of the NP, the findings in the literature show that, despite the increase in scientific production about experiences in the mental health field, there is still a shortage of studies that present methodologies to evaluate the effectiveness of the application of the nursing process in this context²⁶-²⁸.

Given the scant use of theoretical references specific to the core of nursing and the fragile systematization of their practices in the provision of care in the field of mental health, nurses who work in CAPS compromise the constitution of an identity based on the sharing of beliefs, values, knowledge, and practices specific to their professional core, which generates conflicts in the production of identity for the category. As a result, they tend to reinforce their condition of invisibility and devaluation in health work, in which they seek social recognition and the privileges of the professional domains they produce.

In this way, the results of this study point to the need to create new possibilities for dialogue between the psychosocial care model in mental health and the core of nursing, which requires political organization for dialogue with municipal managers, professional councils, as well as the contribution of training spaces and the production of knowledge, to deepen the discussion about the particularities of the work processes of nurses in the field of mental health as significant elements for strengthening professional identity and consequent recognition and social appreciation of the category.

A limitation of the study is that it presents the experience of professionals in a specific local reality. However, the findings correlate with the state of the art on the subject. Furthermore, it is worth pointing out that the qualitative approach does not aim to generalize. Still, the findings point to a diagnosis and possibilities for intervention in constructing the nurse’s professional identity in the field of Mental Health.

FINAL CONSIDERATIONS

Nursing, as a discipline and a professional category, is moving forward in search of affirmation and social recognition. It is a struggle with multiple contours according to historical moments and different social and political contexts, transforming their work processes and, consequently, their identity constitution.

The management of care processes through the device of the technical reference in mental health was observed in this study as a work context that favors the dilution of professional identity in the face of tension against the homogenization of professional roles and the rupture of historical identity references that are opposed to the care logic of the psychosocial care model.

The lack of clarity regarding their scope of knowledge and practice reinforces the lack of definition of attributions historically experienced by the category in various practice settings. This condition, therefore, interferes with exercising their autonomy and recognizing their professional identity, compromising the demarcation and claiming a distinct space for action in the mental health field.

This suggests key elements for further discussion on the constitution of a professional identity for nurses in the mental health field based on the construction and recognition of their category’s know-how, grounded in theoretical references and the core’s private activities.

The findings of this study can support coping strategies through the political and collective organization of Councils, Associations, and Unions to redefine/protect professional identities in a way that works in favor of the struggle for a socially valued and recognized professional category. In addition, it presents contributions to thinking about pedagogical teaching-learning tools/processes/strategies for nursing students and professionals in favor of a political identity formation anchored in the theoretical productions of the nursing field and the psychosocial care model and aligned with the practical reality of these professionals in their daily work at CAPS.

• *
  Article extracted from the master’s “A interface da identidade profissional da enfermeira com o processo de trabalho no campo da saúde mental”, Universidade Federal da Bahia, Salvador, BA, Brasil, 2023.

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Edited by

Associate editor: Dra. Cremilde Radovanovic

Publication Dates

• Publication in this collection
  27 Nov 2023
• Date of issue
  2023

History

• Received
  02 May 2023
• Accepted
  26 Aug 2023