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Revista Latino-Americana de Enfermagem

On-line version ISSN 1518-8345

Rev. Latino-Am. Enfermagem vol.17 no.3 Ribeirão Preto May/June 2009 



Nursing agents' perceptions on their work in mental health with psychotic patients in a psychosocial community center



Debora Isane Ratner Kirschbaum

Ph.D in Mental Health, Associate Professor, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Brazil, e-mail:




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.

Descriptors: mental health; health services; patient care team; mental health services




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), at the expense of the position they occupied in the previous care model. In that model, their duty was to exclusively surveil and control patients' behavior, especially providing care to psychotic individuals.

In the Reform context, the work developed by nurses, nursing technicians and auxiliaries in mental health was expected to be performed in an interdisciplinary perspective, together with the horizontalization of professionals' functions in multi-professional teams, regardless of the original or specific education of each professional. This work process organization, provided and recommended by Law 10216, April 6th 2001, is favored not only by Rules 336/02 and 189/02, but is also supported by funding mechanisms of mental health actions(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 re-signify 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).

The question that motivated this study was how nursing care and mental health treatment were re-signified in the service routine according to the Psychiatric Reform guidelines, so as to conform this new object of work as well as the tools used to transform it.

The aim was to identify the characteristics of the work performed by nursing agents with psychotic patients attended at the first CAPS-III, created in Campinas, SP, Brazil and by the Home-Based 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.



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.

The study was carried out in a CAPS created in Campinas, SP, Brazil in 2000 and transformed in CAPS-III in 2001, due to the decentralization of the Rehabilitation unit of Residents of a Mental Health Service, which was going through a process of deinstitutionalization since 1992(8). It was chosen due to the relevant and pioneering work developed there, to the researcher's connection with the service due to a project of Faculty-Care Integration and also because the Center is an important unit for training mental health professionals and for performing research in the area.

Data were collected through document research, participant observation and non-directive interviews. Documents with information on the concept and service organization were searched: CAPS mission, registry of team meetings, daily registry, on-duty schedules and legislation governing the accreditation of CAPS and its financing. Participant observation was carried out from January to June 2003 during the three work shifts (morning, afternoon and night) and permitted identifying the service routines, which provided important support for interviews and their respective analysis performed later. Interviews were carried out with nursing auxiliaries, technicians and nurses from the three work shifts. Participants agreed to have their interviews tape-recorded and signed a free and informed consent term, which was submitted to and approved by the Ethics Committee at the study institution and also by the Committee at the researcher's institution. Interviews were guided by open questions, which the researcher sequentially asked: agreement to participate in the study; being active at CAPS for at least three months; development of group coordination, workshops, therapeutic follow-up with psychotic patients attended at CAPS; having participated in clinical supervision sessions in the three months previous to the interview; having participated 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.



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 technology based on individualized care, clinical and psychosocial rehabilitation. In crisis situations, alternative solutions will be preferred over psychiatric hospitalizations whenever possible. CAPS actions will have quality and intensity in agreement with demand and will focus on the development of autonomy and quality of life of users, families and others involved. These actions will be developed through a process of interdisciplinary work, connected to other services and institutions (whether they are related to the health area or not).

It would supposedly change the way of conceiving the object of work in mental health and, consequently, the instruments of work, specific to nursing, in the previous model. Theoretically, surveillance, discipline and guardianship were not in line with promoting autonomy and improved quality of life for instance. They should be replaced by work tools called, in the institutional discourse, listening, therapeutic follow-up, stations (similar to operative groups and workshops), collective or individual On-duty Daily Care, in addition to the so-called reference activities, which should be based on individualized care.

The analysis of interviews reveals that the description of the attitude they assume when work tools are put into operation and issues involving teamwork are predominant themes in the participants' discourse. The discourse reveals how they conceive the purpose and characteristics of the object of work.

Interviewees basically problematize it in three axes.

The first is a concept that refers to the notion of autonomy(11-12) as a purpose of mental health care. Asked to talk about what characterized her work at CAPS, one of the interviewees explained that work here is to encourage people. Encourage them to do things for themselves, help them this way. But provide them the necessary material so they can do it by themselves.

Clarification of "encouraging, helping them doing things by themselves" is provided later in the discourse, when she explains ... but people need to have the means to go, I'll help to a certain extent, I'll give the material, I'll provide what's necessary, I'll even accompany them, but I'll let them do it by themselves because, if I take it from them, I guess they've had too many losses and if I take that from them... What they really need is to be encouraged and I think this is our job, to encourage them, you know? To do it by themselves.

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 second axis is based on the concept of rehabilitating and overcoming crisis as a purpose of work and brings to light issues related to an alleged split between clinic and rehabilitation, also in the service mission. In the search to explain the characteristics of his work, an interviewee explained that is very important to work here at CAPS with a core nursing group, you know? You help both the nursing team and the other team of psychologists. But, whenever I work here, I do both things, which are rehabilitation and overcoming crisis.

To clarify what he understood by the latter, he refers to a practical situation that would exemplify related attitudes, in which a patient in crisis with hallucinations and delusional ideas refused to accompany him to another room of the house, have to explain him, otherwise... you know? Tell him that it's true, he's actually seeing it, but there's no reality, you know? Everything is just one world... ok, there're two worlds for him. But we have to deal with it in the most therapeutic way as possible, you know? Explain there is just one world.

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. Referring to her experience acquired in care delivery to residents attended by the Home-Based Therapeutic Services linked to CAPS, another participant reports that ...I already had several cases, I have a lot of experience in households because we work very closely to patients and when I get into a house, I feel like getting into my own house and that's my family, you know? So, many times for you to orient... it's easier to suggest, ask instead of give an order. If you give him an order, you put him down... it's different. "Oh! I'm in my house; you're bossing me around! I see it a lot in households: Look! You don't want do this 'cause you might get hurt. I never say: don't do this because it's dangerous, you know? So, you have to be careful, you know? So, like, I think there have to be interventions, but not let them think that we control more than they do in their own house, I guess it's very important.

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(11-13) 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.

But, like, she can prepare coffee during duty, so like, we're there to deliver care really, you know? In case of any intercurrence, someone gets sick, give an orientation, because we can't forget they are sick people, you know? Because we have to give them freedom, you know? Initiative... but cannot forget they're sick.

The sick individual is understood as someone who suffers losses in social relations, like not having friends, family, a job, partially in consonance with some lines of Psychosocial rehabilitation and care. It is worth noting that, despite the team's option to seek psychoanalysis supervision to discuss cases, there are no reports on the way to address psychosis, for example, as a partial failure of symbolic operation that permits the constitution of a subject, called social ties. Perhaps it would allow them to problematize the idea that there is a relation between the patient and making choices on issues that affect everyday life, including those related to the limits of body and external environment. Another possibility, even considering that this concept might be linked to social representations of madness, still predominant in our society and still supported by psychiatric discourse, is that these concepts derive from a split between clinic and rehabilitation to the extent that, when the first is wrongly identified with the organic psychiatric clinic and when one wants to get rid of it, end up transforming rehabilitation in a technology that relinquishes clinical knowledge and becomes a knowledge one seeks only when crisis is installed instead of using it to clarify what rehabilitation means 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 third axis is care as the purpose of work and the user in crisis and in rehabilitation as characteristics of the object of work in mental health. One of the ways of representing this purpose is exemplified by the following, ...there isn't a recipe. I say like: I get there, I give the medication... I guess there're things that nursing does that is to give medication, take care of the patient's hygiene and everything else, I guess it' depends on each day, each phase, each user, each project we work here. It's not like... there isn't an order... What characterizes nursing work at CAPS, for me, it's it. It'd be care... administer medication, bath... I'd include beauty, organization of the environment, therapeutic follow-up, follow-up at home, and all that.

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 is not a mechanical action without consequences, but should take into account the signification of body for the individual and what body care means to his(er) existence. This is a very important aspect in the case of psychotic patients, given its direct relation with the production of elementary phenomena, in some cases even reported by the interviewees.

This perspective of welcoming with warranties and automatization of work tools reappears in the following report. What we do it's so automatic that when we stop to talk about it, we get lost, you know? So we say; wow! I could have said this and that. But you know, everything is very automatic. Like now, I'll leave my work here at CAPS, I'll get to somebody's home and ask: Look, [guy] did you take a shower? Then, is there anyone to shave? Orient to do... then I go to other houses, administer medications, get back, help to prepare the snacks and then, you know, my shift is over. And then, sometimes, for you to report what you've done is so complicated... (Interviewee 4).

Therefore, it is likely that the concept of purpose of work that leads to the third axis is also associated to different aspects of work conditions only. Its roots can be related with knowledge that supports the conformation of practices at CAPS and which are explained by some agents as follows: 'cause, like, me as a nursing technician... I don't understand suffering. The first thing we do is to put an end to suffering, calling a physician, giving medication, something... I didn't get it, I thought it wouldn't end, I thought it'd take sometime, this kind of thing...nowadays, I have a much clearer perspective of's not it... it's another way of dealing with the problem because both at the outpatient clinic and at the hospital the response is immediate. You have a crisis, you medicate, take another attitude that was prescribed and that's it. Here, you have to know how to talk, there's more contact... let's say there's another way to deal with a crisis. This is very difficult in the beginning, you know... for me to understand that someone is aggressive, beating, and hurting himself, I had to take the person somewhere else and talk, try to understand that crisis and not get rid of the problem so he'd not hurt himself (Interviewee 5).

The findings from this study contribute to broaden and deepen the discussion of results of previous studies, in problematizing the current work process at Psychosocial Care Centers and their problems regarding the construction of knowledge and interdisciplinary practices that focus on the clinic, rehabilitation and social inclusion of psychotic individuals.



The characteristics of the nursing work developed with psychotic patients at CAPS and HBTSs are marked by the construction of, sometimes not very clear, connections between purpose, object and work tools, due to multiple knowledge and concepts on subject and clinic that support the diverse technologies of work process in the same institutional environment. The question regarding the consequences this way of organizing the work process causes for care delivery to psychotic individuals and how undergraduate and technical nursing education can contribute to redirect practices is still unanswered. Considering the coexistence of different ways to characterize purpose and characteristics of the object of work in psychosocial care services, we suggest greater investment in the production of practices and a conceptual corpus that permit changing workers' position on the production of services at CAPSs.



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Recebido em: 28.4.2008
Aprovado em: 10.2.2009

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