Nursing care for people with borderline personality disorder in the Freirean perspective

Abstract

OBJECTIVE

To understand, from the ethical perspective of Freire's, the nursing care for people with borderline personality disorder.

METHODS

This is a qualitative research whose production of information was conducted from May to June 2016 in two psychiatric admission units. We have interviewed seven nurses and eight nursing technicians. The information was analyzed in the light of Paulo Freire’s referential framework.

RESULTS

The following categories have come up: 1) Welcoming and therapeutic relationship as instruments to strengthen linkage; and 2) Drug therapy and restraint: interface between protection, establishment of limits and other challenges for care”.

CONCLUSIONS

Nursing care involved technologies related, medicine administration and physical restraint. There were difficulties in dealing with this disorder. The way to care for nursing, although still permeated by some prejudices, runs through ideologies contained in the ethical assumptions that operate in the light of Freire’s work.

KEYWORDS:
Nursing; Mental health; Borderline personality disorder; Communication; Education, continuing

Resumo

OBJETIVO

Compreender, sob a perspectiva ética de Freire, o cuidado de enfermagem às pessoas com transtorno de personalidade borderline.

MÉTODOS

Pesquisa qualitativa cuja produção das informações foi realizada de maio a junho de 2016, em duas unidades de internação psiquiátrica. Foram entrevistados sete enfermeiros e oito técnicos de enfermagem. As informações foram analisadas à luz do referencial de Paulo Freire.

RESULTADOS

Emergiram as categorias: 1) Acolhimento e relacionamento terapêutico como instrumentos para fortalecimento de vínculo; e 2) Terapia medicamentosa e contenção: interface entre proteção, estabelecimento de limites e outros desafios para o cuidado.

CONCLUSÕES

Os cuidados de enfermagem envolveram tecnologias relacionais, administração de medicamentos e contenção mecânica. Foram referidas dificuldades para lidar com pessoas com esse transtorno. A maneira de cuidar da enfermagem, embora ainda permeada por alguns preconceitos, passa por ideários contidos nos pressupostos éticos que operam à luz da obra de Freire.

PALAVRAS-CHAVE:
Enfermagem; Saúde mental; Transtorno da personalidade borderline; Comunicação; Educação continuada

Resumen

OBJETIVO

Comprender, bajo la perspectiva ética de Freire, la atención de enfermería a personas con trastorno límite de la personalidad.

MÉTODOS

Investigación cualitativa, cuya producción de información se realizó de mayo a junio de 2016, en dos unidades de internación psiquiátrica. Se entrevistaron a siete enfermeras y ocho técnicos de enfermería. Se analizó la información a la luz del marco referencial de Paulo Freire.

RESULTADOS

Surgieron las categorías: 1) Acogida y relación terapéutica como instrumentos para el fortalecimiento del vínculo; y 2) Terapia medicamentosa y contención: interfaz entre protección, establecimiento de límites y otros desafíos para la atención.

CONCLUSIONES

La atención de enfermería incluyó tecnologías relacionales, administración de fármacos y contención física. Hubo dificultades para tratar con personas con este trastorno. La forma de cuidar de la enfermería, aunque esté aún impregnada por algunos prejuicios, pasa por ideologías contenidas en los supuestos éticos que operan a la luz de la obra de Freire.

PALABRAS CLAVE:
Enfermería; Salud mental; Trastorno de personalidad limítrofe; Comunicación; Educación continua

INTRODUCTION

In the perspective of the Psychiatric Reform, the inclusive proposal of people with mental disorders foresees social coexistence, autonomy and the exercise of citizenship. In this direction, the therapies employed are based on relational technologies, among which, therapeutic communication and reception are among the main^1-2. The dialog, according to the educator Paulo Freire, is an existential necessity, basic condition for knowledge. It occurs in the communication between the subjects, starting from an encounter that is realized in the praxis, in the action with reflection, which is based on the commitment with the social transformation³.

This study discusses nursing care for people with borderline personality disorders. This disorder is defined by marked impulsiveness and instability in interpersonal relationships, self-image, and affect. Individuals with this disorder commonly have self-destructive behaviors, such as cutting, scratching, and burning their own bodies, as well as suicide attempts. Many of these attempts are ways of noting the emotional suffering experienced and do not constitute the real intention of taking one's life. However, 10% of the attempts end in consummate suicide⁴. And, as a result, in some cases, individuals with this disorder are hospitalized^5-6.

There are few publications that relate the nursing area to the care given to people with borderline personality disorder. However, there is some evidence of erroneous clinical practices of nursing professionals in the care of the person with such diagnosis⁷, coupled with the high rates of suicide that transform this and other mental disorders into public health problems in Brazil and the world. Thus, it is considered fundamental to conduct research in this area^4,8.

At the international level, in nursing journals, two studies were found from a review on the theme^7-8. One of them addresses the attitudes, experience and knowledge of mental health nurses in relation to adults with personality disorder borderline⁷. Another explores the experiences of people with this diagnosis and makes a discussion about the practice of professionals in Primary Care⁸. At the national level, articles dealing with the disorder come from the field of psychology and, in these, the predominance of review studies⁴.

Given this context, the question of research was raised: How do nursing professionals care for people with borderline personality disorder? We sought to investigate how these professionals relate to patients affected by the disorder during psychiatric hospitalization in the hospital setting. The research may contribute to the reflection and support of professionals working in the area, identifying potentialities and weaknesses in care and possible interventions for their effectiveness. The centrality of the educational action in the professional practice of nurses, which presupposes a theoretical and philosophical reference and their understanding from the socio-political, economic and cultural context of the human being, and in this sense, the possibility of offering integral care and of quality, based on alternative, available and, above all, ethical technologies.

In the light of the presuppositions contained in the work of the Brazilian educator Paulo Freire, especially regarding concepts such as dialogue and autonomy, this study aimed to understand, under Freire's ethical perspective, nursing care for people with borderline personality disorder.

METHODS

This is a qualitative, descriptive and exploratory study. It was carried out in two psychiatric hospitalization units of general hospitals in Santa Catarina, which treat people with mental disorders and dependent on alcohol and other drugs. Participated 15 nursing professionals (seven nurses and eight nursing technicians). It was considered as a criterion for inclusion professionals working in the area of mental health nursing for at least six months and professionals who, at the time of production and recording of the information, were excluded from the service for vacations, medical certificate or leave.

The information was produced by interview, following a semi-structured script, with identification questions and open questions about nursing care to people with borderline personality disorder. The interviews were carried out in a private room of the hospital, after consent of the professionals, with the help of a digital recorder and afterwards, they were transcribed in full.

The processing of the information followed the proposed content analysis⁹, having as theoretical-philosophical framework the works of educator and social scientist Paulo Freire. Thus, the analysis material went through different phases: pre-analysis; material exploration and treatment of results, inference and interpretation.

This research followed all the orientations proposed by resolution 466/2012, of the National Health Council, which regulates research involving human beings and was approved by the Research Ethics Committee of the State University of Santa Catarina - UDESC, according to opinion number 1,522,130, dated April 28, 2016.

To ensure the anonymity of the nursing professionals participating in the research, they were identified by alphanumeric codes, by the letter E (Nurse) or T (Nursing Technician) followed by the order number of the interview.

RESULTS

In relation to the profile of the interviewees, the study was attended by 14 female and one male nursing professionals ranging in age from 21 to 65 years old. As for the professional category, eight professionals were nursing technicians and seven were nurses. The time of performance in the area of mental health ranged from six months to 14 years, with an average of four years and two months. No participant mentioned specific training in the area of mental health, one professional mentioned having undergone an improvement course on chemical dependency.

The exploration of the material allowed to apprehend the relevance between the lines of each professional, to classify the central ideas and to organize them into categories: 1) Acceptance and therapeutic relationship as instruments to strengthen bond; and 2) Drug therapy and containment: interface between protection, setting limits and other challenges for care. The categories will be discussed below.

Acceptance and therapeutic relationship as instruments for bond strengthening

The participants of the study expressed that in their daily practice of nursing in mental health, they performed the care during the whole period of hospital stay in the psychiatric unit. Upon patient admission, they reported interviewing if he can respond the questions. The family members are also interviewed, which makes it possible to cover a greater number of information about the patient's daily life before arriving at the hospital and to carry out the necessary orientations to the family members.

In the practice of care, they report that, immediately after the initial interview, the nursing professional presents the physical space of the hospitalization unit, explains the functioning of the service and the rules of permanence for treatment, such as: separation of the male and female dormitories, feeding, recreation and rest times. If the patient is not psychically able to understand the guidelines, they are performed for the family members.

We must welcome, talk, listen a lot [...] it's up to us because we, in fact, have stayed with them longer. (T1)

We do an interview, we do the homework, we fill out a form [...] we usually talk to the patient and the family, because sometimes they try to hide some information and the family ends up saying the opposite. (E13)

Our service is to take care of, to give care and care that you need, because sometimes you are very needy [patients]. (T6)

We do more observation to see how the patient is evolving because he has those ups and downs. (E9)

You must be more careful with them [with patients], but you cannot leave them at ease, you must have rules [...] you must respect them, and they respect us. She is a sick person and is here to treat herself, and we must help ... the first thing we try is the conversation, both the psychologist, [...] and we [nursing technicians and nurses ]. (T12)

[The patient] is welcomed, presented and shown the whole environment of the unit, how it works, if the patient itself is not able to understand and understand where he is, the family member is guided very well, and he is under the care of the nursing [...] It needs a lot of patience first, patience cannot be lacking, quiet, observation [...] and knowing how to get on the patient. (T15)

Participants refer to these patients as sick people and are there to be cared for. During the hospitalization period, a good reception is necessary, which means listening carefully, understanding, being calm, patience and affection, observing daily its evolution, which usually has sudden changes in mood and behavior.

In this direction, the nursing professionals reported difficulties in establishing the therapeutic relationship with the patient. It is noted that it takes flexibility and patience to deal with the various situations that occur during hospitalizations, since the characteristics of patients with borderline personality disorder difficult to establish a relationship of trust between them and the team.

It could be noticed by the speeches of the professionals that sometimes they feel insecure and do not know how to act in front of the instability of the patient with borderline personality disorder.

[...] [the patients] do not want to bathe and we must know how to get to them, so they do not bother and get angry at us [...] it's very difficult, we must have a lot of patience. (T1)

We never know if they are being true or not, do not know if they are speaking the truth, then the difficulty is that sometimes they end up lying a lot, being very manipulative. (E3)

From one day to the next or the same day [...] the person gets aggressive, agitated [...] it's very complicated, when patients are manipulators, they must have a good set of waist. (T4)

It's hard for you to deal with people like that, because one hour they are well, another time they change, so you cannot trust, you must take extra special care [...]. (T12)

Professionals draw attention to issues of affect that coexist, sometimes prevailing in care. They present discomforts generated by the behavioral characteristics of patients with borderline. personality disorder. Such discomforts are expressed by communication problems, lack of confidence of the nursing team towards the patient, management difficulties to perform various procedures, as well as some elements of moral judgment on the part of professionals. They reinforce the idea that the patient with borderline is resistant, emotionally unstable, manipulative, impulsive, liar, who often tries to draw attention, and who does not report exactly what he is feeling.

Drug therapy and restraint: interface between protection, setting limits and other challenges for care

Regarding nursing care related to the use of drug therapy, the participants reported that they use such a tool, especially in the first days of hospitalization, in which the patient may present psychomotor agitation, heteroaggressivity and self-aggressiveness, putting others and himself at risk. In such cases, the medications are prepared and administered as prescribed.

Mechanical restraint was another therapeutic resource mentioned by professionals. This procedure is used only when verbal resources and drug therapy were not enough to stabilize the patients in times of psychomotor agitation. Mechanical restraint is used to protect the physical integrity of the patient and others, preventing injuries, assaults, suicide attempts and even hospital escape.

When they are upset, agitated, we make medication [...], when we need them, we put in bed. (E2)

The patients end up helping us to contain when there is no other solution [it refers to the lack of professionals]. (E3)

You have to hold your hands in order not to get hurt, we even contain you, because we do not let them get hurt in any way [...] they are false attempts [referring to the suicide attempt], but in these false attempts it can be something worse, that's why we should take special care because they are really sick [...] as people realize if [the patient] is getting hurt, we medicate. (T7)

I call the doctor, the doctor comes, evaluates, prescribes; we are going to bed, if we must contain it, we must contain it, we must meditate and observe [...] we try to talk, if it does not [...] end up containing and medicating, then they calm down. (E10)

The speeches suggest that the professionals perform the mechanical and pharmacological containment without major concerns regarding the clinical evaluation of the patient, do not mention pre- and post-containment care required, and few mention the exhaustion of verbal contention. Still, the professionals report the participation of other patients during the procedure, which is not appropriate. All these items indicate a fine line between the protection of restraint and the establishment of limits on their employment, both for the patient and for the professionals.

Inadequacies in physical structure and lack of human resources in terms of the number of professionals, as well as psychological support for professionals who work directly in the care of patients with borderline, personality disorder were important points highlighted by the participants of the research, as difficulties to provide care.

The participants point out limitations in relation to the space devoid of large and airy areas for the accommodation of hospitalized patients. This environment would allow the professional a ray of vision without obstacles to observe the unit, as well as more environments destined to carry out therapeutic activities.

Lack of human resources is also an obstacle to quality patient care. Participants mention that in times of emergency, they need to activate other patients or police professionals to perform mechanical restraint due to the shortage of professionals.

We are always asking for someone, a man, to stay here with us, need because when someone has changed, there is no one and it is just us, we ask for help for the patients, there are some that help others not and when you need, we call the police, too. (E2)

If I said I would not let myself down, it would be a lie. We try to work hard because you know you cannot take work to work, but there are things that happen, you end up absorbing a little [...] whether or not you want to have more extreme situations that happen in psychiatry that affect a lot [the professional], which shakes and it is no use saying that no [...] because we do not have, there is nobody to take care of who cares. (E5)

The difficulty is that we have enough patients, the space is small, and it is not a suitable space for psychiatry, our rooms are small does not have a wide view [...] then our physical space, in fact, is not appropriate for this [...] people are lacking to work [...] (T7)

[...] we do not have training [...] every patient has something different and we do not know how to deal with them, we end up leading and do not come to any resolution because I think this training is lacking. (E14)

With the participants' speech, we can reflect on the need for permanent education and greater attention to the health of the worker in the study scenario. Nursing professionals cited lack of capacity building, who feel unprepared to deal with certain situations. Continuing education is mentioned as synonymous with empowerment or movement directed towards the care of the nursing professionals themselves, in order to generate feelings of greater competence and comfort, leaving them more prepared and confident to deal with people with borderline personality disorder and other mental disorders. Added to these difficulties is the lack of physical structure, personnel and tools that would allow the discussion of cases for later decision making.

DISCUSSION

Listening, as well as speech, is a condition for dialogic communication between social subjects. It is not speaking that one learns to listen, but it is hearing that one learns to speak with people, never in an upright position, but in a relation between equals. It is imperative never to speak impositively, and even when we do not agree with the other, to regard him as the subject of listening to our word and not as the object of our discourse¹⁰.

Based on such assumptions that guide Paulo Freire's textual work, it is believed that dialogue is a fundamental part of the reception, a moment that brings the patient and the professional closer together and allows the sharing of knowledge and the taking of an empathic, in which the professional demonstrates the ability to listen to the suffering subject, creating a relationship of trust. It does not happen, necessarily, in a space, but rather, at different times and by different agents, which allow the encounter between professional and patient. The act of welcoming involves listening to the needs that are reported in the different life stories. It is an important tool for mental health teams, since it becomes an opportunity to strengthen ties, which presupposes, not only speaking, but also listening, in an exercise of dialogue that involves the senses, in addition to of speech. Link building occurs when the person with mental disorder is free to express their feelings without worrying about judgments¹¹.

In order to promote the integrality of the care provided to patients with mental disorders, in addition to the reception, it is important to perform a qualified listening¹². It is essential for the respect of the singularities and diversities between caregivers and patients and, when not performed, increases the vulnerability and risks of the person with mental disorder².

The speeches suggest that the professionals seek a dialogical attitude with the patients, use the term host, denoting familiarity with the policies of humanization of care. Nursing, when caring for people with borderline personality disorder, has a fundamental role for the reception to take effect. These professionals, acting in contact with the patient, create conditions favorable to the approach and alterity, which contributes to a relationship of safety and mutual respect.

Another finding of the study has to do with medication, an important therapy in the life trajectory of individuals suffering from psychic suffering as one of the strategies for relieving symptoms. When there is a need for the use of medication in the treatment, it is necessary that the administration be carried out with responsibility and ethics. Nursing becomes strategic, as it directly interferes with the administration and orientation of medication therapy and must be aligned with the objectives of the psychiatric reform, as a transformation agent, seeking to improve the quality of life of the individual¹³. Acting outside of ethics, for men and women, is a transgression, since respect for the autonomy and dignity of all is an ethical imperative¹⁰. In this direction, studies point to the focus on hypermediation and isolation as factors that accentuate psychic suffering, which refers to the past, in which people with mental disorders were treated as alienated and undergoing treatments that contributed to this alienation^13-14.

The use of psychoactive drugs is important in the treatment of people with mental disorders, as it helps to reduce and control the symptoms of pathologies. However, it should not be considered as the only possible intervention but should be combined with other modalities of care¹⁴. It is known that non-adherence to drug treatment or the irregular use of psychotropic drugs may have repercussions in successive hospitalizations for implying new crises¹⁵. However, medicalization can sometimes serve the non-accountability of the subject for his problem, since the improvement is deposited in a magical and external solution¹⁶.

Another resource mentioned by the study participants in nursing care provided to patients with borderline personality disorder borderline was the mechanical containment in the bed. It is a technique indicated for frames, and in that the patient exhibits exacerbated behavioral manifestations that endanger one's own physical integrity or of others. It should be used as a last resort when all others are inefficient^14-15.

In the reports of study participants, the practice of mechanical restraint is performed when other methods are not enough to attend and calm patients, especially in times of emotional unrest. In addition, it is a way to avoid self-mutilations and hospital escapes. However, the reports showed that professionals do not feel prepared to perform the technique, just as they feel forced to assume this type of behavior in the face of the need to protect the patient from himself, in an attitude that, by containing and depriving of freedom, is not always seems to promote autonomy, protection and affection.

These affirmations confirm the importance of evolution in knowledge that permeates the practice of psychiatric nursing, which converges with the development of technical-scientific skills, but also of critical awareness to act, including to assist the patient in finding solutions for their condition. In this direction, the concept of Good Nursing Practices emerges, which must consider the clinical experience of the professionals who perform it, as well as the investigation of patients' preferences, since this practice should require the demonstration of their total applicability in the day-to-day life from which it arose and the possibility of maintaining and updating itself with the passage of time. In addition, the patient and his / her family need to be protagonists of care and, for that, it is the role of nurses to foster the development of their social conscience, since the establishment of Good Practices is directly linked to the potential for strengthening these groups which in turn interfere with the biopsychosocial development of the individual¹⁷.

Added to this is the relevance of the understanding of the verbal and non-verbal language of the patient by professionals working with people with mental disorders. Through communication, the human being transforms the world, becoming subject of history, in an ethical and aesthetic direction. This means that Freirean theory and practice are based on an ethics inspired by the human-world relationship and the ability to relate to people and society. The expression of ethics occurs in the forms of aesthetics and in the rescue of the beauty of all forms of human expression. This is the political nature of man. Ethics and the democratic stance imply coherence between theory and practice and respect for thought, tastes, desires and fears of others, and promote autonomy¹⁰.

The participants of the study, when telling about the reality lived in the daily work, demonstrate that there are enough professionals to assist in the accomplishment of the mechanical containment. Therefore, they end up resorting to the help of other patients hospitalized in the psychiatric unit or request the presence of public security agents to assist in containment. A study¹⁸, points out that when it is necessary to activate the Military Police to contain a crisis, it must happen in a context that promotes the subject-subject relationship and not as a form of intimidation. Due to its availability and preparation, this professional acts to bring people in psychological distress to the services and to protect the health team from possible aggressions, however, he does not always know the appropriate management, in order to assist in the procedures. This reflects on the need to propose capacities involving nursing and other sectors and subjects, such as public security agents, in order to construct new social meanings in this shared action, in which the performance of the Police does not represent violence.

Still about this, it should be noted that the prescription of mechanical restraint is a medical indication¹⁵. The Federal Nursing Council, through resolution number 427/2012, normalized the nursing procedures in the use of mechanical containment. It can only be done in the supervision of the nurse, except in emergency situations and urgency, and should always occur, according to protocol of the institutions¹⁹.

Dialogue only exists when there is a deep love of the world and of men and, as a fundamental element of dialogue, affection can be assumed. In relationships of domination, there is no love. Therefore, without love of the world and of men, there is no dialogue. It is from a loving and at the same time respectful relationship that interaction and alterity are established as a possibility by which social subjects complement themselves through a dialogic activity, not necessarily with the same ideas and positions, but respecting themselves from the diversity of thoughts and feelings³. Based on this Freirean assumption, it is interesting to recognize that people with borderline personality disorder present a pattern of intense and chaotic relationship, do not usually have an emotional stability, not recognizing or giving a clear meaning about their identity. For individuals with this disorder, people are considered completely good or completely bad. A nursing professional can be idealized by patients with borderline personality disorder, but if something happens that they do not accept, this same professional, who was considered affectionate, can be seen as persecuting or cruel, in his conceptions^5-7.

Nursing can convey to these patients an attitude of acceptance so that they perceive their value, enabling them to express their feelings. Since they are difficult patients can cause negative feelings in the nurse and he should not allow such feelings to interfere in the therapeutic relationship. It is important that patients are constantly observed for their own safety. This can be done through activities, thus avoiding that the professional seems suspicious and vigilant^5-7.

The role of the nurse is not restricted to performing techniques but to propose a comprehensive care action, developing the ability to communicate, as technology to perform the reception and approach of the patient in the area of mental health. Thus, the relationship between nurse and patient acquires importance in the phenomenon of caring¹¹.

Freire assumed that developing faith in men is an a priori of dialogue. Dialogue happens in a horizontal relationship because of its fundamental relationship with faith in men, with love and with humility. The obvious result of the horizontal dialogue is the trust of one pole in the other, a contradiction if a dialogue with these characteristics provoked mistrust between the subjects. When trust is lacking it is because the elements described have failed: love, faith in men and humility³. In this direction, the therapeutic communication is a unique type of dialogue. It refers to the set of interventions carried out by professionals who, autonomously, have a "therapeutic" potential in the process of rehabilitation of people. There are techniques of verbal and non-verbal communication, in which empathy and assertiveness play a central role. Appropriate communication, centered on the person and his / her context, is considered as an ethical duty and responsibility of any health professional who works in direct contact with people^3,11.

In the study participants' ideology, the therapeutic relationship between nursing professionals and patients with borderline personality disorder is a difficult process to build. However, the construction of this link is essential for improving the patient's condition and for an effective interaction, in which the patient expresses itself in an open way, seeking to understand himself, becoming autonomous and having the perception of the environment that is inserted.

In line with the difficulties mentioned by the participants about the need for care tools for professionals, the literature argues^7,16 that some institutions still encounter difficulties, such as the lack of professionals and their lack of preparation, the lack of permanent education, not always fostered by the intuitions of work, besides inadequate physical space. The work environment, therefore, becomes stressful, damaging the professional inserted therein and, consequently, the process of rehabilitation of the patients.

The importance of services is considered a priority in the discussions, in order to achieve the ambience concept advocated by the National Humanization Policy. The enhancement of physical space provides a welcoming place of care and the construction of effective and humanized health actions²⁰.

FINAL CONSIDERATIONS

The realization of the study made it possible to understand how nursing cares for people with borderline personality disorder. Difficulties were recognized as well as it was possible to observe certain prejudices and the lack of adequate knowledge to deal with the person with the disorder. Based on the presuppositions of Freire, it was possible to reflect on the importance of dialogue, in the communication between patients and professionals, in order to promote the love between these two subjects in the context of mental health.

New studies on borderline personality disorder are necessary, since it is a topic that is little discussed and researched. It was noticed that the distance of the research in understanding the care scenarios of the nursing professionals to the patient with borderline personality disorder focuses on the lack of preparation of professionals to work in the area, contributing to care away from critical and ethical. In this sense, it is suggested the development of listening and other therapeutic resources as promoters of well-funded, scientifically based nursing care. In addition, research possibilities focusing on family members and individuals with borderline personality disorder are recommended, considering the need to explore the familiar interface in the care process.

Because of uncritical and disqualified care, nursing no longer plays its part in the integral care and defense of the user in their needs and particularities. Therefore, the paradigm shift in care for patients with mental disorders is a challenge for nursing. In order to think about strategies, it is considered the possibility of permanent education and the use of Good Nursing Practices for care. In the scope of university education, the teaching-service integration, aiming at learning in real scenarios, can allow the approximation of the future nursing technician or nurse with the reality of institutions of this nature.

From the content of this research, it is hoped to contribute to the knowledge of the scientific community on the subject and to the reflection and awareness of the nursing professionals about how certain nursing skills clearly interfere in the therapeutic process, the care provided and in the rehabilitation of the patient. The way of caring for nursing, although still permeated by conventions, passes through ideals contained in the ethical and political presuppositions that operate in the light of Paulo Freire's work. As the educator suggests, it is necessary to take the object to perform critical reflection, generating reflection on reality and instrumentalizing the professional to create a new reality.

It is important to highlight the importance of this research for teaching, management, research and, especially, for the care part in nursing. It is considered as limitations of the study the lack of data on the concrete working conditions offered to the professionals who work in the area to develop their activities, at different levels of care. In this direction, it is understood that the actions and the work process of these professionals deserve deep and continuous studies.

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Publication Dates

• Publication in this collection
  10 June 2019
• Date of issue
  2019

History

• Received
  27 Apr 2018
• Accepted
  27 Dec 2018