In Brazil, the process of Psychiatric Reform began in the 1970s, sharing the ideals of the Brazilian Sanitary Reform and constituting a broad and challenging political, economic, legal, social, and cultural movement that fostered transition from the governing health care model by means of constitutional guarantees (Bessa & Waidman, 2013; Frazatto & Sawaia, 2016; Pessoa, Santos, Clementino, Oliveira, & Miranda, 2016).
Through this process, changes have been made to public mental health policies, which have led to an emphasis on deinstitutionalization as an important guiding principle for mental health care management. Due to this emphasis, the goal of health care has focused on improvement of mental health patients' quality of life, their rehabilitation process, and participation of family members in their care (Pessoa et al., 2016).
As new policies were implemented, new laws, ordinances, and health services emerged that promoted elimination of asylums and the asylum model in Brazil. In recent years, Law No. 10.216, dated April 2001, known as the Reform Law, and the establishment of the National Mental Health Policy have led to development of a humanized model of holistic care in the public mental health care network (Presidência da República, 2001). These policies brought a change in emphasis and, whereas previously hospitalization was considered the sole option for treatment, focus has shifted to considering treatment of patients in other care settings (Mitkiewicz, Magalhães, Araújo, Lovisi, & Tavares, 2015; Pessoa et al., 2016).
In this context, Ordinance no. 3.088, dated December 2011, regulated the Psychosocial Care Network within the Brazilian Health System, for treatment of individuals with mental disorders or conditions related to the use of crack, alcohol, and other drugs (Brazil Ministry of Health, 2011). This regulation aims to broaden the general population's access to psychosocial care; to promote easier access to treatment for individuals and their families who are affected by mental disorders and conditions related to the use of crack, alcohol, and other drugs; and to ensure articulation and integration of the network of health care access points in the region, enabling continuous care and emergency treatment (Brazil Ministry of Health, 2011). In terms of hospital care, psychiatric beds in general hospitals are included in the same units as beds for individuals in treatment for other diseases. Hospitals with psychiatric beds are called hospital referral services (Brazil Ministry of Health, 2011).
There are 187 hospital referral services with beds for individuals with mental disorders in Brazil, with a total of 888 psychiatric beds. In Minas Gerais, there are 42 referral hospitals and 176 psychiatric beds (Brazil Ministry of Health, 2015).
At these hospitals, the presence of a family member is allowed during treatment and hospitalization. The family member's participation in daily care may result in the following: shorter hospital stays, increased social contact, and reduction of conflict between staff and family (Bessa & Waidman, 2013; Carniel et al., 2016). Despite the fact that few hospitals offer this type of psychiatric care in the country and the lack of research on these hospitals, it is important to emphasize that the family bond is the basis for humanized care. This bond can help rehabilitation and reduce length of hospitalization. In general, when individuals were hospitalized at psychiatric hospitals, family visits were scarce and patients remained hospitalized for longer periods of time (Machado & Santos, 2011; Miranda, Santos, Azevedo, Fernandes, & Costa, 2010).
Considering the possibilities of interactions with patients and their family members implemented in the new proposal of the psychosocial model, it is important for nurses to adopt a therapeutic rather than oppressive role. Adopting a therapeutic role requires detachment from the biomedical model focused on solely the disease and not the social context of the patient, and requires that the psychiatric patient be treated holistically. Therefore, professionals need to plan their treatment as holistic health care, based on a more flexible and creative approach (Esperidião, Silva, Caixeta, & Rodrigues, 2013).
The family/caregiver plays a significant role in the therapeutic process of the psychiatric inpatient at a general hospital. The caregiver develops opinions and expectations regarding the nursing care offered to the relative. The role of the caregiver represents a new dynamic for nursing teams, which are still adapting to the role of family/caregivers in general hospitals.
The goal of the current study is to investigate perceptions and expectations of the family member/caregiver regarding nursing care provided to psychiatric inpatients at a general hospital.
The current descriptive–exploratory study is based on a qualitative research approach. The study was conducted in the interior of Minas Gerais, Brazil, in a medium-sized city with a population of approximately 300,000 inhabitants. The research setting is a medium- to high-complexity hospital with six psychiatric beds located at two clinical wards divided equally between female and male patients. The hospital provides services to the macro-region of the South Triangle in the state of Minas Gerais.
Ten relatives of psychiatric inpatients participated in the study. All participants met the following inclusion criteria: age ≥18, self-appointed as the patient's primary caregiver (i.e., primary individual responsible for care) or secondary caregiver (i.e., individual who provides assistance when needed), lived with the relative, and were the main caregiver during the hospitalization period.
To collect data, semi-structured interviews were conducted, and the questions involved caregivers' perceptions and expectations about services provided by the nursing team. Interviews were conducted by one of the researchers (M.F.M., F.C.P.) during 3 months of the year 2016 on hospital premises. The responses were recorded and later transcribed for analysis. Data collection was stopped when data met the saturation criterion, which establishes that inclusion of new participants should be suspended when information is repeated (Fontanela, Ricas, & Turato, 2008).
The interviews were analyzed according to the content analysis procedures outlined by Bardin (2009). First, comments of each participant were analyzed. Then, points of similarity and differences in content were listed, as well as information identified as relevant to research objectives. Results were grouped into categories and discussed based on the literature review.
The current study departed from a larger project, “Nursing care for the mentally ill patient hospitalized in medical clinics for clinical intercurrence,” in which approval was given under ruling 447.029. All participants in the current study received clarification on the research objectives and signed an informed consent form to formalize their agreement to participate.
Of the 10 family members who participated in the current study, caregivers were predominantly male (70%), parents (50%), primary caregivers (80%), married (60%), and not working because of retirement or leave (60%). In addition, caregivers had an average age of 58.8 years, an approximate monthly income of two minimum wages (50%), and 0 to 8 years of education (60%). The pathologies of the hospitalized patients were: schizophrenia (60%), depression (30%), and illicit drug abuse (10%). Analysis of the data revealed the perceptions and expectations of the relatives/caregivers concerning nursing care.
Perceptions of Family Members/Caregivers Regarding Nursing Care
Three distinct categories emerged from data analysis: satisfaction of care-givers concerning the quality of care provided by the nursing team; specific characteristics of the nursing professionals in developing good interpersonal relationships with the patients; and, as mentioned by one family member/caregiver, the technical and medical aspects of care.
Regarding these categories, participants described their overall satisfaction with nursing care with various statements:
- I think it is really good. They always ask if we need something else and write everything that we ask in order to provide to us.
- Really great. Here everything is well arranged.
- Top quality, very good.
- Good. The members of the nursing team come here all the time.
- Great. They try to do everything in time so he is not nervous.
- Very good.
- They are very good, the care is very good, and they bring everything for us to stay well here.
Overall, participants demonstrated satisfaction with the assistance provided by the nursing team in the hospital environment. Furthermore, some caregivers/relatives identified specific qualities of nurses that helped them to develop good interpersonal relationships with the patients:
- Professional, caring people and dedicated to the care.
- I am so grateful for their affection and dedication.
It is evident from these comments that some participants recognize characteristics in the nursing team members that help form bonds that enhance treatment. Not all participants recognize the bonds as important, although one participant appreciated the technical and medical features of the care: “They really help me a lot, they watch over him, help him shower, give him medicine, which I do not do because I'm weak.”
This comment indicates satisfaction with the technical and medical services provided by the nursing team, which also correspond to the qualities of the nursing profession. The specificity of care in psychiatry requires different therapeutic interventions, which lead to recovery, restored autonomy, and social reintegration. It is important that the nursing team takes biopsychosocial needs into account, as mental disorders affect various dimensions of the lives of the patient and his or her family.
The development of a multidimensional treatment process enables direct interaction with the patient and family/caregiver, who hope that the nursing team will meet their expectations during the hospitalization period. It is, therefore, important to recognize these expectations.
Expectations of Family Members/Caregivers Regarding Nursing Care
In terms of expectations of the family concerning the nursing care, findings revealed various themes, including: expectations that are limited to what is already being provided by the nursing team; expectations related to interpersonal skills (e.g., interaction with, patience toward, attention given to patient), and expectations for the nursing care to focus on the individual's hygiene and eating.
Most participants did not indicate higher expectations regarding the nursing care than what was already being provided to patients who have been hospitalized because of psychiatric disorders and/or conditions resulting from drug use. Patients remarked:
- It's okay the way it is. I can always count on them.
- It's really great. I always come here when I am having difficulties, it's really great.
- What they are doing is very good, the more they do the better, they are taking good care of him.
- The staff is very good, there is nothing to complain about. Here, I feel we are comfortable and this is very important.
- I think the team is doing a lot of good to help me and helping him too.
Participants seemed to believe that the services provided by the nursing team were meeting the needs of the patients. In addition, one participant mentioned that the nursing team helps him in addition to helping the patient, which highlights a possible partnership between the caregiver/family member and the nursing team in caring for patients.
Other participants expressed their expectations for improved care:
- Maintain care and attention. This is very important here, because without this the patient will not get better.
- They need to talk more with her, counseling on what she should do after discharge.
These remarks demonstrate that the members of the nursing team are expected to engage in active listening that allows emotional and psychological needs to come to light, so that the team can implement directed interventions. It is also essential for the nursing team to develop relational skills, which will enable them to provide care focused on emotional and psychological needs. The professionals are expected to be sensitive to the psychological reality of patients and their caregivers/relatives.
Not all participants' expectations were related to emotional and psychological needs. For some, expectations focused on diet and hygiene:
- Bathing and encouraging eating.
- Keeping her with clean clothes is very important.
Caregivers saw this care provided by the nursing team as a form of respect and affection, which provides continuity to the care the patient receives at home.
Overall, expectations of the family concerning care provided by the nursing team fell within the scope of the nursing team's tasks. Nevertheless, it is common for mid-level professionals to feel unprepared to provide care in a general hospital to patients with mental disorders and/or conditions related to alcohol and drug abuse. Therefore, they tend to intervene inappropriately in crisis situations, as one participant stated when asked about expectations: “Give support. Yesterday they were aggressive, because he was nervous. I wish they wouldn't do that again.”
In this comment, the participant expresses an expectation that the nurses be more tolerant toward the patient's nervous behavior.
Through content analysis of the interviews, it was evident that there were more positive than negative perceptions, which may indicate that the companions or family members who work as caregivers are sensitized, because they consider caregiving a burden and feel that work performed by nurses can ease the pressure they personally experience. Therefore, they do not feel entitled to expect better care, and they accept the care nursing professionals provide to psychiatric inpatients.
Perceptions of family/caregivers should be valued, especially in the new care settings resulting from the psychiatric reform movement, such as the psychiatric units in general hospitals (Bessa & Waidman, 2013; Portugal, Nogueira, & Hespanha, 2014).
Given the importance of family in the care process, valuing their opinions can lead to improvement of health care and management processes, as their feedback can allow service managers to revise their goals (Barros et al., 2016; Nagaoka, Furegato, & Santos, 2011).
In the current study, family members/caregivers predominantly reported being satisfied with the care provided by the nursing team, which is considered in the scientific environment a positive indicator for managers seeking to plan and improve the quality of health care (Nagaoka et al., 2011).
Some study participants also reported that good interpersonal relationships between members of the nursing team and psychiatric patients were a point of satisfaction. It is recommended that the nursing team promotes a welcoming environment built on trust among staff, patients, and family members (Bessa & Waidman, 2013). In addition, the nursing team should be inspired by the psychosocial model that prioritizes patients' reception, care, independence, autonomy, and contractual power (Borba, Guimarães, Mazza Vde, & Maftum, 2012). This model requires the good interpersonal relationship the participants reported.
It was evident that some participants' opinions focused on care concerning hygiene and medication, and not on the characteristics that enable establishment of relational bonds. In this regard, Monteiro (2006) posits that nursing is about diet, hygiene, administering medication, assessing vital signs, rest, caring for possible risks, and other clinical procedures required for human well-being. In care for individuals with mental disorders, the nursing team needs to adopt a specialized approach, which is based on biological as well as psychological and emotional needs.
It should be added that health care can be divided into maintenance treatment and recovery treatment. Maintenance treatment includes diet, hygiene, and rest, among other factors. It is less complex, more noticeable by the individuals who receive it, and valued more by staff. On the other hand, recovery treatment aims to monitor and treat the disease so that the patient recovers. Recovery treatment requires administering medication, measuring vital signs, and caring for possible risks (Passos & Sadigusky, 2011).
Given the various types of treatment, it is common for the family member/caregiver to have expectations about the care provided by the nursing team during the period of hospitalization. Nursing care offered to individuals with mental disorders and/or conditions relating to alcohol and drug abuse should meet the needs of the patient and his or her relative/caregiver to ensure satisfaction of both parties (Santos, Pestana, Guerrero, Meirelles, & Erdmann, 2013).
Most participants did not report having higher expectations than what was already provided by the nursing team, and one participant even mentioned the nursing team's help in the care process, which represents a positive and fundamental partnership for the care process in psychiatry (Melo, Sousa, & Silva, 2014).
Some participants had expectations regarding the relational bonding between the team and the family/patient. Recent studies claim that developing interpersonal bonds is necessary to meet the basic needs for mental and physical health, and that the nursing team, together with patients and family members, should develop these bonds (Barros et al., 2016; Cardoso, Santos, Ribeiro, Silva, & Mota, 2015). For these bonds to be established, it is essential that communication occurs between the health professional and patient (Sequeira, 2014).
Active listening was also mentioned as an expectation and measure to evaluate the quality of nursing care. Active listening is a type of listening that prioritizes the needs of the speaker and values dialogue with a readiness to listen for needs besides those explicitly stated (Mesquita & Carvalho, 2014).
Although health professionals strive to provide proper care to psychiatric inpatients, mental needs make the patients vulnerable. Therefore, nurses need to exhibit care that goes beyond the technical aspects of treatment and addresses patients' psychological and emotional needs (Dorigan & Guirardello, 2013).
Not all participants' expectations were centered on addressing psychological and emotional needs, as some concerned the care directed toward eating and hygiene. During episodes of psychiatric crisis that result in hospitalization, patients may present symptoms that compromise their autonomy for these basic functions. Consequently, nurses are regarded as facilitators during meals and hygiene, which leads the family member/caregiver to perceive this intervention of care as a sign of affection (Fonseca, Penaforte, & Martins, 2015).
Some participants cite the nursing team members' lack of preparation to intervene in crisis situations. This lack of preparation was evidenced in a recent study, in which lack of proper training of nursing professionals to cope with individuals with mental illness and drug/alcohol abuse was identified (Moll, Silva, Magalhães, & Ventura, 2017). Thus, health professionals should develop emotional and psychological skills to handle interventions in crisis care. A therapeutic approach needs to be implemented based on humanized and personal evaluation. This approach requires the professional's emotional control to approach the patient calmly and convey the desire to help and, if necessary, seek help from professionals in other fields (Oliveira & Furegato, 2012).
Overall, positive expectations of family members/caregivers prevailed, which may be an outcome of minimizing the feeling of burden during the hospitalization period, when the caregiver shares responsibility with the nursing team. The scientific community notes the burden of care on family members/caregivers who continuously perform objective and subjective care, including material, physical, emotional, and psychological care (Eloia, Oliveira, Eloia, Lomeo, & Parente, 2014).
It is the responsibility of mental health services to seek strategies that meet expectations of all involved in care (i.e., patients, their relatives/caregivers, the community). Humanized care is required to ensure the provision of holistic treatment, meet needs, and respect human dignity (Cardoso & Galera, 2011).
Considering that general hospitals have only recently become an environment for psychiatric care in which family members/caregivers are often allowed to stay with the patient, perceptions of the nursing process of caregivers of patients in general hospitals are valuable.
In the current study, there was a predominance of positive perceptions, represented by satisfaction with the care the nursing team provided, expressed as professionalism and characteristics that promote good therapeutic interpersonal relationships (e.g., affection, dedication).
Most participants did not have higher expectations concerning the care provided. One participant emphasized the need for the team to develop better care skills for the patient when in crisis.
Family members continually caring for individuals with mental disorders may have few expectations regarding nursing care as the nursing team assumes responsibility during patient hospitalization. Future studies should address the family/caregiver's point of view, as psychiatric hospitalization in general hospitals is a recent practice that needs to be the subject of further reflection and discussion to enhance quality of care.
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