RESEARCH ARTICLES
House of Hope Healthcare: psychiatric nursing care in a traditional model (1975-1993)
Ângela Aparecida Peters RodriguesI; Maria Lelita XavierII; Tânia Cristina Franco SantosIII; Mariangela Aparecida Gonçalves de FigueiredoIV; Antonio José de Almeida FilhoV; Maria Angélica Almeida PeresVI
INurse, Mestranda da Escola de Enfermagem Anna Nery da Universidade Federal do Rio de Janeiro. Brazil, Email: angelaprodrigues@yahoo.com.br
IIPhD. in Nursing Professor at the School of Nursing at the State University of Rio de Janeiro, Brazil, Email: lely108@hotmail.com
IIIPhD. in Nursing, Professor, Anna Nery Nursing School at the Federal University of Rio de Janeiro, Researcher for the National Council of Scientific and Technological Development, Brazil, Email: taniacristinafsc@terra.com.br
IVPhD in Nursing, Coordinator of Nursing, at Suprema in Juiz de Fora, Minas Gerais, Brazil, Email: mary.hu@ig.com.br
VPhD. in Nursing, Professor, Anna Nery Nursing School at the Federal University of Rio de Janeiro, Researcher at the Research Center for the History of Nursing Brazilian, Rio de Janeiro, Brazil, Email: ajafilhos@gmail.com
VIPhD. in Nursing, Professor, Anna Nery Nursing School at the Federal University of Rio de Janeiro, Researcher at the Research Center for the History of Nursing Brazilian, Rio de Janeiro, Brazil, Email: angelica.ufrj@uol.com.br
ABSTRACT: It is a social-historical study concerning the psychiatric nursing care at the House of Hope Healthcare (Casa de Saúde Esperança) (CSE), in Juiz de Fora, during the period from 1975 to 1993. The goals are to describe the context of psychiatric care in the city of Juiz de Fora and its relation with the Psychiatric Reform movement and analyze the nursing care at CSE, when it followed the traditional psychiatric model. Methodology: Primary sources are written and oral documents. The oral documents were produced through interviews with 11 professionals who worked at CSE. The analysis was based on concepts of Michel Foucault. Results: The CSE kept the traditional psychiatric model until 1993, where nursing care was exercised mostly by nursing attendants, guiding it in maintaining the strict institutional discipline, keeping the patients monitored and applying punitive techniques such physical and chemical restraints, with criticisms on their own practices exercised.
Keywords: History of Nursing; psychiatric nursing; psychiatric assistants; nursing care.
INTRODUCTION
The House of Hope Healthcare (Casa de Saúde Esperança) (CSE) was created in 1939 in the city of Juiz de Fora, Minas Gerais (MG), Brazil to assist psychiatric patients of both genders. The CSE remained in operation, until the 1990s, marked by healthcare based exclusively on admission and in traditional psychiatric treatment, initially performed by a team consisting of doctors and nursing attendants1. The model of traditional psychiatry is characterized by alignment to the clinical-biological model, taking the psychiatric hospital as a center of treatment2. In this model, care made no pretensions to rehabilitation, it just needed to keep the patient socially isolated, which allowed the nursing care to be performed by unqualified personnel.
Nursing care in CSE is marked by an absence of professional Nurses until 1975, when a nurse arrives to provide volunteer services informally, ensuring the general supervision of the nursing services1.
With the beginning of the movement of Psychiatric Reform in Juiz de Fora, the CSE, as all other psychiatric hospitals, had to adapt to a new model, which has led to the changes in care over the decades of 1980 and 1990, being that until today this process is in progress.
The trajectory of this institution reveals that it has been the scene of two distinct moments; first, a shortage of nurses in the institution, where the nursing staff was not qualified and without specific supervision, they practice a nursing care within the standards of traditional psychiatry. Second, with the nursing care headed by nurses and provided by teams composed of nursing assistants and technicians, exercised in accordance with the proposal of Psychiatric Reform.
Considering the above, this study identifies the first time, having as its object the assistance of psychiatric nursing in CSE, in the period from 1975 to 1993. The starting point is the year of arrival of a nurse to provide volunteer services in the CSE and the final milestone is the year before hiring nurses for all shifts, which represented a break in the traditional psychiatric model until then exercised.
It is worth noting that, in 1993, the CSE counted with 450 beds and the nursing team was composed of 32 nursing attendants, 12 nursing assistants and 1 nurse. In 1994 four nurses were hired to compose the teams on duty, which began a transformation in nursing care3. Thus, if allowed to nurse, as a member of this team, recover their role and practice, to face the new challenges of restructuring care for mental disorders4.
We believe in the importance of registering the existence of an institution that still maintained the traditional psychiatric model in the 1990s, to help understand the development of the Psychiatric Reform in Brazil. To know the trajectory of institutions in different regions and historical periods allows studying the practice of psychiatric nursing in public and private health care networks before the Psychiatric Reform movement. Therefore, we will take as a reference the CSE, a reference psychiatric hospital in Juiz de Fora. The objectives of the study were to describe the context that preceded the psychiatric reform in Juiz de Fora and analyze the nursing care in CSE, when this followed the model of traditional psychiatry.
theoretical-methodological framework
Socio-historical study, whose primary sources were written documents found in the collection of CSE, and oral documents produced in the period from August to December 2011, through interviews with 13 professionals who worked in CSE. The secondary sources were books and articles1-10.
For the production of documents, an oral thematic history was used, understood as a process of extending of the possibility for the use of sources for the writing of history, as well as bring to the historians instrument to deal with subjectivity5. The interviewees are cited in the text with the corresponding initial sequence number to the profession and the order of the interview in order to ensure the confidentiality of information. Example: doctor (M1), nurse (E1) and nursing technician (T1).
The data analysis was sustained in objective ideas8. Moreover, in accordance with the historical method5. Thus, the analysis of the documental corpus comported the analysis of the context in which the documents were produced, as well as the internal and external criticism. In this process, repeated readings were performed with views for the identification of relevant elements in the text.
The project that gave rise to this study was approved by the Ethics and Research Committee of the School of Nursing Anna Nery/Hospital School San Francisco of Assisi/Federal University of Rio de Janeiro (protocol 040/2011).
Results and Discussion
Background of the Psychiatric Reform Movement in Juiz de Fora
Until the arrival of the Psychiatric Reform movement in Juiz de Fora psychiatric care was performed by residential and private institutions as well as agreements with the Unified Health System (SUS) and they are as follows:. Clínica São Domingos (240 beds); Clínica São Domingos Filial (180 beds); Casa de Saúde Esperança (450 beds); Hospital Aragão Vilar (380 beds); Clínica Serro Azul convênio (190 beds); Clínica Pinho Masini (132 beds); and Hospital São Marcos (220 beds). The last two attended exclusively female patients6.
We can observe that the psychiatric institutions existing in Juiz de Fora, the CSE and the Clínica São Domingos, which belonged to the same group of partners, were those that had a higher number of beds, which gave them greater political and financial importance in the region. Of these, the CSE was larger, since the Clínica São Domingos divided their patients into two units. However, in all institutions mentioned above, the treatment consisted of isolation of the patient and the symptoms manifested in medicalization6.
In Minas Gerais, a milestone was the Minas Gerais III Congress of Psychiatry, held in Belo Horizonte in 1979. This event led to the expansion of the discussion beyond the scope of mental health professionals, reaching the public across the country, ensuring the presence of the state of Minas Gerais in the national scenario of the Psychiatric Reform7.
At that time, Minas Gerais kept a large number of psychiatric hospitals concentrated in Belo Horizonte, Barbacena and Juiz de Fora, which were virtually the only psychiatric care resources. In the 1980s, debates and seminars were promoted on the reality of these institutions, aiming at humanizing them and create new forms of healthcare that would gradually ignore their existence7. Therefore, state psychiatric hospitals, especially public, began a process of humanization of care through the implementation of the Mental Health Program of the Department of Health of Minas Gerais6. This initiative resulted in the adoption, in 1986, of the Project of Reformulation of the mental health Care in the Micro region of Juiz de Fora , which Established guidelines for a new practice, ambulatory and interdisciplinary emphasis, unlike the previous model7.
Until the year 1986, there were 1792 psychiatric beds in Juiz de Fora, distributed in seven hospitals, where 60% of clients admitted were long-stay and the extra-hospital component system functioned just as resolute and often transit camp for new admissions6.
There was, on the one hand, the Integrated Outpatient Mental Health (AISM), a service of general psychiatric care exclusively, remnant of the care model of the former National Institute of Medical Assistance and Social Welfare (INAMPS), which could not be used for care records, or regular scheduling and return consultations. As well as the Special Programs intended for patients with specific disorders, among which a Psychosocial Care Center (CAPS), with multidisciplinary teams, but with a volume of visits by professional quantitatively lower than that registered in AISM. All services met a spontaneous demand, coming from the city of Juiz de Fora and surrounding cities, and because of the absence of turnover, were unable to accept new patients6.
As of the year of 1992, the influence of the Project of Law Paul Delgado led to the adoption, in several Brazilian states. The first laws that stipulate the progressive replacement of psychiatric beds by an integrated network of mental healthcare7. In this context, the psychiatric institutions of Juiz de Fora came into focus and the new policies have established rules to be complied with, in order to change the health care model provably in disagreement with the interests of users of SUS and the new ideology of mental health care, which was strengthened within Brazilian society.
The Model of Traditional Psychiatry in CSE and Nursing Care
Since its creation in 1939, the CSE adopted the model of traditional psychiatry, which posed the hospital at the center of treatment and where nursing formal preparation is not required. One cannot forget that, until the beginning of the Psychiatric Reform movement, the majority of institutions for psychiatric care aligned themselves to the theoretical assumptions of the traditional model, where the work process has as its purpose the social control and the object of intervention is the disease7.
According to the architectural model of nursing homes, the CSE was built in an L-shape, with two floors. In each segment was installed a Hospitalization Unit, differentiated by patient gender. At the vertex, were kitchen and cafeteria sectors, with offices on the upper floor. The wide hallways were bright with adequate ventilation and the wings were separated by doors that remained always locked1.
This enclosed space, indented, guarded at all its points, where the individuals are inserted in a fixed place, where the smaller movements are controlled, where all events are recorded, where the uninterrupted work of writing connects the center and the periphery, where the power is exercised without division, according to a hierarchical figure continues and constitutes a compact model of disciplinary apparatus8:163 .
The patients were selected and distributed in the sectors by the type of behavior they presented and stayed in a space where they could be monitored and where it was possible to record their activities.
The hospital had in fact three female and two male wards, it was divided in the following way: patients more dependent, regressed more as they spoke, more agitated, those who bothered most, they were put on the 1st floor, ground floor, the better ones were put on the 2nd floor, and those who did not need to be hospitalized, were on the 3rd floor. (M1)
This configuration space is characteristic of the asylum care model, structured in a rigid discipline, which came to be criticized and transformed by the Psychiatric Reform Movement.
The nursing service was controlled by attendants, since that the CSE had its trajectory marked by difficulty of hiring nursing staff:
There was always a poverty of hiring of both nurses and nursing assistants and technicians, there was always a very important economy of these professionals, we even came to place advertisements in newspapers, it was very difficult [...]. (M3)
The difficulty in hiring nursing professionals for the psychiatry ward is not specific to the CSE.
History shows that the nursing care for the mentally ill has gone through difficulties to be recognized, because when a nurse was dedicated to this area they were considered a bad professional , which had no better possibility of work or who was sent to work with mentally ill as punitive measure for the omissions carelessly committed in their previous unit9.
In 1975, the CSE began to count with a volunteer nurse who, in an Article published, highlighted the difficulties encountered and the strategies used to overcome them:
Structuring a nursing service in a hospital specialized in mental illnesses is not an easy task. Because they lack consultation sources or even other hospitals that serve as model which have served us up to now in our frequent structures and planning is taking advantage of them, in part, some routines that reach us through newspapers, magazines and even the hospitals in large Centers. Facing this truth, leaving us with only great courage and absolute desire to serve, making plans, routines, creating and improvising appropriate techniques in order to maintain the name of the CSE at the high level of that it has within society1:56.
On the organization of the nursing service in the CSE, in the 1980s, it was reported that:
At the time I worked there, we controlled the kitchen, cleaning and laundry. [...] Everybody stayed longer because of bureaucratic part and care was more because of assistants and aides even. [...] Everyone worked as a boss even and in the absence of nurse assistants made the decisions. (E2)
Soon, the work of the single nurse was determined in accordance with the orders and tasks, which are confined to fill the medical prescriptions, without participating in any patient care activity. The treatment consisted in the isolation of sick and the use of psychotropic drugs as therapeutic measures, which also functioned as repressive and even punitive measure. In the view of another employee, the model of traditional psychiatry and the situation of physical restraint are also highlighted:
[...] I had a lot this thing, which is still traditional psychiatry asylums even, was a constant monitoring of patients, and the contention was a form of punishment. (E3)
Still on the physical containment, we have:
At that time, the assistance was based on monitoring and punishment. Still had the strong room that was the ward closed [...] the patient was restrained in any way, we had no prescription, and we had nothing [...]. They were treated like animals, sleeping prisoners and were loose in the morning. It was a terrible time. (T1)
Faced with this reality, the nursing team became responsible for imposing a conduct, which imposed the sick an unnecessary suffering and even more the title of punishment. It is necessary moderate and calculate the effects of return corporal punishment on the instance that exercise and the power that they intend to pursue, in order that the loss of dignity of the patient does not occur, before the invalidity and physical mutilation8.
Physical restraint was not questioned in most institutions and existed throughout the country reports of mistreatment, which also occurred within the CSE:
There were many allegations of mistreatment of physical restraints and sometimes chemicals without prescription and not give any instructions, and which had never been investigated, and no one held accountable for it. Therefore, it was a total disregard to the patient. Some of the patients came to be mutilated by poorly made bad contentions, without guidance and monitoring. (M1)
In this excerpt, the nursing staff is criticized for the conduct of performing chemical restraint is not prescribed by the doctor, as well as to cause harm to patients due to badly made physical restraints, which often aimed to punish the patient for their conduct.
The relationship of mental patients with physical and chemical restraint dates back the years in the history of madness. It is one of the most representative icons of the asylum model, because it was used as punishment when the mad individuals were aggressive, unruly or resistant to the treatments offered10.
On the physical and chemical containment performed in CSE, they were followed by the institution as a whole, because it was a characteristic perpetuated in psychiatric hospitals and historically accepted:
In a way, the nurse ended up being complicit with what the institution produced and the institution gave sustenance, because nobody was punished, nothing was investigated [...]. Some physical containments were only punitive; it was as if it were like this: you do not do what I want then I will restrain you in bed. (M1)
The art of punishing, brings “the penalty perpetuates that crosses all points and controls all the moments of disciplinary institutions, compares, differentiates, hierarchizes, homogenizes, excludes. In one word, it normalizes”8:153.
The main reference for the patient's physical containment, in addition to their admission is the strong room, a space built for their containment. Its existence was common in psychiatric institutions since the creation of the first hospice in Brazil and CSE this punitive space was used by the care team until the beginning of the 1990s:
As soon as I arrived there the strong-room still existed, the toilet was the one type latrine which is on the ground, and a shower of cold water, because they said that he could not install the shower with electric energy, because if not the person could use what to kill themselves, then it was a torture room even, the food was given by a crack in the gate, the room was with cell, sometimes two patients only in the room, the bed of made of cement and a thin cushion. Many patients were naked there, and in the cold weather, so that they did not feel very cold sometimes they put two or three together, so that they heated one another and wore only a blanket. (M1)
The description above leads us to reflect on the condition disqualified from the nursing team of ECI, who did not realize that the attitudes of humanization that practiced were inhumane, i.e., submitting the application of disciplinary techniques imposed by traditional institutional model, the nursing staff was thought impossible to operationalize changes in their practice. This is because the discipline permeates the entire hierarchical pyramid, so that the nursing team of CSE, at the same time that he exercised the disciplinary power, also suffered from its effects.
In the statement of a nursing professional, whose training prepared him for the exercise of a qualified assistance, there is a severe criticism of the care model of CSE and the nursing care that was practiced:
When I arrived here, it had many beds, a large amount of patients and still had the strong room, which they called the special ward. In that ward, hygiene was very precarious, had many lice, scabies, [...] no one did anything, the nurses would not even go there, it became the attendants responsibility. (T1)
In the description of the care provided to the patient imprisoned in the strong room, the lack of treatment and the appalling conditions offered by the institution to patients was observed. At the same time, it is evident the role of nursing practices were rooted in historical constructs and originated from the treatment, where the moral responsibility to the nursing the exercise of disciplinary techniques. They placed the patient in the strong room, even being prescribed by the doctor it was performed by the nursing staff, responsible for monitoring them and ensuring their feeding, hygiene and medication.
To minimize the cold, which is quite intense in the region depending on the season of the year, the nursing staff of the CSE used as strategy grouping the sick, intended to minimize the discomfort, subjecting patients to situations of living in precarious conditions such as dividing a bed for three patients.
At the core of all disciplinary systems, operates a small penal mechanism. Is benefited by a kind of privilege of justice, with its own laws, its offenses specified, its particular forms of sanction, and its instances of trial. The disciplines establish an 'infra-penalty'; quadruple a space left empty by the laws; qualify and thwarting a set of behaviors that escaped the great systems of punishment by their relative indifference8:148.
The affirmative of Foucault, previously cited, allows us to characterize the CSE, until the 1990s, as an institution, which followed the traditional model, once that if identified in primary sources the disciplinary procedures, described by him. As For nursing, it is evident that they had detailed control over the body of the patient, the monitoring and carrying out of treatment measures that functioned as punishment. These mechanisms of entry also formed of the nursing staff a group fragile, it functioned as a motivator for political-financial scheme, which, for many years, allowed the operation of institutions in traditional psychiatric model. Thus, the CSE imposed a formally unprepared nursing team, which worked without supervision of a nurse, a relation of docility-utility, which had the effect of generating a nursing care guided by control mechanisms.
CONCLUSION
As well as to reflect on the topic, this study allowed view the trajectory of psychiatric practices in Brazil, before the deployment of healthcare transformations resulting from psychiatric reform, where the CSE. By its political and economic value in Juiz de Fora, we served as a model for the recognition of the former constitution of nursing care in institutions exclusively for hospitalization and where there were no professionals were formally prepared for psychiatric care.
Therefore, it was evidenced that the institutional structure facilitated the perpetual surveillance and the existence of the strong room was the main characteristic of traditional psychiatric model, which aimed at exclusion. Added to this is the practice of physical and chemical restraint used by the entire health team without questioning on their practice and the harm that they may have caused to the ill.
The Foucaultian perspective on the exercise of disciplinary power in the CSE has enabled the understanding of what the nursing staff, who worked for 35 years without the presence of the nurse and, therefore, without planning or direct professional supervision, remained in a docile situation, despite also exercising the power in this institutional space.
Thus, the study allows us to record the past of psychiatric nursing, not with the intent to criticize it, but valuing a trajectory of suffering and destitute exercise, favoring interests that were beyond care. We also ensure the comparison with the new practices currently exercised within the Psychiatric Reform, where the nursing transformer plays an important role.
REFERENCES
1.Silva RBC, Guimarães JCL.Casa de Saúde Esperança. Rev. Centro de Estudo Karl Jaspers. 1980; 1(1):
2.Silva ALA, Guilherme M, Rocha SSL, Silva MJP. Comunicação e enfermagem em saúde mental...Rev.Latino-Am Enfermagem. 2000; 8 (5): 65-70.
3.Casa Saúde Esperança. Livro de Registro de Funcionários de 1976 a 1993. Juíz de Fora (MG): 1993.
4.Gonçalves JRL, Luís MAV. Atendimento ao familiar cuidador em convívio com o portador de transtorno mental. Rev enferm UERJ. 2010; 18: 272-7.
5.Chiozzini D. Memória é matéria prima do trabalho do historiador. Com Ciência São Paulo, mar. 2004. Available at: http://www.comciencia.br/reportagens/memoria/04.shtml
6.Marques AJS, Pitta AMF. Reabilitação psicossocial e a Reforma Psiquiátrica em Juiz de Fora. São Paulo: Hucitec; 1996.
7.Secretaria de Estado de Saúde (MG). Linha Guia da Saúde Mental. Belo Horizonte. (MG): SES; 2006.
8.Focault M. Microfísica do poder. Rio de Janeiro: Vozes; 1986.
9.Peres MAA. Barreira IA. Relações institucionais Escola Ana Néri (EAN) / Instituto de Psiquiatria da Universidade do Brasil (IPUB) (1957-1963). [dissertação de mestrado]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2004.
10.Paes MR. Maftum MA. Mantovani MF. Cuidado de Enfermagem ao Paciente com Comorbidade clínico-psiquiátrica no pronto atendimento de um hospital geral, Curitiba. [dissertação de mestrado] Curitiba (PR): Universidade Federal do Paraná; 2009.