Professional identity of mental health nurses: a phenomenological study in Merleau-Ponty

La identidad profesional de la enfermera en el campo de la salud mental: estudio fenomenológico en Merleau-Ponty

ABSTRACT

Objective:

To understand the professional identity of Mental Health Nurses.

Method:

Qualitative research, based on Maurice Merleau-Ponty’s phenomenology, conducted between October 2019 and April 2020, with sixteen Nurses working in the field of Mental Health, located in two municipalities of the State of Bahia, Brazil. The Phenomenological Interviewwas used to produce the data, which, after transcription, was submitted to analysis using the Analytics of Ambiguity.

Results:

We outlined the categories: From Classical Psychiatry to Psychosocial Care;Identity leap mediated by the experience of the body itself. We understand that the know-how of Mental Health Nursing is being built in the intersubjectivity with users and the multiprofessional team.

Final considerations:

Although the Nursing performance reveals ambiguities that show the transition between Classical Psychiatry and Psychosocial Care, it proved to be powerful to make the “identity leap”, a transcendence that shows how much this experience enables acting in Mental Health.

Keywords:
Nurse’s role; Nursing care; Mental health

RESUMEN

Objetivo:

Conocer la identidad profesional de la Enfermera en el ámbito de la Salud Mental.

Método:

Investigación cualitativa, basada en la fenomenología de Maurice Merleau-Ponty, realizada entre octubre de 2019 y abril de 2020, con dieciséis Enfermeras que trabajan en el campo de la Salud Mental, ubicadas en dos municipios del Estado de Bahía, Brasil. Para la producción de datos, se utilizó la Entrevista Fenomenológica, que, tras su transcripción, fue sometida a análisis mediante la Analítica de la Ambigüedad.

Resultados:

Delineamos las categorías: De la psiquiatría clásica a la atención psicosocial; Salto de identidad mediado por la experiencia del propio cuerpo. Comprendemos que el saber hacer de la Enfermería en la Salud Mental se está construyendo en la intersubjetividad con los usuarios y el equipo multiprofesional.

Consideraciones finales:

Aunque la actuación de la Enfermería revela ambigüedades que muestran la transición entre la Psiquiatría Clásica y los Cuidados Psicosociales, se mostró poderosa para dar el “salto de identidad”, una trascendencia que muestra cómo esta experiencia la hace capaz de actuar en Salud Mental.

Palabras clave:
Rol de la enfermera; Atención de enfermería; Salud mental

RESUMO

Objetivo:

Compreender a identidade profissional da Enfermeira no campo da Saúde Mental.

Método:

Pesquisa qualitativa, fundamentada na fenomenologia de Maurice Merleau-Ponty, realizada entre outubro de 2019 e abril de 2020, com dezesseis Enfermeiras atuantes no campo de Saúde Mental, localizados em dois municípios do Estado da Bahia, Brasil. Para a produção dos dados utilizou-se a Entrevista Fenomenológica, que, após transcrição,submeteu-se a análise por meio da Analítica da Ambiguidade.

Resultados:

Delineamos as categorias: Da Psiquiatria Clássica à Atenção Psicossocial; Salto identitário mediado pela vivência do corpo próprio. Compreendemos que o saber-fazer da Enfermagem na Saúde Mental vem sendo construído na intersubjetividade com os usuários e equipe multiprofissional.

Considerações finais:

Embora a atuação da Enfermagem revele ambiguidades que evidenciam o transitar entre a Psiquiatria Clássica e a Atenção Psicossocial, mostrou-se potente para dar o “salto identitário”, transcendência que evidencia o quanto essa vivência a torna capaz para atuar na Saúde Mental.

Palavras-chave:
Papel do profissional de enfermagem; Cuidados de enfermagem; Saúde mental

INTRODUCTION

For many decades, professional identity has been the subject of research in several areas. In this study, in particular, we sought to understand the identity issue of Nursing in the field of Mental Health, in the light of Maurice Merleau-Ponty’s phenomenological approach, which allows us to relearn to see the world1^-2. For that, we start from living experiences as Nursing professors in the field of Mental Health, with a view to producing knowledge involving the perception of Nurses on the theme, since the perception corresponds to the field of revelation of the sensitive world and the sociocultural world of the human being.

In the phenomenological conception of perception, the apprehension of the senses happens from a corporeal attitude, from intercorporeality. The perceptive experience would therefore be this own body, which allows us to experience ambiguous sensations and constitutes field experiences, that is, the experiences of the own body happen in a phenomenal field, and refers to our insertion in the world of life, since every perception, for Merleau-Ponty, is always the perception from the point of view from those who experience it3.

The understanding of the identity term permeates several perspectives, but all share the same thought of a broad and multiple construct, being dynamic, relational and situational4. Therefore, we can state that, throughout the existential pathway in which people experience the different processes of socialization with others and with themselves, in a given sociocultural reality, the various conceptions of identity are constructed5.

In the scientific literature, we observed that national and international publications address the identity construction of Nursing professionals, focusing on university education. Such publications emphasize that it is in the academic experience, from the point of view of institutions, models, curricula, professional choices and profiles, biographies and how essential these aspects are in the conduct of each person’s professional life, that the Nurses’ professional identity is outlined4^-12.

The discourses about Nurses’ know-how in the field of Mental Health are based on the need to define their identity in this sphere of action, with a view to make visible their work in Psychosocial Care. This shows that it is possible, in a field that values multiple knowledge and interdisciplinarity, to show what is proper to it, the core of professional nursing knowledge.

In this way, we agree with the understanding that by outlining the identity, the Nurse's know-how, we clarify its core of knowledge; and when we talk about a space of limits, not so delimited, in which each discipline and/or profession seeks in others the necessary support to carry out its theoretical and practical tasks, we are talking about the great field of Mental Health13.

This need for identity clarity does not disfigure the logic of care in Psychosocial Care, but corroborates the visibility and importance that each professional area has in this field of activity, by exercising what is its own, it is plural and interdisciplinary.

The dialogue with Merleau-Ponty’s philosophy led us to a much broader and deeper perception on professional identity of mental health Nurses, as phenomenology seeks as its primary task “returning to things themselves”, which means recognizing in what we do something that is proper to us, that is, to have an identity, an identification with what we do in our daily lives1.Therefore, if we know how to recognize what is proper to us, it means to say that we identify with what we do.

In this perspective, the study emerged from the following research question: how is the identity of the Mental Health Nurse shown?

OBJECTIVE

To understand the identity of Mental Health Nurses.

METHOD

Type of study

Since this is a study that aims at describe experiences as they show to human perception, without the concern to explain the facts, we consider it pertinent to ground it on the theoretical-philosophical framework of the phenomenology of experience by Maurice Merleau-Ponty, who admits the idea that knowledge production occurs from the dialogic and intersubjective relationship1.

Phenomenology, as a qualitative research modality, sets the perception as one of the fundamental elements of its proposal, since it is through it that one can inhibit naturalist theses referring to the knowledge of things, space, time and freedom, through which we have access to the other and to the world. However, perception shows as an ambiguous experience, because it reveals the ambiguity of the world, unveiling possibilities of transcendence1^,14.

We emphasize that the study complied with the verification domains of the Consolidated Criteria for Reporting Qualitative Research (COREQ), a guide instrument for promoting scientific writing of clear and accurate research reports.

Studys cenario

The scenario consisted of the following devices of the Psychosocial Care Network (Rede de Atenção Psicossocial- RAPS) of the Unified Health System (Sistema Único de Saúde - SUS): (1) Psychosocial Care Centers (Centros de Atenção Psicossocial - CAPS): two CAPS II, one CAPS AD and one CAPS AD III, in the cities Vitória da Conquista and Jequié, both in the state of Bahia, Brazil. (2) Family Health Strategies (Estratégias de Saúde da Família - ESF): four services in the city of Vitória da Conquista, in which the matrix processes and Mental Health actions take place.

Theoretical-methodological framework

It was adopted the theoretical-methodological framework of Maurice Merleau-Ponty’s phenomenology of experience. For the author, the access to the other and to the world takes place through perception, this occurs as an experience of the body itself, an ambiguous experience, since every perception involves a horizon of the past and another of the future, which are updated in a present, and each experience of this perceptive synthesis is dynamic, each moment corresponds to a new experience, in which the experience of transcendence takes place, the possibility of re-signifying one’s personality and becoming another self from the experience of temporality1^,14^-15.

Study participants

Fourteen female nurses and two male nurses participated in the study, inserted in thementioned scenario. Due to this proportionality, the participants of this study will be referred to as for female nurses. Inclusion criteria adopted: Nurses in effective exercise in the devices of the research scenario for at least six months. Exclusion criteria were: being away from work due to vacation, transfer, strike and leave at the time of data collection. In order to preserve the anonymity of the participants, the participants were identified by fictitious names.

Sampling definition

For sample selection, we followed the suggestion of Bauer and Gaskell (2019), in which the number of participants in qualitative research, regarding individual interviews, may be between 15 and 25, because, in summary, the objective of the research is to present a sample of the point of views16.And, considering the phenomenological study, the fundamental of the research is the in-depth understanding of what is unveiled to perception, from intersubjectivity, and not the number of participants and information produced.

Period and strategy of data collection

The experiential descriptions (research data) were collected from October 2019 and April 2020. For the field stage, previous contacts were made with the coordinators of the Mental Health and Primary Care from the cities selected as scenarios, for authorization for its execution. The coordinators indicated possible participants according to the pre-established criteria. Twenty-one Nurses were identified, of which sixteen agreed to participate in the study.

To collect the experiential descriptions, the Phenomenological Interview was used, which favored the unveiling of experiences through a movement of understanding17. This kind of interview is recognized as an existential approach between two people, that is, a meeting, uniquely established between the researcher and each participant, in order to apprehend a phenomenon from the perspective of the one who is experiencing it and giving meaning, in this case the Nurses inserted in the field of mental health18. All interviews were conducted by the responsible researcher, who has been studying the phenomenological approach since her master’s degree, deepening her understanding in the doctorate, through studies and courses, on Merleau-Ponty’s Phenomenology of Perception, method and phenomenological interview in qualitative research, looking at Analytics of Ambiguity, an analysis technique created by her advisor3.

Before starting the interviews, there was a moment to sensitize the participants and reflect on their being-person-professional, encouraging them to observe their own reflection in a mirror asking the following question: “what do I see in the mirror?”. This moment was an opportunity for the participants to perceive other perspectives in relation to the field of professional activity, allowing them to broaden their horizons of themselves and the world around them.

In this sense, we were able to reach the themes that mobilized the interviews: Daily practice of nurses in Mental Health care; meanings attributed by the nurse in the context of Mental Health care; identity of the nurse in Mental Health. Each theme was followed by guiding questions, e.g.: “What do you consider to be the nurse’s identity, with regard to Mental Health care in the context of Psychosocial Care?”. The questions mobilized the dialogue, prepared from the statements of the participants themselves and emerged from the researcher’s listening exercise17, in order to reach the understanding of the object of study. The time assigned to the interviews ranged between 30 and 90 minutes.

Aiming at ensuring confidentiality, the interviews were recorded in full, and soon after each one of them, they were transferred to a file on the computer.

Data analysis

It was used the Analytics of Ambiguity, a methodological strategy based on the Merleau-Ponty’s notion that dialogue produces and reveals a broad sense of experiences that appear to be perceived as ambiguities2^-3. This strategy is similar to the experience of appreciating a landscape since the perception of a “figure” requires the abstraction of other figures. This process belongs to the reflective domain3. In this way, it was conducted the analysis of the Nurses’ experiential descriptions, their reports being considered abstracted figures that emerged from a background.

In this way, we followed all the steps recommended by the technique, namely: organization of experiential descriptions (speech) in text form; exhaustive readings of the material; and objectification of theoretical categories. In this universe of notions, which, by the understanding of the nurses’ experiential descriptions, we found ourselves in a phenomenological reduction regime. Thus, in the intersubjectivity with the text, emerged several ambiguities inherent to the dialogic experience and, since it is a phenomenal field, certain objectifications were carried out - categories3. Such ambiguities, conceived in the perceptive experience, involved two poles: the pre-reflective (sensitive) and the reflective, in a movement of “transmutation1”.

The reading of the material flowed, allowing the phenomena to show themselves, from themselves, which means to say that we experience the perceptive experience during the reading and we recognize ourselves as coexistence14^-15. In such a way, the phenomenon of the Nurse’s identity in Mental Health revealed as an ambiguous experience, dragging with it different profiles in an intersubjective experience.

Ethical aspects

The research was developed complied with the ethical aspects of research with human beings, in accordance with Resolution No. 466 of 2012 of the National Health Council19. The research project was submitted to Plataforma Brasil, under CAAE Nº: 17741019,8,0000,0055, being approved by the Research Ethics Committee of the Universidade Estadual do Sudoeste da Bahia (CEP/UESB), under Opinion Nº 3,560,186/2019. It should be noted that the interviewed participants voluntarily signed the Free and Informed Consent Form.

RESULTS

Seeking to achieve the objective of the present study, in the light of the Analytics of Ambiguity, thematic categories emerged that constituted the empirical basis on which we proceeded with the theoretical-philosophical support of the study.

From Classical Psychiatry to Psychosocial Care

Nurses participating in the research, working in RAPS devices, understand that they need to establish their professional identity from the point of view of Psychosocial Care. However, often driven by the sociocultural being, they still show knowledge and practices that are still based on Classical Psychiatry, a medical-centered and hospital-centered model:

We need to enhance the leading role of the user, with his/her participation, which is sometimes difficult, because, even in this environment (CAPS), we have interference from our culture, from colleagues, but also from me, who expect him/her to do it in a standardized way, pre-established, but he will have other pathways, including his experience, which is totally “out of the box”. (Speaks firmly) (Isabel)

We observed that, as much as the professionals emphasized the satisfaction of being included in a new perspective of care, which aims at the psychosocial rehabilitation of users, they emphatically bring the appreciation of principles that highlight hospitalization, the medicalization of the body (of life), besides to highlighting biological and clinical issues, through technical attitudes:

[...] I would not be willing to work in that hospital-centered model. [...] I feel good collaborating with Psychosocial Care, in the sense of empowering the person, making the user responsible for his/her own care [...] I feel better than if I were in the hospital with the person sedated, tied up or getting shocked. [...], but I have a greater professional identification with the hospital, I also work in a hospital (laughs). So, here at CAPS there is no conflict because it is very different from the hospital. (José)

Other Nurses were anxious about a “not knowing” the policy of the service (Harm Reduction) in which they are inserted, which possibly raises doubts about Nursing know-how:

[...] my anxiety is that, although the users are here, they do not fully adhere to the CAPS, to the treatment. They stay here for a period and think it's good and that's it! He/she stopped using (drug) only that period at the weekend he/she uses it abusively and returns to the CAPS. To what extent are they really treating themselves? Or to what extent am I developing my role, or am I caring? [...]. (Upset) (Marta)

[...] this anguish increases when we talk about the issue of Psychosocial Care, I don't see it happening! What can I offer to them? What have we done for the user? [...] the work is pleasurable, but, at the same time, it anguishes me, for not seeing the network happen, the users being “stuck” inside the service, the service not “opening” to the territory. (Upset) (Maria)

On the other hand, the need for identity clarity was evident when the professionals reported, at several times, the Nurse’s role as the “does everything” in Mental Health, which reinforces the importance of recognizing what is proper to her, which has to do with the core of nursing professional knowledge:

[...] I joke that I forget my role as a Nurse because I don't have this specific identity in Mental Health (laughs), except for the technical parts of Nursing, the consultation, which includes the history, the evaluation, the physical examination [...]. But, when you're out of it, I even forget, I'm more of a Mental Health technician, we do everything here. (Laura)

We do a little bit of everything, sometimes I consider myself more technician in Mental Health, because I get involved in everything [...], but what I see as more specific is the issue of the clinical evaluation, the Nursing consultation, anamnesis, vital signs, medication administration, continued care in intensive care. (Ana)

Identity leap mediated by the experience of the body itself

In the process of the statements, it was unveiled an extraordinary profile of the body itself - the body of the other or the experience of the “other myself”. And this notion of the other for Merleau-Ponty does not refer to the similar, but to this experience of transcendence.

In this category, we outlined the identity of Mental Health Nursing, with the intention of pointing out possible strategies for experiencing the transcendence of care. Care that presupposes a relationship that is crossed by permission, by desire, and by the user’s effective participation in care, as long as he/she feels free to do so:

[...] it took me two years for the user to understand that he/she was self-sabotaging, for him to allow to be taken care of, apart from the time he had here with other professionals. I understoodthat I need to do my job every day, considering the right of this user to all the services he needs, but without creating expectations that are mine (smiles and points to herself).

[...] there are several variables that interfere with desire, with his decision, and this interferes with the result.

[...] This for me is what clarifies every day what I have to do here inside, because this work here is very fluid, because it is multidisciplinary, interdisciplinary, and with those loose edges of interdisciplinarity (Spontaneous smiles). (Isabel)

It is at this point in the interviews that happens what we call an “identity leap”, this “insight” that the Nurses gave at the moment when we were talking about Nursing know-how in the Mental Health device (CAPS), that has to do with the experiential dynamics and with the power that speech has, to make us see, to clarify, that is, to show us what this identity of the Nurse is, that takes place, gains body in the service, unveiling transcendence, the “I can”, enabling to perceive changes in the way of being and seeing the world of Nurses. Which was evident below:

[...] when I came to the CAPS, I saw that we do not have a specific role of the nurse in the patient's consciousness and, sometimes, for some team members, I also realize that they do not understand our role. But, now analyzing better, when I'm providing care I have this awareness [...]. The reference service that I, Nurse, provide is different from the reference service that the pedagogue or other professional provides, because I have the vision of that user who is part of my professional knowledge (points to herself). (Eva)

[...] any action I do at the CAPS, I'm already doing psychosocial rehabilitation. Everything we do here is to socialize the user, for that goal. Whether it is a medication, a chat, a visit, manual activities, therapeutic follow-up, anyway, any intervention, it is with the intention of improving their quality of life. (João)

[...] after I went specifically to Mental Health, I lived with the biopsychosocial team and saw the potential that the Nurse has to develop actions that are part of daily life, that we perform and have significant results, which do not necessarily permeate a technical care, [...], and in fact, this expanded look makes all the difference (laughs).(Rebeca)

Nurses unveil what distinguishes them from other professionals, but always making it clear that the role of Nursing in Mental Health takes place in shared care, without canceling the specificities of each professional. Thus, it was described knowledge that generates several possibilities related to the know-how of Nursing in Mental Health. As we see in the statements:

[...] I find interesting Mental Health that uses this expanded view, teamwork, care shared with other services [...]. Today it has a meaning that goes much further, [...] it allows to improve the quality of life, the way the user will feel, even the environment we need to consider. (Esther)

[...] in my undergraduate course, the issue of the interpersonal relationship with the user, therapeutic communication and qualified listening was strongly emphasized. [...] this is part of our identity as Nurses. [...] we provide referral care to elaborate, re-elaborate and evaluate the Singular Therapeutic Project (STP) with the user. Therapeutic follow-up, as we monitor the user in some needs out of CAPS, but always encouraging autonomy, so that he/she can go alone, but saying: “I'm here if you need it!” (watering eyes). (Isabel)

Embracement; referral care, crisis management, STP, family group; family care; intersectoral meetings; team meetings; case studies; home visit; home mediation; I do the contractuality, that is, when I lend him my professional credibility, like a contract, I go with him to solve, find out how the process is, and over time he walks alone; I do everything that has to do with psychosocial rehabilitation. (Mirian)

[...] we learn since college and bring to here, that comprehensive and shared care, we see Mental Health not only the physical aspect, but something else that has to do with that complaint [...], permeates the expanded look of the whole team. (Noemí)

DISCUSSION

The discussion of the results of the study consisted in the interlacement of our view, as researchers, with the theoretical categories of Maurice Merleau-Ponty, the scientific studies that deal with the theme and the empirical material of the research. In this dialogical experience, which translates as intersubjectivity, the Merleau-Ponty’s approach led us to a broad and deep experience of the perception of the identity of Mental Health Nurse, considering the notion of the philosopher’s perception as her own body.

The author deals with the theme based on his discussion on temporality, in which the body is understood as time, and consists of the synthesis of the “here and now” experienced in the experience of perception; the person updates, in the present, a horizon of the past and another of the future, always in a creative way; the term “own” means the human being’s potential for transcendence in the temporal flow, in the perspective of changing the self1.Thus, Merleau-Ponty describes the body itself as intercorporality, which corresponds to the exercise of perception, mediated by the intersubjective relationship, which is always ambiguous.

The experience of the own body involves the five dimensions described by Merleau-Ponty, namely: habitual body, perceptive, sexual, speaking and body of the other1. In this study, to better discuss the results, we decided to base them mainly from the dimensions of the habitual body, sexual body, and body of the other.

The experiential descriptions of Nurses participating in the study corroborate the fact that they are in a world that is characterized by ambiguity, in a phenomenal field, while they recognize themselves as people, as professionals, immersed in the context of a Mental Health device, bring impersonality, a sensitive dimension, which affects the way to perceive and act as professionals. Therefore, identity is dynamically constructed and reconstructed, in a movement between the universes of feel (feelings) and think (rationality, sociocultural)1^-2^,14^,20.

The paradigmatic transition from the field of Classical Psychiatry to the field of Psychosocial Care has been partially shown in the know-how of professionals in Mental Health devices, since, although there have been advances in epistemological foundations of care in this area, in practice, progress does not seem to have been so significant, especially in Nursing; and the fact points out to a possible repercussion on the Nurse’s identity, as it highlights the difficulty in clarifying the role of Nursing in the field of Mental Health.

In the study, it was evident the difficulty for nurses to turn the perspective of Psychosocial Care into an act, despite demonstrating the existence of changes from a theoretical point of view. Thus, paradoxically, the study reveals that the production of care by Nursing in Mental Health devices still has emphasis on Classical Psychiatry as approach.

In the context of the CAPS, we found some examples of such approach in practices that reinforce the appreciation of physician-psychiatrist knowledge and the medicalization of the body21^-22. We noticed an important identification with the biologicist know-how, despite being inserted in a device that profess the psychosocial approach.

Studies correlate this identification with the professional’s limited knowledge about the principles and objectives of the Brazilian Psychiatric Reform (BPR), leading to adopt a practice without stimulating reintegration into the territory and into recovery of social life7^,23^-25. These authors corroborate our findings, since they add that such aspects also reflect on the lack of identity clarity of Mental Health Nursing.

The lack of identity clarity, regarding the role of the Nurse in the Psychosocial Care device, seemed evident when we asked the research participants to talk about their daily work in services, and they described the Nurse as the professional “does everything” in the field of Mental Health. Studies indicate that this reality is not different in other countries of the world. Authors who discuss the identity issue of Nursing in Mental Health point out that one of the main problems for the construction of identity would be the fact that the Nurses play a variety of roles without professional status, situating their role by the colloquial term “jack of all trades”7^,20^,24.

However, other scholars in the area contest this idea of disqualification and reinforce the idea that the Mental Health Nurse is shown to be a multi-qualified professional, who considers all the needs of the subjects in a comprehensive way and performs her function based on flexibility and creativity6^,26.The findings of our study lead us to agree with this thought, since the Nurse in the field of Mental Health develops her know-how from the perspective of comprehensive care, as it comprises the subject in his multiverse needs, in a spiritual and biopsychosocial-cultural approach27.

Comprehensive Mental Health concerns an action committed to breaking barriers, allowing the embracement of the person with mental suffering, demystifying the ideology of hospitalization/institutionalization and medicalization, as forms of isolation/social repression, disqualification and loss of autonomy of the subjects6^,28.

According to the National Curriculum Guidelines for the Undergraduate Nursing Course, nursing training has a generalist, humanist, critical and reflective character; which enables the Nurse to act with a sense of social responsibility and commitment to citizenship and the comprehensiveness of the human being29. Thus, during the training process, the Nurse learns to perform a comprehensive care to the subjects, considering all dimensions that involve the human way of being and living and based on comprehensiveness. Thus, in addition to scientific and technical knowledge, he/she adopts philosophical, ethical and sociocultural knowledge in their practice.

This style of acting for Nurses should not be different in Mental Health, as the generalist training guarantees them a basis to act in several scenarios and, during their undergraduate course, they develop skills and abilities that are improved throughout their professional career. Therefore, we understand that the Nurse’s professional identity is consistent with the proposal of Psychosocial Care, sometimes performing their role focusing on their core of professional knowledge (disciplinary), sometimes in the field of Mental Health (multi and interdisciplinary).

To better situate the know-how of Mental Health Nurses, the field and core of knowledge are important. Understanding the core of knowledge of a given profession concerns the combination of knowledge13, which, in this particular case, is about the specific knowledge of the Nursing area that outlines its actions and roles in health services. Therefore, the core would delimit the identity of an area of knowledge and professional practice. The idea of the field, on the other hand, is about actions and practices in a space of limits not so well defined between one profession and others, where each one would seek mutual support to accomplish their theoretical and practical tasks13.

In the experiential descriptions of the study, we showed the division of the Nurse’s know-how into two situations: actions that are characteristic of the Nursing core or specific to the profession; and actions recognized as a field of Mental Health, that is, not exclusive to Nursing.

The Nurses in this study described some actions they perform at CAPS, which we consider to be the professional core of Nursing: preparation, implementation and supervision of the Systematization of Nursing Care (Sistematização da Assistência de Enfermagem - SAE); Nursing consultations; crisis management; management of the Nursing team, supplies and medicines; administration of medication in the service or at home; provision of care related to basic needs, such as hygiene, nutrition and sleep; nursing home visits; collection of laboratory tests and referrals to tests or other services that address specific general health care4^-5^,9^-11.

Regarding the activities in the field of Mental Health, shared among the multiprofessional CAPS team, the Nurses highlighted actions that also corroborate the literature7^,24: embracement; participation in team meetings and mini teams; conducting groups and therapeutic workshops; participation/representation in spaces of social control (Municipal Health Council, local Council); intersectoral meetings; reference groups; acting as a reference professional for service users; non-specific home visits; contractuality or therapeutic follow-up; referral service; family care; team case studies; participation in preparation and execution of the Singular Therapeutic Project.

To better understand the temporality of the Nurses who presented themselves to us at the moment of analysis, we based on Merleau-Ponty’s thought1, according to which, each perceptive act brings with it the announcement of something that is much more than what it shows and does not depend on volition; it always reveals itself in profile, although it carries with it a background, a habit, which is spontaneously constructed as a story, unveiling the ambiguities of the world of life1.

The habit, then, is constructed as an experience of our body in the world, so that the habitual body appears in the Nurses’ work when they exercise Nursing in the CAPS. In our study, we noticed that, in their daily work, Nurses involuntarily (habitually) resume knowledge and practices rooted with experiences related to the historical process of construction of Psychiatric Nursing know-how. Thus, it was possible to notice that the psychiatric model has repercussions on the identity design of the profession in the field of Mental Health. However, in the light of Merleau-Ponty, we understand that the current experiences of Nurses in the area always open possibilities for projecting the future, as something that happens in a creative way, with a perspective of transcendence, shifting paradigms, since the experiences of the habitual body allow the becoming another.

Thus, despite the influence of the tradition of Classical Psychiatry, the experience of thebody itself, through the habitual body dimension, enables Nurses in Psychosocial Care devices to re-signify their know-how in line with the perspective of this field. It is, therefore, in terms of Merleau-Ponty, a temporal experience as it is in the daily routine of professional practice, experienced in various points of Mental Health care, where the Nurse can synthesize horizons of past and future and, thanks to its creative potential, manages to make the leap of rupture with the remnants of the institutionalizing model and to appropriate the know-how in Mental Health.

In the dialogical experience with the study participants, we had the opportunity to make visible the real context of Nursing practices in Mental Health devices. Nurses were mobilized to reflection, so that they felt affected and driven to change not only their view, but also their practices, highlighting the need for Nursing identity in that mode of care.

Thus, the experiential descriptions of the study participants allowed us to understand that the know-how of Mental Health Nursing can be constructed in the practical experience of the services, in the interaction with users and the multiprofessional team. This aspect has been reiterated by other studies, which confirm that daily situations experienced in team meetings, for example, are important resources for nurses to base their practices7^,30.

From this perspective, feelings of satisfaction/pleasure in acting as Nurses in a Psychosocial Care device were unveiled, even if, paradoxically, experiences of hospital-centered practices/attitudes appeared in the daily work of Nursing in services that generate feelings of anguish in Nurses. This ambiguity that interweaves the feeling and doing of Nurses is inherent to human nature, to perception, and occurs in the intersubjectivity with the similar1_.

The intersubjectivity, which consists of openness to the other, Merleau-Ponty characterizes as sexuality or sexed body. It is an experience of pleasure and joy, in which the person turns to his sensitive dimension, to the narcissistic experience, described by the author as coexistence, in this case, sexual coexistence, which has nothing to do with the genital1. It consists of experiencing sensations of affection, satisfaction, learning, among others, which mobilize, for example, the Nurses involved in the dialogical relationship to visualize perspectives for future, with possibilities of overcoming practices not consistent with Psychosocial Care.

From the dialogical experience between the universe of feeling and the universe of reflection, Nurses seem to understand that Mental Health care is opposed to all forms of pathologization and institutionalization of the subject. Thus, there is a transcendence of the Nursing care paradigm, from the institutionalizing and asylum perspective to the perspective of Psychosocial Care.

In the light of Merleau-Ponty’s thought, we understand that every transcendental experience corresponds to a change in perception, therefore, the operation of thebody itself. Regarding the construction of the Nurse’s identity in Psychosocial Care, the own body is revealed as the body of the other, that is, as an experience of becoming an “other myself”, which happens through the appropriation of theoretical-practical knowledge that guides Mental Health actions, recommended by the BPR movement, principles and guidelines of the National Mental Health Policy and model of care.

All this process of construction and paradigmatic transcendence in Mental Health emerges from collective mobilization, which involves several social actors such as anti-asylum activists, organized civil society, Mental Health workers, family members and users. This idea of producing know-how is in line with Merleau-Ponty’s perspective, whose primary understanding is that all knowledge is constructed in an intersubjective relationship, a phenomenon that the author describes as being a mystery, in which change happens through the interweaving of the private with the social, showing the creative, the new and the possibility of becoming another1.

Moreover, we understand that the “identity leap” of Nursing from the psychiatric model to Psychosocial Care, according to the research participants, goes beyond the domain of knowledge of technical-scientific, ideological, and ethical apparatus related to Mental Health Nursing care. It is an ambiguous experience of the professional in the face of the suffering of the other, in which at the same time that one is recognized in the similar what is proper to himself - humanity -, considers it as strange, different, when it refers to the social history of madness and the various forms it has dealt with it over the centuries.

Therefore, the research allowed the deconstruction of the thesis that the identity of Mental Health Nurses is linked to a construct defined in itself, whether polarizing in aspects of technical care, or in communication and interpersonal relationships. Transcendence, translated in this study as an identity leap, is unveiled in the uniqueness of Nursing practice, based on its specific scientific field, which involves theories and technologies of care for the subject in its biopsychosocial and spiritual dimensions, supported by a broad and interdisciplinary knowledge - Mental Health, considered a field of knowledge, a public health policy and a model of Psychosocial Care.

FINAL CONSIDERATIONS

The experience of research development allowed us to see Mental Health Nursing in its power. Although it transits between the ambiguity of the know-how of Classical Psychiatry and the construction of knowledge in Psychosocial Care, it shows to be potent in taking the “identity leap”, transcendence, evidencing how much its experience enables to work in Mental Health.

In Merleau-Ponty’s phenomenology, we understand that the perceptive experience and, consequently, the experience of the body itself, allow us to discuss on the issue of identity in Mental Health Nursing under a more flexible and creative perspective, since we start to consider the knowledge as a field occurrence. This means that we do not find it in the physical acts of the Nurses’ doing themselves, in working in the various devices of the area, nor in their intellect, but in the relationships they establish with the other as intercorporeality, in daily work with other professionals, users, family and community.

Although we recognize the maxim of the phenomenological approach that knowledge is always unfinished, we highlight as a limitation of the study the fact that it shows the experience of professionals inserted in Mental Health devices of only two cities in Bahia. Thus, it is evidenced the need for the study to reach other contexts of the country.

Since this is a phenomenological research, we understand that the study opens the possibility for the production of knowledge about how nursing care has been developed in the BPR process, considering the need for compliance with the guidelines of Psychosocial Care. In the academic scenario, we aim that the questions unveiled can support critical-reflective discussions about the professional practice of Nurses who work in the context of Psychosocial Care and contribute to the structuring and dissemination of references, conducted by scientific evidence for the identity clarification of Mental Health Nursing.

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Edited by

Associate editor:

Helena Becker Issi

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  13 Mar 2023
• Date of issue
  2022

History

• Received
  30 June 2022
• Accepted
  17 Oct 2022