Nursing care and the exercise of human rights: An analysis based on the reality of Portugal Cuidados de enfermería y el ejercício de los derechos humanos: Un análisis a partir de la realidad em Portugal

Objective: To describe the nursing care provided in adult psychiatric services in a city in Portugal, from the perspective of the exercise of human rights. Methods: Eighty hours of indirect observation of nursing care provided in four psychiatric services for adults. Data were registered in a field diary and underwent thematic analysis. Results: The following thematic units were identified: reception of patients at admission; nursing care plan; family approach; and, strategies for social insertion developed by nurses. In general, nurses valued preventive, educational, social and care dimensions when providing care, but patients' families were not included in the therapeutic process. Conclusions: Care practices were based on sensitivity towards patients with mental illness and their condition, which demonstrated respect for human rights in all of the services.


INTRODUCTION
As a result of ignorance, preconceived ideas and stereotypes, in the past, people suffering from mental illness were excluded, segregated and even violated.Yet in recent years, changes have occurred in how health care and mental illness are conceived of, and public social services have tended to reflect these developments.
In the 1950s, a movement to humanize mental health care began.From an ideological point of view, societies were sensitized to issues of human rights, condemnation of acts of violence against human beings, and solidarity among peoples, all of which resulted in the creation of the United Nations (1945) and the World Health Organization (1948), with a mandate to promote the health of all human beings, as well as the adoption of the Universal Declaration of Human Rights (1948), which reaffirmed the dignity and basic rights of all people.Furthermore, scientific research led to the development of drugs to treat mental illness, that enabled the rehabilitation of mentally ill patients with drugs such as lithium (1948) for treatment of mania, chlorpromazine (1952), with antipsychotic effects, and anti-anxiety medications such as meprobamate (1954) and chlordiazepoxide (1957).
Nonetheless, although pharmacological innovations enabled better control of mental illnesses, and the movement towards recognition of human rights has fostered equality between people regardless of their condition, the reality of mentally ill people is still permeated by hospitalizations and separation from family and social life, which predispose these individuals to permanent bias and isolation, and therefore result in frequent violations of their rights.
On the other hand, the development of anti-asylum movements in the 1950s and 1960s, which questioned not only psychiatric practice but the very concepts of mental illness and psychiatry, forced a reflection on the role of asylums as instruments for social control and perpetuation of inappropriate behavior.From this perspective, one recent study indicated that "anti-psychiatry believes that traditional psychiatric treatments meet clear political and economic interests, given the political nature of psychiatric science, which annuls the individual in the name of maintaining order and good exercise of power.The psychiatry that the anti-psychiatry movement opposes punishes by imprisonment individuals considered unproductive and dangerous to the capitalist system" 1:151 .
In this context, an international social reform movement emerged, which proposed an intervention model that allowed for the deinstitutionalization of patients with mental illness through deconstruction of the asylum concept, and invention of new practices that enabled the recovery of citizenship and social reintegration of this vulnerable population.In this sense, the psychiatric reform must be collectively constructed, and tends to produce legal, legislative, administrative and cultural initiatives 2 .
Thus, the reform movement was largely responsible for advances in protecting the rights of people with mental illness in the international sphere, since it motivated reflection and the internal construction of specific legislation on knowledge and care practices in effect, seeking to eliminate exclusive interventions and to create proposals centered on valuing human life, consistent with the practice of affirming human rights 3 .
Portugal participated in the reform movement, and there were five landmark events of this process in the country: psychiatric hospitalization (1848-1945), when the first psychiatric hospitals were created; the Law of Psychiatric Care (1945), which created the first community psychiatric services; regionalization and decentralization of mental health services (1945-1970), integration of mental health into the national health care service (1971-1992), into the subsystem of primary health care; and the development of a new community model (since 1998) 4 .Since then, legislation has been proposed, including Law Nº 36/98 and Decree-Law Nº 35/99, highlighted in this study, which directed the reorganization of mental health in the country.In this scenario, in 2007, the National Mental Health Plan was created, with established goals to be achieved by 2016.These goals prioritize equitable access to mental health care, reducing the impact of mental illness on populations, decentralization of mental health services, and integration of mental health care into the National Health Care System 5 .
Nonetheless, this has not been a linear path in Portugal.One study pointed out that if on the one hand there is growing knowledge and recognition of these mental illnesses, on the other hand, there are social and cultural beliefs that generate the stereotype that mentally ill patients are dangerous and their diseases are incurable 6 .There is official recognition that this stereotype exists, and the Report of the National Commission for Restructuring Mental Health Services states that "despite the high prevalence of mental illness, myths about it and the stigmatization of these patients persist, even among health professionals (...)" 5:12 .
The same report also emphasizes that "there is extensive international evidence that the rights most often violated, especially in the context of psychiatric hospitals, but also in the communities where individuals with mental illness live, include the right to be treated with humanity and respect, the right to voluntary admission into a psychiatric institution, the right to privacy, freedom of communication with the outside when hospitalized, the right to vote, the right to receive treatment in the community, and to give informed consent to treatment, the right to judicial safeguards, the right to work, education, independent or sheltered housing, and social protection, among others" 5:12 .
In this context, the aim of the present study was to describe nursing care in adult psychiatric services in a town in Portugal, from the perspective of exercising human rights.
Nursing care was selected as the focus of this study because nursing professionals provide continuous and direct care, and also play a coordinating role in the daily activities of health care services.Specifically in the hospital environment, nurses, more than any other class of health care providers, often have opportunities to facilitate and demonstrate respect for patients' rights, and to advocate for these 7 .

Nursing and the exercise of human rights
Moll MF, Mendes AC, Ventura CAA, Mendes IAC There are also laws that mandate that nurses' actions must be guided by respect for human dignity and provision of care with quality and ethics.To this end, in Portugal there are specific laws pertaining to this profession that guide bureaucratic, operational and ethical aspects of the nursing profession.In this context, one of the guiding principles of the activities of nurses described in the Nursing Ethics Code 8 is respect for patients' human rights.Additionally, Article 8 (on the professional practice of nurses) of the Regulation on Professional Nursing 9 established that nurses should be guided by a responsible and ethical conduct, and act based on the respect for rights and the legally protected interests of citizens.
In general, the legislation cited above boosted the quest for understanding of the guideline of respect for human dignity, and encouraged exercise of the right to health in nursing practices.With the focus on specific actions of nurses specialized in mental health, the authors of the present study were faced with the following description developed by the Order of Nurses of Portugal: "promotion of mental health through prevention, diagnosis and intervention in the face of maladjusted or maladapted human responses to transition processes that cause mental suffering, change or illness" 10:2 .
It should be noted that there are few studies on the subject; therefore, to describe the reality of adult psychiatric health care services in one town in Portugal can contribute to developing nursing actions that are founded on legal principles of the psychiatric reform and the exercise of human rights, with emphasis on the right to health and respect for human dignity.

METHODS
This was a qualitative study carried out in four adult psychiatric services in one town in Portugal (the psychiatric ward of a general hospital, a day hospital, a unit for compulsory hospitalization due to safety reasons and a community service).
The study was conducted during 80 hours of indirect observation by one of the authors, who spent 20 hours in each of services listed above, in periods of four hours for five consecutive days.On the first day, the researcher was introduced to the staff of each service, and subsequently, throughout the observation period, worked discreetly in order to not disrupt the work of the nurses being observed.The research observation focused on the provision of nursing care and work dynamics of the psychiatric services, and was recorded in a field diary.
Study participants were nurses and patients who were receiving care in the psychiatric services for adults in a town in Portugal.Data collection started after authorization from the Research Ethics Committee, through opinion P101/6-2012 of the Research Ethics Committee of the Research Unit in Health Sciences.The nurses and those responsible for the patients under their care all signed a free and informed consent form (FICF).To obtain the signed FICF, the nurses working on morning and evening shifts were approached at the end of a staff meeting, when they were presented with the risks, benefits and purpose of the study.The relatives or legal guardians of the patients were approached individually, and the purpose, risks and benefits of the study were also explained to them.
Thematic analysis was used to analyze the data recorded in the field diary, based on the discovery of nuclei of meaning, which constitute a communication on the frequency or presence of significance to the object in question 11 .
To this end, systematic reading was performed of the previously organized material, and the fragments that were repeated or had semantic similarity in different records were grouped.Then, the constituent elements of the subject were categorized, completing the three stages of analysis: pre-analysis; exploration of the material, and treatment and interpretation of the results.In the final analysis, the data built while collecting the theoretical framework were articulated, in order to meet the study objective 11 .

RESULTS AND DISCUSSION
The following thematic units were structured to systematize the information: embracement of patients at admission; nursing care plan; family approach; and strategies for social insertion developed by nurses.

Embracement of patients at admission
The contact of patients with the different mental health services depends, above all, on the psychic condition of individuals and their ability to seek and obtain help.Whatever the way in which these people interact with mental health services, one can assume that embracement at admission is a critical element of this interaction, and reveals how the different actors and organizations position themselves in regard to this problem.
In the community service, embracement was performed by the receptionists that enabled the service required by the patient.The professionals responsible for this first care visit were social workers, psychologists or nurses, according to the needs of those seeking the service, which were in mental distress, but did not require continuous monitoring, as usually occurs in hospitalization.After this initial care, the individual was inserted into projects aligned with their age and need, which were consistent with the purpose of the service that focuses on health promotion and monitoring, as well as prevention, and the diagnosis and treatment of the disease.
In the day hospital, the nurse received the patients admitted through a formal conversation that aimed to evaluate the individual's history, for further identification of nursing diagnoses that justified the development of the therapeutic proposal that should include their biological, psychological and social needs.
In the unit for compulsory hospitalization for safety reasons, patients were received by the nurse at their admission, and this professional showed them the physical space and standards of the service.Later, the medical psychiatrist, nurse and social worker assessed the mental functions and physical and social aspects of these individuals.After this initial procedure, the Nursing and the exercise of human rights Moll MF, Mendes AC, Ventura CAA, Mendes IAC patient was installed in individual wards for close observation of their behavior, beginning of drug therapy to stabilize symptoms and mandatory use of institutional pajamas (mandatory for one month).This practice was defended as a means to protect the patient, because it was believed that these garments facilitated the patient's identification during the acute phase, when there was an increased risk that they would try to flee.
In the psychiatric ward of the general hospital, embracement of patients was preceded by psychiatric medical evaluation in the emergency room, where the patient's drug prescription was provided.After this evaluation, patients were referred to the inpatient unit, where they were received by the clinical nurses that also evaluated them, in accordance with a guiding instrument that prioritized psychological function, behavior and the condition of basic human needs.
The description above on the embracement of patients at admission shows that the nurses observed in this study actively participated in this process; therefore, it can be said that the embracement by nurses in all four services observed was guided by an attitude of full understanding, in which behavioral and biological aspects provided information on the needs of the individuals receiving care.This participation encourages humanized care, because it seeks to establish a bond of trust and commitment with patients from the moment they are admitted, which favors the development of a nursing care plan.Thus, the nurses established a propellant contact for provision of care, in line with embracement guided by listening, valuing the complaints of the individual and their family, and identifying their needs, respect for differences, creating dialogue and relationship between the patient and their family and the nurse 12 .
However, the mandatory use of institutional pajamas, as observed in the unit for compulsory hospitalization for safety reasons, even for a limited period of time and justified by a policy for patient protection, may be indicative of ongoing attitudes of depersonalization and disempowerment that degrade the patient.The vulnerability of individuals with mental illness places them in an unequal position in relation to others, and which requires nurses to orient their work according to the principles of non-maleficence and beneficence and the balanced use of the rights to freedom and safety 13,14 .
The balance between the routine use of these principles and respect for individuality and autonomy of all patients proved to be ongoing challenges to nursing when exercised in an institutionalized environment, especially psychiatric institutions, as observed in this study.It should be noted that this situation was worse in the service that received patients by compulsory admission, since patients assumed a double stigma as being mentally ill and perpetrators of a criminal offense.

Nursing care plan
As described above, in all of the mental health services observed, embracement enabled the systematization of nursing care, and therefore the development of a nursing care plan.
In the community service, nursing care was directed and guided by a project coordinated by a professor from a school of nursing, along with students specializing in mental health.The nursing care plan sought to provide activities that promoted the stabilization and psychosocial rehabilitation of people with mental illness, and also offered support to families.To this end, nursing consultations were carried out using validated scales used in scientific circles (Quality of Life Scale (QLS); WHOQOL-BREF, PANSS, LSP and LSP-39, Portuguese version) to identify the needs of individuals and families, and further develop strategies that benefit the quality of life of these subjects.Among the strategies most used, the following stood out: inclusion in compatible age groups, relaxation and offer of guidance on drug therapy, and other matters that relate to the health of the individual (alcohol or drugs, work, leisure, family relationships, etc.).Individual and group psychoeducational activities were carried out for family members, and, from time to time, patients and their families were reevaluated using the structured instruments mentioned above.
In line with the objectives of the day hospital, the nursing care plan was focused on actions that encouraged the psychosocial rehabilitation of patients.For example, training for relaxation, distribution of prescribed drug therapy and guidance on correct use of medicines; psychological education and social skills training were the specific responsibility of nurses.There were also activities that took place with the participation of all professionals, such as assembly-type meetings, health education and recreational activities such as karaoke.
To compose the care necessary to meet the demands of the unit for compulsory hospitalization due to safety reasons, the nursing care plan prioritized the safety of patients and those around them (for newly admitted) and psychosocial rehabilitation (for those that were already inserted into the routine proposed).In this context, nursing care activities included health education; monitoring in proposed community outings; administration of prescribed medications; assessment of clinical and psychological conditions; identification of need for medical assessment by other specialists, with subsequent scheduling of these consultations with the public health care service; completion of evaluation of degree of dependence; rigorous evaluation of suicide risk, particularly among people who have murdered close relatives; confirmation of medications sent by the pharmacy service, based on the prescription and, if necessary, contact with the service for necessary adjustments; and registration in the clinical and information records of the nursing team on the next shift on care to be prioritized for each hospitalized patient.
So that the patients hospitalized in the general hospital were not removed from their social lives, and emphasizing the need to provide intensive care to this demand, which is in an acute phase of illness, the nursing care plan included the following actions: encouraging bathing and other personal care actions that the patients could self-administer; providing personal care and bed bath to hospitalized patients who were bedridden; collection

Nursing and the exercise of human rights
Moll MF, Mendes AC, Ventura CAA, Mendes IAC of biological material for laboratory tests that require fasting; administering prescribed medication at breakfast; administering prescribed medications via injection, and examination of the conditions of venous punctures and, if necessary, installation of serum therapy prescribed by the physician; encouragement of patients to use leisure devices, religion and the gardens around the hospital; performance of clinical assessments, risk of falls and degree of dependence; registration in medical records of the clinical development of each patient, and reception of visitors, providing them with freedom and comfort during visits, which have flexible hours, with children being allowed to visit due to the low rate of hospital infection in this inpatient unit.
It was found that in all health services that were observed, care was guided by plans that valued respect for human dignity in all its dimensions, exercised the right to health and, consequently, comprehensiveness and equity in access to mental health care.
From the perspective of comprehensive mental health care, it is necessary to follow a care plan that includes actions such as embracement, initiative, creativity and the establishment of affective and social bonds 15 .From the considerations of the authors of this study, they perceived that the nurses working in adult mental health services valued the care plan for provision of care, developed based on the embracement, when the patient's needs were evaluated, and extended to the structuring of social inclusion.The observations showed that the integration of nursing professionals with patients aimed at the construction of a therapeutic relationship with a multidimensional focus that not only considered the mental illness, but the individuals' suffering from this as human beings.
After presentation of the actions proposed in the nursing care plans of the adult psychiatry services, it was shown that only the community service valued the extension of care to family members, which propelled the structuring of the following theme, emphasizing the approach of the family.

Family approach
In the community services, consideration of the approach of the family took place starting in primary care, and family members were assisted by nurses who inserted them into the therapeutic plan, since the family environment and relationships were essential to the recovery and stabilization of people with mental illness, as well as their social integration.
It was observed in the day hospital that there was no systematic activity for families; instead, family members were contacted by social workers when they needed to understand the patients' history.
As in the day hospital, in the unit for compulsory hospitalization for safety reasons, there were no actions structured for family members of patients.However, visits were permitted with no restrictions on time or location in the hospital premises.Regardless, there were few visits, a fact that may be related to family's discrimination and judgment against the criminal act that was committed by their member hospitalized in the institution.In this sense, the data from the present study indicated that illegal acts such as crimes and drug use made mental health services that meet this demand intensify interaction with patients' family members, to confront the social stigma of patients 16 .
Because of the flexible schedule and number of family members for visits to the general hospital, contact of nurses with family members was ongoing, as long as they attended, because there were also no systematic actions for approach of the family.
The reality of the family approach portrayed above confirmed that only the community service valued inclusion of the family in the care provided to patients with mental illness, which enabled the social inclusion of these subjects, since the family received the support needed for treatment, recovery and crisis prevention.
This highlights that in order to enable good results in providing nursing care, it is important that there is a close relationship between the person being cared for, their families and the nurse, which allows for comprehensive care, because it has been shown in the literature that nursing care is no longer based solely on technical care, and it is necessary to have a broad view to work on a team/community/family in order to better understand aspects that directly interfere in the health-disease process of the person in the environment in which they live 17 .
In Article 5, Portuguese mental health legislation holds that people with mental illness have the right to "communicate with the outside and be visited by family, friends and legal representatives, with limitations associated with the operation of services and nature of the disease" 18:3544 , and the recommendations and organizational guidelines of the National Mental Health Council reinforce the need to integrate families and communities into mental health care 19 .Therefore, it is important that the nursing care plan for all mental health services for adults is inserted into care of the family.
Based on this concept, it is important to present the social inclusion strategies developed by nurses, because they provide a more effective exercise of human rights, especially civil rights, that relate directly to the family context.

Social inclusion strategies developed by nurses
Whereas the nursing care plan should include social inclusion, this theme was developed to address these strategies in each of the adult mental health services observed for this study.
In the community health care service, there was no uniform strategies for social inclusion developed by nurses, since these strategies were proposed according to the needs identified and severity of pre-existing symptoms, as well as community resources present in the vicinity of the residence of each of the patients served.
A result of the care ideology of the day hospital, the nursing care plan prioritized social inclusion strategies, especially social skills training.The authors of the present study emphasize that the frequency of care at this hospital varied according to the needs of each patient, and this defined a treatment plan that was variable and depended on the evolution of each patient, as well as their integration and maintenance in social, employment and family activities, among others.

Nursing and the exercise of human rights
Moll MF, Mendes AC, Ventura CAA, Mendes IAC One strategy for social inclusion used by nurses at the unit for compulsory hospitalization for safety reasons was the organization of monthly trips for patients to tourist attractions and religious sites, in order to provide hospitalized patients contact with the outside world, promote their (re)integration into the community, and enable new experiences.Another strategy with the same purpose are administrative leaves that can last for up to three days (without the need for prior authorization by a judge).To this end, patients filled out an administrative leave form that was discussed in a multidisciplinary meeting, so that an opinion was issued by the professionals who were responsible for the care of the patient filing the request for leave.Then, the nurse responsible for the patient sent the opinion and established a verbal contract with the patient regarding their return to the hospital.If the patient wished to leave for more than three days, authorization of a judge was required in addition to that of staff.
In the general hospital, there were no systematic actions for social inclusion of patients.However, in this service there were physical spaces such as a games room, TV room, smoking room and dining room that encouraged contact between the people hospitalized there and academics from various professional categories that interned at the institution, as well as between the patients and staff.It is noteworthy that in the TV room there were two computers with Internet access, which seemed to facilitate patients' ability to maintain contact with their families, friends and lovers.Based on the existence of these computers, it was identified that the nurses always encouraged patients who had physical mobility get out of bed and do some activity.
Faced with the reality of such strategies for social inclusion, it can be concluded that the treatment plan established in these services stimulates, albeit partially, the maintenance of patients' ties with their social network.Patients' ability to participate in outings to tourist attractions, and other personal activities such as paying bills and making purchases, reinforced and respected the patients' right to come and go.The adoption of a policy for humanized care presupposes opposition to the violence of denying the other, and articulating technologies with the relationship, where the human factor is essential for the effectiveness of organizational health devices 20 .
Thus, in order to humanize care, it is essential to adopt a new ethic founded on philosophical grounds, that includes nursing care, through an attitude of understanding and action different from that used only in technical aspects, which requires the nurse to associate their knowledge of human rights with technical skills in their daily care routine.When incorporating this perspective of care into their work, the nurses should value autonomy, shared responsibility, the protagonist role of patients, solidarity between the bonds established, respect for the rights of users, and collective participation in the management process.Thus, instrumental reasoning opens space for sensitive and cordial reasoning, based on ethics, human values and complementarity in the managerial relationship 21 .
It is essential to stimulate individuals with mental illness to participate in activities that enable the (re)construction of life, both in terms of treatment and social life, through activities that strengthen citizenship 22 .
Based on the information presented above, this study shows that the reform movement in mental health has resulted in advances to protect the rights of people with mental illness in the international sphere, because it generated specific reflections on knowledge and current care practices aimed at eliminating exclusive interventions, and creating proposals focused on valuing human life, which is consistent with mental health care practice grounded in human rights principles 3 .
Currently, mental health services for adults in Portugal are based on the comprehensive care of patients, and, therefore, nurses offer interventions that value preventive, educational, social and care dimensions.However, the lack of systematization of nursing care for relatives of mental health patients may hinder this process, especially as regards the exercise of the right to health of the patients in the services studied.

FINAL CONSIDERATIONS
In conclusion, the present study identified that the provision of nursing care favors the exercise of the right to health for people with mental illness, that received care in adult psychiatric services in one town in Portugal.However, there is evidence that changes still need to be made in order to achieve the full realization of this right, emphasizing the importance of structuring actions for the relatives of persons that receive care in these services.Closer relationships are also needed between nurses and other professionals (social worker, occupational therapist, psychologist, etc.) that make up the support staff of mental health care services, so that knowledge can be accumulated and shared, along with practices that enhance human dignity.
However, the study also noted that there are care practices permeated with sensitivity for mental health patients and their condition, which demonstrated respect for human dignity in all services.Finally, it is important to emphasize that this characteristic of the profile of nurses can facilitate mental health patients' proactivity in society, as well as redefinition of their life.mainly through strategies for social inclusion of the mentally ill.