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Revista Portuguesa de Enfermagem de Saúde Mental

versão impressa ISSN 1647-2160

Revista Portuguesa de Enfermagem de Saúde Mental  no.15 Porto jun. 2016

http://dx.doi.org/10.19131/rpesm.0133 

ARTIGO DE BOAS PRÁTICAS

 

Reasoning and planning of therapeutic occupation activities

 

Raciocínio e planificação de atividades de ocupação terapêutica

 

Razonamiento y planificación de actividades de ocupación terapéutica

 

Carlos Melo-Dias*, Amorim Rosa**, & Alberto Pinto***

*Enfermeiro Especialista em Enfermagem de Saúde Mental e Psiquiátrica; Mestre em Ciências de Enfermagem; Doutor em Enfermagem; Investigador na Unidade de Investigação em Ciências da Saúde: Enfermagem; Investigador no Portugal Centre for Evidence-Based Practice: an Affiliate Centre of the Joanna Briggs Institute; Professor Adjunto na Escola Superior de Enfermagem de Coimbra – Pólo B, Unidade Científico-Pedagógica de Enfermagem de Saúde Mental e Psiquiatria, Rua 5 de Outubro, Apartado 7001, 3046-851 Coimbra, Portugal. E-mail: cmelodias@esenfc.pt

**Enfermeiro Especialista em Enfermagem de Saúde Mental e Psiquiátrica; Investigador na Unidade de Investigação em Ciências da Saúde: Enfermagem; Professor Adjunto na Escola Superior de Enfermagem de Coimbra – Pólo A, 3046-851 Coimbra, Portugal. E-mail: amorim@esenfc.pt

***Enfermeiro Especialista em Enfermagem de Saúde Mental e Psiquiátrica; Investigador na Unidade de Investigação em Ciências da Saúde: Enfermagem; Professor Adjunto na Escola Superior de Enfermagem de Coimbra – Pólo A, 3046-851 Coimbra, Portugal. E-mail: mpinto@esenfc.pt

 

ABSTRACT

BACKGROUND: Psychosocial rehabilitation offers the patient the opportunity to reach the maximum functioning potential in community while performing physical, emotional and intellectual skills. Therapeutic Occupation Activities are systematic activities which structure and guide the participant's functional performance, within the interpersonal nurse-client relationship, and empowering for autonomy and promoting satisfaction and accomplishment in both occupation and recreation.

AIM: To explore the reasoning and planning that substantiates the Therapeutic Occupation Activities (TOA’s) in Mental Health and Psychiatric Nursing.

METHODS: Using a concept-based design, the methodological step-by-step framework to build the reasoning will be described as well as the planning which substantiates the Targeted Nursing Interventions (TNI) on TOA’s will be described.

CONCLUSION: The clinical reasoning in Nursing allows for an updated, adaptive, sensitive and constructive decision-making. The various domains in which the TOA’s are developed reveal the holistic nature of the intervention and the impact of Nursing in the individuals’ life and health. The preservation of the optimal well-being and the prevention of relapses and long hospital stays are ultimate therapeutic indications which expand the philosophies of care and lead to achievable benefits, such as the feeling of social utility and the building up of self-esteem and self-image of those involved. The implications for the clinical practice derive from the association between social functioning and personal satisfaction, positive and corrective reinforcement in performance, and from consistency and proportionality of modelling, assertiveness and generalization. The use of clinical indicators consistent with and sensitive to the Nurse's intervention has a clinical influence on the participants’ performance and outcomes.

Keywords: Therapeutic occupation activities; Psychosocial rehabilitation; Reasoning; Targeted nursing interventions

 

RESUMO

INTRODUÇÃO: A reabilitação psicossocial oferece ao doente a oportunidade de atingir o máximo potencial de funcionamento na comunidade, desempenhando habilidades físicas, emocionais e intelectuais. As Atividades de Ocupação Terapêutica são atividades sistemáticas que estruturam e dirigem o desempenho funcional do participante, enquadradas na relação interpessoal enfermeiro-cliente promovendo e habilitando a autonomia e satisfação na ocupação e na recreação.

OBJETIVO: Expor o raciocínio e decisão da planificação de Atividades de Ocupação Terapêutica (AOT) em Enfermagem de Saúde Mental e Psiquiátrica.

METODOLOGIA: Suportado concetualmente, reflete-se passo-a-passo a construção do raciocínio e da planificação necessários à preparação das Intervenções de Enfermagem Focadas (IEF) em AOT’s.

CONCLUSÃO: O raciocínio clínico em Enfermagem permite gerar decisões atualizadas, adaptativas, sensíveis e construtivas. Os diversos domínios em que as AOT se desenvolvem expõem o carater holístico da intervenção e impacto da Enfermagem na vida e saúde das pessoas. A manutenção do máximo bem-estar e a prevenção das recaídas e hospitalização prolongada são extremos das indicações terapêuticas e expandem as filosofias de cuidados, gerando benefícios alcançáveis, desde o sentido de utilidade social à edificação da autoestima e autoimagem de todos os envolvidos. As implicações para a prática clínica decorrem principalmente da associação do funcionamento social à satisfação pessoal, do reforço positivo e corretivo no desempenho, e ainda da coerência e proporcionalidade da modelagem, assertividade e generalização. A utilização de indicadores clínicos sintónicos e sensíveis à intervenção do Enfermeiro implicam-se clinicamente no desempenho dos/as participantes e nos resultados.

Palavras-Chave: Atividades de ocupação terapêutica; Reabilitação psicossocial; Raciocínio; Intervenções de enfermagem focadas

 

RESUMEN

INTRODUCCIÓN: La rehabilitación psicosocial ofrece al paciente la oportunidad de conseguir el máximo potencial funcional en la comunidad, poniendo en práctica las habilidades físicas, emocionales e intelectuales. Las Actividades de Ocupación Terapéutica son actividades sistemáticas que estructuran y dirigen el desempeño funcional del participante, en la relación interpersonal enfermero-cliente, que potencian la autonomía, promueven la satisfacción y el éxito tanto en el ámbito profesional como en el recreativo.

OBJETIVO: Estudiar el razonamiento y la planificación de las Actividades de Ocupación Terapéutica (AOT) en Enfermería de Salud Mental y Psiquiátrica.

METODOLOGÍA: Con base en un diseño conceptual, se expone paso a paso el razonamiento y la planificación de las Intervenciones de Enfermería Focalizadas (IEF) necesarias a las AOT.

CONCLUSIÓN: El razonamiento clínico en Enfermería permite tomar decisiones adaptativas, sensibles y constructivas. Los diversos dominios en los que las AOT se desarrollan revelan el carácter holístico de la intervención y el impacto de la Enfermería en la vida y salud de las personas. El mantenimiento del máximo bienestar, la prevención de las recaídas y la hospitalización prolongada son la suma indicación terapéutica que da lugar a beneficios alcanzables, como el sentido de la utilidad social y la construcción de la autoestima y la autoimagen. Las implicaciones para la práctica clínica provienen de la asociación entre el funcionamiento social y la satisfacción personal, del refuerzo positivo y correctivo en el desempeño, y de la coherencia y la proporcionalidad del modelado, la asertividad y la generalización. El uso de indicadores clínicos coherentes y sensibles a la intervención del enfermero tiene una influencia clínica en el desempeño y los resultados de los/las participantes.

Palabras Clave:Actividades de ocupación terapéutica; Rehabilitación psicosocial; razonamiento; Intervenciones de enfermería orientadas

 

Introduction

The psychosocial rehabilitation offers the opportunity to reach the maximum potential for independent functioning in the community, teaching the patient how to perform the physical, emotional, and intellectual skills necessary for leading an autonomous life with the highest level of well-being possible (Melo-Dias, Rosa & Pinto, 2014).

The Therapeutic Occupation Activities (TOA’s) are defined as systematic and organized activities that structure and guide the functional performance of the participant within the interpersonal nurse-client relationship and the assessment of the Fundamental Human Needs (FHN). Nurses make use of therapeutic techniques which are selected and prescribed according to the intended objective(s), with psychotherapeutic, psychoeducational, psychomotor, psychosocial, socio-therapeutic and spiritual consequences. They aim to promote, prevent, empower, maintain and/or recover and develop the individual's skills so as to reach their maximum potential for performance, autonomy and satisfaction of their FHN, daily activities, and occupation for achievement and recreation (Melo-Dias, Rosa &Pinto, 2014).

Clinical reasoning in nursing practice is a thinking process based on (theoretical and practical) knowledge and (professional and personal) experience. It integrates the complexity, reflexivity, creativity, intuition and cognition of the nurse, the client and the context so as to systematically select, compare, test, infer and decide on the clinical evidences of the patient’s clinical path, thus leading to decisions and conclusions (Melo-Dias e Lopes, 2010; Melo-Dias e Lopes, 2011).

The clinical decision and reasoning process underlying the TOA’s in Mental Health and Psychiatric Nursing corresponds to treatment choices in which the therapist, based on the available possibilities and options, builds a model/type of activity directed toward the client(s) and respective needs, while respecting the scientific, ethical and esthetical principles (Melo-Dias, Rosa, e Pinto, 2014).

 

Aim

The purpose of this article is to explore the reasoning and planning underlying the Therapeutic Occupation Activities in Mental Health and Psychiatric Nursing.

 

Background

Fields of Use of Therapeutic Occupation Activities

The TOA’s may be clinically relevant and decisive in the following domains: Personal and Domestic, Recreation and Leisure, Self-Expression, Psychoeducation, Health Education and Interpersonal Relationships.

All these domains comprise two dimensions: the temporal dimension and the environmental dimension. The temporal dimension includes the age, the developmental stage and its role in this phase of life of individual; the environmental dimension encompasses the structural, social and cultural variables of the individual’s micro/macro environment.

 

Key Features of Therapeutic Occupation Activities

The following are key features of these Nursing Activities (Figure 1):

 

 

The Nurse’s Role

The nurse's therapeutic role in the TOA’s implies a scientific intervention in the health area and requires excellent interpersonal skills, knowledge of the cognitive-behavioral therapies, enthusiasm with his/her work, resilience to perform thorough procedures with negligible/minor situational feedbacks and also the ability to use feedback and feedforward processes (Decreto-Lei n.º 161/96; Melo-Dias, Rosa, e Pinto, 2014; Sampaio, Sequeira, & Lluch-Canut, 2014).

From a well-defined and diversified set of general principles, the following are highlighted: self-awareness even during the therapeutic relationship, the ability to provide encouragement, flexibility in adaptation and the promotion of harmony between the professionals working with the client (Melo-Dias, Rosa, e Pinto, 2014, p. 16).

This active role inevitably includes the management of the therapeutic environment (as milieu therapy) and is interpreted in TOA’s in their structure and dynamic dimension. The structure and facilities are managed within the classic variables (eg. temperature, space, equipment’s ...). In the dynamics of interaction between the different participants, we have the strategies and methods intrinsic to TOA's, which confer, shape and ensure the management of personal and social functioning of participant in a therapeutic manner.

 

Autonomous Nursing Interventions

Nursing clinical practice is focused on the interpersonal/therapeutic relationship between a nurse and an individual/group, which is distinguished by the training and experience of the nurse who develops his/her skills in a partnership (Ordem dos Enfermeiros, 2001). Therefore, as autonomous interventions, the nurses are responsible for prescribing and implementing the TOA’s.

 

Receptive, Processing and Sending Skills

The following tree types of skills are identified: Receptive Skills (to interpret relevant cues or signals efficiently); Processing Skills (to assess the information received, the objectives and the planning of a behavioral response); Sending Skills (adequate verbal, non-verbal and paralinguistic behaviors) (Coelho e Palha, 2006).

 

About Reasoning

In “Social Learning”, the consequences of the behavior affect its repetition, and the observation of external models accelerates the learning process more than if that behavior had been performed by the “apprentice” himself/herself. This assertion is based on the four determinants: 'Attention Process'; 'Retention Process'; 'Reproduction Process'; and 'Reinforcement Process'.

Observation is also a key process in the TOA’s. Although it does not have an end in itself, this process is subject to each individual and their complex processes of bringing intelligibility to reality, providing the necessary empirical data for further critical analysis and critical assessments (Melo-Dias, 2009).

 

Virginia Henderson's Nursing Need Theory

In the Virginia Henderson's model, the concept of “Need” is defined as vital for the individual, who will have to meet his/her needs in order to preserve his/her physical, psychological, social or spiritual balance, thus ensuring his/her development and growth (Phaneuf, 2001).

The satisfaction of needs shows a relative variation in an independence/dependence continuum, depending on the level (quality/quantity) of help that the person requires or needs (Table 1).

 

 

About the Planning Process

The human responses to development and disease processes, and also the length and type of hospital stay, the cultural and demographic characteristics, the life projects and expectations, the disruptions caused by the new roles, the pain and the (physical, mental and social) suffering, the adaptation difficulties, and the cognitive impairment have a general and specific influence on the design of nursing interventions in TOA’s (McGurk et al., 2013; Melo-Dias, 2014; Rainforth & Laurenson, 2014). Also, the Nurse, as leader and rater is in a position of co-territoriality, because is emotionally and rationally integrated in the situation, while maintaining a technical distance (Melo-Dias, 2009).

 

Determinants of Therapeutic Occupation Activities in Mental Health and Psychiatric Nursing

There are several key variables that determine the type of TOA to be prescribed, such as: Stigma, Standards and Philosophy of Care, Nurses' Motivation, Funding Difficulties, Emotional and Behavioral Deficits, Impaired Communication Skills, and Learning difficulties.

The therapeutic indications for prescribing TOA’s in Mental Health and Psychiatric Nursing (MHPN) are (Figure 2):

 

 

Benefits of Therapeutic Occupation Activities in Mental Health and Psychiatric Nursing

 

The following benefits for the clients are correlated with the specific objectives (Figure 3):

 

 

Methods, Reasoning and Clinical Decision

The clinical reasoning and decision process applied to TOA’s in MHPN corresponds to the treatment decisions and choices, in which the therapist builds a model/type of activity directed toward the client(s) and respective needs, while taking into account the available possibilities and choices and respecting the scientific, ethical and esthetical principles (Melo-Dias, Rosa, e Pinto, 2014).

The planning of TOA’s is focused on the individual needs, while respecting preferences and lifestyle and concomitantly maintaining the clinical appropriateness on a properly informed client, thus ensuring its therapeutic potential and clinical utility.

 

Basic Framework Design

It will always be possible to develop various designs, tables or summary schemes to plan TOA’s; however, in order to ensure a quick and effective consultation by the TOA’s’ Team Nurses a transversal design to all activities is recommended.

The following scheme shows the step-by-step methodological process to plan the TOA interventions (Table 2).

 

 

Title / Theme

100% Creativity + 100% Specificity. It will be read by several audiences: health care professionals, potential clients and other interested parties (e.g., the family). The title will be descriptive, represent the activity which will be performed and, at the same time, captivate participants.

 

Place, Date, Time and Duration

Setting a time and place will ensure that the activity is properly integrated in the dynamics of the health care team. The item “duration” should take into account the participants' invitation, the immediate preparation of the environment, and the duration of the activity itself.

 

Aim (Overall Objective)

The objectives of the TOA’s need to be previously outlined, as they are structural activities aimed towards the individual’s functional performance which is partially or totally impaired.

This section presents the Nurse’s main purpose of developing the TOA session/s.

Example: To Promote… to Empower… to Improve ... to Reduce… or to Develop…

 

Specific Objectives of the Participants

The specific objectives are focused on the participant and his/her performance, behavior, action and functioning, which are inherent in the Sensorimotor, Cognitive, and/or Psychosocial dimensions. By associating social functioning and personal satisfaction, the definition of objectives will enable the participants to be successful in every session.

It is always complex to turn a desire into an intention and, in turn, that intention into the actual fulfilment of the objective(s), a process which should necessarily take into account the degree of desirability and feasibility.

This equation becomes even more complex when the objectives are outlined by others. As a result, the Nurse should evaluate together with the client the willingness to perform the action, making sure he/she has understood the purpose of the objectives. The Nurse takes on the responsibility of supporting the client in case of anxiety about the unknown and anxiety related to the emotional demands of the experience and the client's perception and understanding that the situation may or not be out of her/his control.

As a general rule, the objectives should be quantifiable/ measurable and explain what is intended to be reached within a given period of time.

The following SMART mnemonic is acknowledged as effective: S= Specific, M=Measurable, A=Attainable, R=Realistic, T=Timebound (Doran, 1981).

There are three key dimensions for objectives construction/creation: Coherence and integration in the proposed activity; Proportionality between the expected results and the available time and resources; and Focus on the priority/main results of the performance (Melo-Dias, 2012).

 

Participants: Selection Criteria

Whenever possible, inclusion and/or exclusion criteria are established to support and ensure the therapeutic dimension of the TOA.

It is important to have a deep knowledge about the participants to select them, namely through a previous assessment of their FHNs, preferences and lifestyle.

There are some decision principles that should also be respected. First, the criteria should not be excessively strict, for instance, to facilitate the participation of clients who may have “borderline level” skills. Second, the criteria should ensure balance among the group of participants, for example by selecting those who will benefit from the activity in the short and in the long term and those who have different skill levels. Third with inclusion one mean tuning base skills between clients, so the activity is thus developed in pairs or subgroups, bringing together more and less skilled participants, in order to potentiate and empowering both. Fourth with exclusion one mean the assumption that in that clinical moment participation on TOA didn’t constitute therapeutic benefit for that specific client. Finally, could be pertinent the definition of the maximum amount of clients participating in TOA session, to be fitted with the areas of facilities and equipment’s, and also because of the management response to ensure the success of the activity with all and each one of the clients.

 

Necessary Resources

The resources can be analyzed from a simpler perspective (like academic learning environment) to a more complex one (like organizational environment and/or calls for funding/tenders).

The selection of the available resources to support the performance of the activity, as well as its continuity (if that is the strategy), depends on that level of complexity, ensuring always an sustainable cost-benefit balance.

There diverse resources could be human, proficiency, materials, equipment, structural, financial and organizational resources.

 

Methodologies and Strategies

The task of explaining objectives and actions to another person requires that those explaining them have both the ability to adequately analyze the skills and motivations of those who will be accomplishing them, and the ability to communicate in a consistent and coherent way with that analyzes. Within this process, the nurse-client relationship should be as consolidated as possible in order to consume less energy in the persuasion process of both performers: nurse and client, and consume more energy on the client to accomplish goals.

Patients can learn relatively complex material despite their transitions of health and illnesses, as also can meaningfully improve the continuity of their own care by participating in these structured recovery and development programs (Melo-Dias, 2015).

These Targeted Nursing Interventions (TNI) comprehend the action Nurses make by identifying and focusing its interventions direct toward the core areas of client functioning/performance, such as interpersonal relationship, burden of symptoms, cognitive functioning, coping with disease and treatments, generalization and social integration, contributing to reduce and/or problem resolution.

The implementation of the activity using the teaching-learning methodologies together with the human resources/space management and decision-making strategies is presented by chronological order of use. Every stage of implementation of the TOA will be described with the necessary details (it may even include the estimated duration of each stage), so as to enable its replication and continuity in similar settings and with similar participants.

Example of Methodologies: Oral presentation, Brainstorming, Simulation.

Example of Strategies: Modeling, Assertiveness, Coaching, Generalization.

 

Assessment Indicators

The participants' performance is assessed through criteria or indicators in line with specific objectives sensitive to the Nurse's intervention, translating into clinical quantitative/qualitative results (Melo-Dias, Rosa, e Pinto, 2014).

The selected indicators arise from the specific knowledge and experience put into the intervention by each Nurse (or team).

·         Calculations (solving stages/steps).       

Example: How many self-massage steps did perform? How many breathing cycles per minute?

·         Dichotomous answers (two mutually exclusive alternatives).

Example: Says the person’s name, yes or no; Throws the ball, yes or no?

·         Levels of performance and/or behavioral expression.

Example: What is level of anxiety observed: mild, moderate, high?

Example: In the six-level dependence-independence continuum, what is the current level regarding the need x / problem x / focus of attention x? (Phaneuf, 2001).

According to Moorhead, Johnson, Maas, and Swanson (2010), a nursing outcome indicator is a specific variable that is responsive to a nursing intervention. It corresponds to a state, behavior, feeling or expression of observable perceptions or assessments reported by the client classified in a specific level. Each outcome is assessed on a five-point Likert type scale that quantifies a continuum from least desirable (1), to most desirable (5), and provides a rating at a point in time.

The following are examples of NOC outcomes: Interacts with other appropriately; Expresses emotions during play activities; Difficulty concentrating; Verbalized anxiety; Irritability; Respiratory rate; Pulse pressure; Verbalizes a coherent message; Handles written communication; Recalls immediate information accurately; Self-initiates goal-directed behavior; Engages in effective exercise routine; Performs tasks or activities; Walks with effective gait.

The following is an example of a Likert scale: Extremely compromised=1; Substantially compromised=2; Moderately compromised=3; Mildly compromised=4; Not compromised=5.

The indicators are sensitive to Nursing interventions, enabling Nurses to document the effects of their interventions and to be individually and collectively held accountable for the care delivered to patients (Moorhead et al., 2010, p. 71).

Open-ended questions. Advantages: (free) expression of the participant; indicate that the trainer is interested in the participant’s opinion; increase the participant’s share of responsibility in the assessment. Disadvantages: increase complexity in analyzing the answers (content analysis); subjectivity (with personal content); require writing and reflection skills; and require more time spent writing the answer.

 

Ethical Aspects to be Considered

The free informed consent is the core concept in these relationships. Although it coexists with a typical environment of tensions, these should be aimed towards continuing to build a free, democratic and pluralist society based on an agreement established between those who are part of it (Melo-Dias, 2003).

The Nurse's interventions are concerned with protecting the freedom and the dignity of the human being and the Nurse. Thus, responsible freedom and the capacity of choice aiming at the common good are universal values to be pursued in the professional relationship (Decreto-Lei n.º 104/98).

The informed consent may be an autonomous action or an institutional authorization. In this case the focus is on the “autonomous action”, for it gives the Nurse permission to intervene (or to investigate) with a therapeutic plan, complying with the following conditions: (a) a reasonable knowledge of the client; (b) the absence of third party control; (c) the client's intentionality, and (d) the permission for Nurse’s action (Melo-Dias, 2003).

Regarding the ethical aspects to be considered in the TOA’s (as in other Nursing interventions), we believe that an informed consent requires more than a mere signature; it entails the acknowledgement of the client’s autonomy and of a free, voluntary and intelligent decision made by an autonomous adult person in full possession of his/her mental faculties, giving permission for something proposed by another person to be accomplished (Melo-Dias, 2003). Therefore, we have two forms of expressing consent: tacit consent (the client's behavior or verbalizations express his/her approval) or express consent (documentary expression of consent).

 

Persons Responsible for the Activity

This section is important to hold the nurses accountable for the technical-scientific procedures responsibility, both when leading the session and when assessing the participants' performance.

 

Conclusion

Therapeutic Occupation Activities (TOA) are organized to promote, prevent, enable, maintain and/or recover and develop the individual's skills to holistically express his/her Fundamental Human Needs (FHN), thus responding to nursing problems / focus of attention. These activities are prescribed, implemented and assessed by nurses based on the nursing diagnoses and clinical reasoning (Melo-Dias, Rosa, e Pinto, 2014).

The clinical reasoning emerges in the complexity, reflexivity, creativity, intuition and cognition of the nurse, client and context, making it possible to draw updated, adaptive, sensitive and constructive decisions, leading and implementing Targeted Nursing Interventions (TNI).

The various areas in which the TOA’s are developed reveal the holistic nature of the intervention and of the impact of Nursing in people's lives and health.

The Nurses' interpersonal skills manage feedback and feedforward processes in a therapeutic relationship of encouragement, flexibility and adaptation, aiming for the maximum functional adaptation through cognitive, behavioral, and affective learning processes.

The preservation of the maximum level of well-being and the prevention of a long hospital stay are the two extremes of the TOA’s' therapeutic indications.

The TOA’s are a key therapeutic tool for the Nurse in MHPN, and try to expand the limits of the stigma and the existing philosophies of care and lead to a wide variety of achievable benefits from the feeling of social utility to the building of self-esteem and self-image of those involved: patient, family, nurse and other professionals (Melo-Dias, Rosa, e Pinto, 2014; Carvalho, 2012).

In psychosocial rehabilitation, the TOA’s improve symptomatic and functional outcomes by teaching relapse prevention skills to patients and their caregivers and reducing vulnerability through the improvement of functioning areas such as interpersonal relationships, psychosocial functioning, burden of psychotic symptom, health, cognitive functioning, empowerment, long-term competitive work/employment/occupation, and quality of life (Mueser & Gingerich, 2011; VanMeerten et al., 2013; Svedberg, Svensson, Hansson, & Jormfeldt, 2014).

Benefits in improved functioning revealed also that the implementation of these psychosocial rehabilitation programs to persons who had been hospitalized was associated with decreased duration of hospitalizations and costs savings of all inpatient that had participated (VanMeerten et al., 2013; Melo-Dias, 2015).

It is also important to emphasize the use of indicators in tune and sensitive to the Nurse's intervention and translated into quantitative/qualitative clinical results. They enable the Nurses to document the effects of the interventions made available to the clients (Melo-Dias, Rosa, e Pinto, 2014; Bulechek, Butcher, Dochterman, & Wagner, 2013; Moorhead et al., 2010; de Cordova et al., 2010), while holding them accountable for the technical-scientific procedures responsibility, and also of crucial impact on social media exposure of Nursing autonomous outcomes.

 

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Recebido em 20 de maio de 2015

Aceite para publicação em 30 de maio de 2016

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