Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.61-69 61 Empathy in Mental Health Nursing Care in Brazil Samyra Fernandes Gambarelli1, Christian Marx Carelli Taets2, Gunnar Glauco De Cunto Carelli Taets2* 1Federal Fluminense University, Brazil 2Federal University of Rio de Janeiro, Brazil Corresponding author: master@ufrj.br ABSTRACT Background: Empathy, from the Greek empathetic means to enter into the feeling, a term initially used by aesthetic theorists, to designate the ability to perceive the subjective experience of the other. For empathy to occur as a therapeutic process, it is essential that a relationship of mutual respect be developed and that nurses provide individualized care, respecting the culture, beliefs and values of the person. Purpose: This study aimed to determine to know and characterize the scientific production on Empathy in Mental Health Nursing Care in Brazil. Methods: This is a metasynthesis performed in the first half of 2018 that involved five stages: formulation of the problem, data collection, evaluation of the collected data, analysis and interpretation of the data, and presentation of the results. Results: Of the 6 studies that were part of this metasynthesis, the method most used among the forms of treatment among the health professional/patient is the biomedical model, focusing on the disease and not on the human being in a broad and holistic way, consequently, being performed only one punctual care and not a care in order to meet all the biopsychosocial needs of the patient. Conclusion: As a way to improve care and meet the patient's needs, empathy is one of the main tools of mental health care in Brazil, because with it we can gain trust and establish bonds with the patient, thus gaining an effective relationship for both parties, thus being able to perform an affectionate, integrative and productive care. Keywords: Empathy, Nursing, Mental Health. Received July 14, 2020; Revised July 30, 2020; Accepted August 15, 2020 DOI: https://doi.org/10.30994/jnp.v4i1.109 The Journal of Nursing Practice, its website, and the articles published there in are licensed under a Creative Commons Attribution- NonCommercial-ShareAlike 4.0 International License. mailto:master@ufrj.br https://doi.org/10.30994/jnp.v4i1.109 Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.61-69 62 BACKGROUND The Brazilian psychiatric reform began in the late 1970s, as a social movement and scientific field. Psychosocial Care Centers (CAPS) are the equipment that organizes the mental health network and aims to replace the numerous hospital beds of the asylum model. On a territorial and community basis, CAPS serve people with severe and persistent mental disorders (LEAL, 2007). In this new paradigm of care, it is essential that the professional is willing to contact the experience lived by the client, guiding his care for it. Empathy, from the Greek empathetic means to enter into feeling, a term initially used by aesthetic theorists, to designate the ability to perceive the subjective experience of the other (GOLEMAN, 1995). For empathy to occur as a therapeutic process, it is essential that a relationship of mutual respect be developed and that nurses provide individualized care, respecting the culture, beliefs and values of the person. The main therapeutic tool of nurses is the use of oneself in the interpersonal context. Empathy is a skill that can be performed with the user verbally and non-verbality. Its development is extremely important when we propose to help someone. Therefore, it is necessary that the professional is willing to know the potentialities and limitations of both his or her and the user's own in order to provide the necessary therapeutic nursing care. Fish & Shelly (1986, p. 110) define empathy as the "ability to understand what a person is feeling and transmit understanding to him, while maintaining a certain objectivity to be able to provide the necessary help". Also, according to these authors, two other elements can be evidenced in an interpersonal relationship. One of them, sympathy, that first contact, first look, first smile. The other, intellectualization, where data are observed and collected objectively, without getting involved. They state that only when feelings and facts are placed side by side and objectively analyzed will they discover the cause(s) of the client feeling how he/she feels; we can then provide the necessary help, that is, act with empathy. Often the professional-user relationship is close and considered a one-way street, where the subject does not have active participation in his own treatment, being only the object of study that needs to follow guidelines without having the right to question what may be better for himself or seek solutions together with the professional, thus providing an open, continuous dialogue that will make both, co-responsible for the therapeutic process. The theme was chosen due to recognizing the need and importance of empathy as a light care technology, so that it contributes to interpersonal relationships, enabling the user to share feelings and desires. Thus, the health professional is able to develop a look from the perspective of the user intervening effectively and effectively. In the field of mental health, according to Peixoto (2016), empathy allows a better understanding of the user experience, favoring the professional-user relationship and care. However, various forms of psychopathology, cultural, religious and social differences present themselves to it as an obstacle. The failure of empathy can weaken the bond with the user, thus preventing the construction of a therapeutic relationship. OBJECTIVE This study aimed to determine to know and characterize the scientific production on Empathy in Mental Health Nursing Care in Brazil. METHODS This is a metasynthesis performed in the first half of 2018 that involved five stages: formulation of the problem, data collection, evaluation of the collected data, analysis and interpretation of the data, and presentation of the results. Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.61-69 63 The formulation of the problem was characterized by the guiding question: how is the use of empathy in mental health nursing care characterized in scientific production? For data collection, the Scientific Electronic Library Online (Scielo) and Virtual Health Library (VHL) databases were used. Through the descriptors: empathy, mental health, nursing care. In the VHL, 1321 articles were found. The following filters were applied: full text, year of publication 2012 to 2017 and language Portuguese. Six articles were found, where repeated articles were excluded, totaling 3 articles in the VHL database. Through the descriptors: "empathy" and "nursing care" in Scielo, 47 articles were found. We apply the following filters: language Portuguese, year of publication 2013 to 2017. We found 15 articles, where repeated articles were excluded, totaling 14 articles in the Scielo database. Through the descriptors "nursing care" and "mental health" in Scielo, 182 articles were found. We apply the following filters: language Portuguese and year of publication 2013 to 2017. We found 37 articles, where repeated articles were excluded, totaling 35 articles. The search resulted in 3 articles in the VHL and 49 articles in Scielo, being careful reading of the articles to verify the approximation with the proposed theme, 6 articles were selected for analysis and discussion. The methodological path followed by being visualized through Figure 1 Figure 1. Methodological path traveled, 2017. Sources of researchers.. RESULTS To organize the information of the articles, a synthesis of the main information of each study was performed in a table that contains the following topics: title, author, year, type of study and a brief summary of the study (Chart 1). It was possible to observe the need for strategies and tools that contribute so that health professionals, especially nurses, can assist the service user with more empathy, that is, in the way they would like to be assisted or cared for. Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.61-69 64 Table 1: Title Author Year Type of Study Synthesis Article 1 The affective touch in the nurse's vision Days AB, et al. 2008 Analytical- descriptive with qualitative approach The objective of this study was to investigate the nurse's conception of affective touch as a tool for the promotion of care and to identify its meaning in nursing care and the moment where it is used as a care instrument. Through data analysis, the use of affective touch was demonstrated strictly during invasive procedures, even considering it an effective instrument to establish empathy. Article 2 Nursing Care and Jean Watson: A reflection on empathy Savieto RM, Lion ER 2016 Theoretical- reflective It relates empathy with the Theory of Human Care in the current context of nursing. It proposes a discussion about empathy and its relationship with the Theory of Human Care, by Jean Watson, in contemporary practice of Nursing. It is imperative to combine technical and humanistic aspects in the provision of nursing care, in addition to rescuing the appreciation of the empathy approach in the education of health professionals, as well as in the continuity of studies after graduation. Article 3 The Permanent Education Of The Nursing Team For Care In Mental Health Services McM Tavares 2006 Exploratory- descriptive It analyzes the need for permanent education of the nursing team to care for mental health services. It was found that the mental health nursing team demands broad-spectrum qualification. It is concluded that the permanent education of the mental health nursing team requires, in addition to educational programs based on the definition of specific competencies, critical Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.61-69 65 educational processes aimed at the development of interdisciplinary knowledge. Article 4 The Importance of Empathy in Health Care and Nursing Terezam R, Kings- Queiroz J, Hoga LAK. 2017 Critical review It provides a reflection on nursing practice in today's world, full of difficulties. It highlights the need for health professionals to be empathetic to themselves, so as to be able to offer effective care permeated by the empathic attitude. Where the search for this care must be constant. Presenting tools/strategies necessary to realize this ideal. Article 5 Psychiatric Nursing, Aben and the Scientific Department of Psychiatric Nursing and Mental Health: advances and challenges Esperidião E, et al. 2013 Theoretical- reflective It proposes to contextualize psychiatric nursing and mental health in Brazil, considering the main historical, political and social milestones that influence nursing care in this area. Bringing the paradigm change in the care context as well as in the nursing education. The achievements desired for this specialty permeate a critical and politically organized scientific community, thus the Scientific Department of Psychiatric Nursing and Mental Health is established as a strategy to bring together and consolidate the work of specialists, aiming at the excellence of care. Article 6 Medicalization and Mental Health: Alternative Strategies Zanella M, et al. 2016 Expository- argumentative The regulation of the behavior of patients with psychological distress is based on pharmacological prescription in an indiscriminating manner, disregarding psychological, historical and social aspects. The objective is to discuss the alternatives to the biomedical model, suggesting possible strategies in Mental Health and Psychosocial Care, offered in Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.61-69 66 the Public Network. It shows that all health professionals should feel able to produce care beyond pharmacological treatment, based on empathy and active listening. Article 1 presents the nurse's point of view on affective touch as an instrument for promoting care. According to Dias AB, et.al 2008 in the care provided by nursing, there are two types of touch: instrumental touch, characterized by objective care, through technical procedures and affective touch, where care is subjective, based on sensitivity, creativity, support and intuition to care for another being; because the client is lacking holistic care. Also according to Dias AB, et al. 2008, touch in the context of nonverbal manifestations allows nursing to demonstrate both its technical ability and its ability to be supportive and understanding. Despite the movement towards humanization in care, nurses still feel embarrassment when caring for the holistic, integral being, remaining restricted to the technical care required. It was observed that empathy has been used during invasive procedures as a communication tool, but in a restrictive way, which hinders the nurse-patient relationship. Article 2 addresses nursing care, based on Jean Watson's theory. Nursing has sought possibilities to understand and care that go beyond the limits constructed through the biomedical model. In such a way that there is appreciation of personal, subjective and cultural conditions of those involved in the care process. (Savieto RM, Leo ER 2006) Empathy according to Watson is the most appropriate instrument for establishing a good relationship with the client. The Clinical Caritas contains ten elements that consider being cared for as sacred, showing in each element the empathy to the client, not only technical competence, but active listening, respect, compassion, the valorization of human aspects, providing nurses with a way to expand their field of action, enabling a more complete attention to the needs of those who are being cared for. This article reinforces the importance of this reflection for care practice with the real needs of patients, which are certainly not fully contemplated by the biomedical approach, but by a holistic and empathetic approach. Article 3 aims to analyze the need for permanent education of the nursing team for care in mental health services. The study points out that in the 1980s the transfer to the mental health sector was associated with punishment, there was a great deal of resistance on the part of health professionals, where very few professionals went willingly. And most nurses did not have specific qualifications to work in this field, a reality experienced nowadays. Due to lack of qualification, some have doubts about how to deal with patients who have aggressive behavior, and above all, doubts about the meaning of their role as a professional. The lack of preparation to live/work with users in the crisis highlights the need and urgency of assistance to help mobilize the resources needed to intervene in the crisis. Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.61-69 67 DISCUSSION Throughout the study, it is evident the interest of nurses and staff in qualifying so that there is no compromise of humanized care and that the bond for care care care is not broken. The permanent education of mental health nurses requires in addition to educational programs, but shows the need to build integral systems of permanent education within the service itself. Article 4 is a critical review based on the book "Cultivating Empathy", by author Kathleen Stephany, which shows the importance of empathy for care. During the criticism, it is evident the need for health professionals to be empathetic, to put themselves in the place of the other, understanding their pain and suffering. Empathy in mental health care is placed in the client's relationship with the family, where nurses need to create strategies with the family where there is home harmonization, and it is necessary that the family member put himself in the user's place to better understand his/her situation and behavior; thus improving its relationship with the user himself, through efficient listening, understanding that there are two types of communication and that the nonverbal is present and needs to be respected and understood. These are important aspects for the adoption of empathic attitudes: self-knowledge, the ability to discern between emotions that are proper and those of others, the absence of prior judgment, and the ability to remain attentive to the effects of words themselves and reactions on others. (Terezam R, Reis-Queiroz J, Hoga LAK, 2017) In article 5 it is possible to see the advances of psychiatric nursing and mental health in Brazil from the psychiatric reform, evidencing the paradigm shift and what benefits were achieved for the nursing field and for subjects in psychological distress with such transformation. According to the historical milestones, care began to be carried out through psychosocial care. According to Federal Law No. 10,216, the creation of Psychosocial Care Centers (CAPS) provided better monitoring, access, reception and bonding; providing a holistic look at the health-disease process. In nursing practice, nursing consultations are the exclusive actions of nurses as an important resource with the user and his/her family, as well as the supervision and training of the nursing team. According to Esperidião E, et AL, 2013, it was also up to nursing to assume a therapeutic, critical-reflexive attitude, from a humanist perspective and professional autonomy, learning to deal with group techniques and valuing interpersonal relationships. However, it is still possible to frequently perceive the attributions of nurses focused on the individual scope and in the psychiatric hospital environment, still valuing pharmacological treatment, without considering subjective care, despite recognizing its importance and need. Article 6 focuses on medicalization and mental health, where it proposes alternative strategies with the objective of demystifying the rooted concept of the biomedical model, which has medicalization as primacy. According to Foucault, 2010 and Zanella M, et al, 2016 medicine and its pharmacological techniques will be the great dominator of mental illness, shifting all the explanation to the biological entity, in order that society can neutralize this subject. Medicine can even end mental illness, just as it did with leprosy, but nothing can suppress man's relationship with his ghosts. However, light technologies are the tools used by health professionals that enable a better understanding of psychic suffering by establishing care based on subjective care. The study exposes that there are ways to work around the situation by building together with the person in mental illness, methods of suppressing the biomedical model, Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.61-69 68 these being some of the instruments: dehospitalization, welcoming, autonomy, family and team co-responsibility, Psychosocial Care Network (RAPS) and deinstitutionalization of the individual, family and also society. According to Zanella M, et al, 2016 are the possibilities of substitute services with the focus of demedicalizing, proposing new therapeutic possibilities to users of the Unified Health System (SUS). One of them would be to develop actions together with caps such as nursing consultation, home visits, therapeutic groups and workshops. The main idea of the above-mentioned article is not to end with medicalization, but to show that each has the right and duty to choose the most appropriate treatment in each case, whether medicated or not; although in some cases there is a need for medicalization in other alternative methods can be used for the benefit of the user, demonstrating that nurses need to feel able to produce care based on empathic attitudes. CONCLUSION It is concluded that the most used method among the forms of treatment among the health professional / patient is the biomedical model, with a focus on the disease and not on the human being in a broad and holistic way, consequently, being carried out only punctual care and not care in order to meet all the biopsychosocial needs of the patient. As a way to improve care and meet the patient's needs, empathy is one of the main tools of care, because with it we can gain trust and establish bonds with the patient, thus gaining an effective relationship for both parties, thus being able to perform an affectionate, integrative and productive care. In the execution of daily care provided by nurses within the mental health scenario, we can observe that empathy is often not put into practice, leaving aside the patient's reception and unfortunately causing damage to the establishment of bonding. Empathy is a light care tool that requires only a more attentive and open practice to holistic care. However, empathy is a skill that can be developed by the professional based on their sensitivity, respect, appreciation of the feelings of the other, with this, it is expected that this work can serve as a reflection, contributing to the reorganization of ideas and concepts about essential improvements that are necessary to the current practice of Nursing in the field of mental health. CONFLICTS OF INTEREST The authors declare that there is no conflict of interest in the publication of this article. Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.61-69 69 REFERENCES Dias, A.B., Oliveira, L., Dias, D.G., Santana, M.G. (2008). Affective touch according the nurse’s perspective. 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