Challenge and Perception of the Meaning of the Nurse ’ s Job in the Brazilian Prison System

1 Master in Nursing from the Department of Nursing, Botucatu Medical School, Paulista State University, SP, Brazil. 2 RN, PhD, Assistant Professor Department of Nursing, Botucatu Medical School, Paulista State University, SP, Brazil. 3 RN, PhD, Assistant Professor Department of Nursing, Botucatu Medical School, University Estadual Paulista, SP, Brazil. 4 RN, PhD, Associate Professor Department of Nursing, Botucatu Medical School, University Estadual Paulista, SP, Brazil. 5 PhD in Social Psychology, Department of Penitentiary Administration, Psychologist at "José Parada Neto" Penitentiary in Guarulhos (SP) and University Professor. * Extradited article from the Master's Dissertation: "Meanings attributed by nurses to assistance that serve individuals in prison situation", presented to the Graduate Program, Professional Master's in Nursing, Botucatu Medical School, FMB/UNESP, 2013.


Introduction
The creation of the Unified Health System (SUS) in Brazil was conceived as a way to revolutionize and guarantee universal access to health.According to this principle the Ministries of Justice and Health instituted the National Health Plan in the Penitentiary System, through the publication of the Interministerial Ordinance no.1,777, dated September 9, 2003.Thus, it is planned to include the penitentiary population in the SUS, to ensure that the right to citizenship is effective in the perspective of human rights [1], nowadays this ordinance has been replaced by the National Policy for Integral Health Care in the Prison System, Interministerial Ordinance nº 1, January 2014 [2], in that same year was published the Ordinance No. 482/GM/MS, of April 1, 2014 [3], which establishes norms for the operation of the National Policy of Integral Attention to the Health of People Deprived of Liberty in the Prison System within the Unified Health System (SUS), with the purpose of qualifying the registration of the information in the System of National Register of Health Establishments (SCNES), it is necessary to identify the teams of professionals that integrate the Integral Health Care for Persons Deprived of Liberty in the Prison System, the Ministry of Health published to Administrative Rule no.305, dated April 10, 2014 [04], which establishes norms for the registration in the SCNES of the teams and services that will be part of the Basic Health Care of Prison and includes in the table of Types of Teams of the SCNES, the types of Health Team in the Prison System (ESP), resulting in the compatibility between this System and the Policies implemented by the Ministry of Health.The State of São Paulo in Brazil is qualified, but this policy has not been implemented in the State of São Paulo, so, according to the rules established, federal entities that did not implement said ordinances will maintain compliance with Interministerial Ordinance No.The risk factors that the prison population is exposed to and the conditions of confinement impress.There is a high prevalence and incidence of cases of infectious, respiratory, dermatological and mental illness, suicides, trauma, infectious diarrhea, and other relevant problems such as systemic arterial hypertension and diabetes mellitus.It can be added social marginalization, dependence on alcohol and drugs, low socioeconomic status, impoverishment and to widen the problem, poor conditions of the health service in the localities, and access to other levels of care [5][6][7][8].
The Brazilian Penitentiary System, due to overcrowding in prisons, poor physical conditions, lack of human resources and the inability to implement quality public policies, has privileged issues related to safety and discipline, which relativizes and suppresses the principles of access to health [6].This is opposed to the desired universal access, defined as the absence of geographical, economic, sociocultural barriers of organization or gender [7].
This research is justified by the complex situation of the prison system and the serious problems of public security faced in the country.In this scenario there is social anomie, being imperative that in this condition the nursing professionals maintain their performance based on ethical and legal principles.The nurses' work process, developed through their competencies, can contribute to the increase in health coverage, aiming at the desired assistance based on integrality, equity and universality.
Nursing has a significant contingent of professionals and constitutes an extremely important axis for supporting health policies, including assistance and care of the person in settings such as prisons [9].
In the situation of confinement and restriction of freedom, in prison reality, the conflicts and tensions between the different actors impose on the subjects a tendency to prioritize the problems related to security and immediate survival.This applies most clearly to the actions of prison security officers, to the detriment of issues related to access to health [9].
The Criminal Enforcement Act (LEP) No. 7,210 of 1984, which regulates the enforcement of custodial sentences, includes detailed guidance on how persons deprived of their liberty are classified by sex, criminal record and legal status.They ensure the entitled "assistance" about food, clothes, hygiene facilities, health care, legal assistance, educational assistance and preservation of rights not affected by deprivation of liberty [10].
In the reality of the prison system and in a way that contradicts what is described in Law No. 7,210 [10], nursing care occurs.The assistance is proposed by the clinical evaluation and the reception that can result in the support to the maintenance of the order, hygiene and security.In the nurses' work process, the first intention of guaranteeing ethical attributes is implicit, especially for this vulnerable population that does not have easy access to health demands, scarcity of human resources and multiple skills of staff and technology.
Nursing provides services to the human being with actions that interfere in the results of the health-disease process and when carrying out the assistance practice, aims at the promotion of health.The activities are directed to the individual or to social groups, based on scientific and technical knowledge, added by the social and political practices experienced in the assistance.
As essential theoretical elements, ethics and bioethics permeate the daily life of the nursing profession and these principles guide the evaluation and proposition of all health interventions, so that praxis can be realized, which is the practice of theory.
When assuming care as a structural element in nursing practice, the problem highlighted in this research is: what is the meaning of nursing care attributed by nurses working in the Penitentiary System of São Paulo State, Brazil?
The intention is to focus the work of the nurse who works in prison units, a space still not very explicit, but inserted in proposals related to health policies.It seeks to collaborate with the reflection and strengthening of the role and identity of the professional of this area, to contribute to the improvement of the quality of health care offered in such a specific context and in the fulfillment of the legal requirement that bases the profession.It is also hoped to offer subsidies for the academic training of nurses, preparing them to work in the care of individuals institutionalized in the penitentiary system.
The objective of this study was to characterize the prison units with a closed sentence enforcement regime in the western region of the State of São Paulo, Brazil and to identify perceptions and meanings attributed by nurses working in these places on nursing care offered to individuals deprived of their freedom.

Method
This is a descriptive study with a qualitative approach to understand the meaning attributed to the nurse's work in a peculiar context and the characterization of the prison units and the subjects.
As a Theoretical Reference for the study, a theoretical framework was chosen on Ethics and Bioethics in Nursing Assistance in situations of vulnerability which are aligned with the object of the study.The intention was to use scientific productions of authors who study these concepts.
As a methodological procedure, the Discourse of the Collective Subject (DCS) technique was used to organize and analyze the discourses about the perception and meaning of the nurse's practice in the prison context [11].
The Discourse of the Collective Subject (DCS) technique proposes to articulate a series of operations on the collected testimonies, through an interview with semistructured questions.Thus, the collective testimonies provide the perception or positioning of the investigated subjects [11].
The analysis of the material aims to extract the relevant contents of each response, the key expres-sions and their corresponding central ideas.The term key expression designates the fragments, excerpts from the collected material that depict the essence.Each homogeneous set of key expression receives a denomination or linguistic expression that exposes in a synthetic and concise way the meaning present in the analyzed answers, which is designated as central ideas.The grouping of similar central ideas can be called category [11].
The result of the DCS technique is the conception of a synthesis speech, written in the first person of singular, of the similar apprehensions that belong to the same central idea.As a research methodology, the DCS makes it possible to rescue in the studied social context the nature of the contradictions and similarities between the perceptions of the social agents or collective subjects.Thus individuals expose their internalized social representations, free from the group's psychosocial pressure, so that the group of these individuals can represent a collectivity [11].As a tool for the development of this methodological process, the Qualiquantisoft software [12] was used.
Prison units were included by modalities, categorized by model according to the sentence established to be fulfilled, and in this way the prison units with the closed regime were part of this study.From a total of 36 prison units that compose the Coordination of Prison Units of the Western Region of São Paulo State, according to the administrative division of the Penitentiary Administration Secretariat, only 27 are closed regime units and 19 units have accepted to participate in this research, these units are located in 16 different cities.As inclusion criterion of the nurses who would participate in the sample, it was considered the nurses who worked in care assistance from January to December of the year 2010, because it was understood that this would be the adequate time of action to have the phenomena of the prison environment experienced and meanings attributed to its practice, resulting in a sample of 35 nurses.Those who did not fulfill the inclusion criterion, those who refused and those who were away or on vacation were excluded.
Data collection took place from October 2011 to January 2012, individually, previously scheduled.The technique of interview with semistructured questions was carried out, having as guiding question "what is the meaning attributed to nursing care provided within the prison unit for the population deprived of liberty", the interviews were recorded in digital mode and later transcribed.The duration of each interview, between performing the security procedure to enter the unit and the application of the interview script was two hours.The interview script was prepared by the authors and consists of two parts: The first with data related to professional identification and quantitative data of the services performed in the prison unit, the second with questions about the perception and performance of nurses and the factors that influence their practice in caring for the prison population.
The research project was approved by the Research Ethics Committee of the Secretariat of Penitentiary Administration -CEP / SAP under number 004/2011 of 05/19/2011, thus fulfilling the formal requirements contained in national and international human research standards.

Results
In the 19 Closed System Prison Units of the Western Region of the State of São Paulo, there were a total of 46 nurses in these units, in professional activity in the sector called "Hospital Pavilion" or "Nursing."There are in these units variation in the number of placed nurses from 04 to only 1 nurse; the workday of these nurses varies from six hours a day from Monday to Friday and a twelve-hour day worked for thirty-six hours of rest in the on-call system, also from Monday to Friday, which totals thirty hours a week.In the 19 prison units in 2010 there were seventy-six thousand and one hundred nursing care; it was also observed that, in the majo-rity, these prison units are with 45.65% of inmates above their capacity.
Of the 35 nurses interviewed, the majority were female (77.1%), age 36 to 55 (68.6%), major time between two to five years ago (28.6%), six to ten years (20%), eleven to twenty years (28%).As for the time spent working in prison, the majority was between two and three years (45.8%).
The analysis of the Discourse of the Collective Subject allowed the apprehension of two themes that guided the representations of the assistential nurses in the characterized reality.
The first theme expresses the daily challenges of the work of the nurse in Prison Units related to the characteristics of the system itself and the ethical dilemmas they face to exercise nursing care.
It is presented the identified Central Ideas and the Discourse of the Collective Subject (DCS) extracted from excerpts of the interviewees.

Theme 1 Challenges of the work of the nurse in Prison Units
A. To work in the prison system is a challenge B. In the prison system professional roles are reversed ...The papers here are very distorted, the prisoner himself sees us as a medical professional, come, consult, want medication... the prison agents think that nurses have the obligation to give the medicine, to solve the problem of the prisoner inside here, to avoid the removal of the prisoner ..., unfortunately we find ourselves in a situation in which we are obliged to prescribe something, a dipyrone, a paracetamol, a diclofenac, and we know that our Board of Nursing forbids such action in the way it is being done ...., The activities are very limited only to this service ... the free citizen goes there at the pharmacy and buys, here he does not have the pharmacy, he has the nurse, the hospital pavilion, he arrives here and finds only the nurse, the nurse prescribes, it is wrong, but, I do not feel that way, it was the time that I felt guilty doing it, today I do this with a clear conscience, ethically speaking, because he is in the custody of the government, my obligation is to solve his problem of pain N28, N29, N30, N31, N32.

C. It's a very difficult and complicated job
...Throughout the system our service is face to face with the sentenced, we are the ones who listen to the complaints, we are the ones who evaluate their condition and from there we decide whether to go or what we do.... knowing the system for me was a shock, it was scary to see the reality, but then we adapt ourselves, is a totally different reality.At graduation we do not have contact with this type of environment...In relation to the diet of hypertensive and diabetic people we are restricted, because we do not have a nutritionist, we are restricted to the medication.Because it is a confinement environment there is a higher probability of disease onset.Here there is no way to give continuity,... to make a group, to guide, to do other types of activities.The security sector is always intruding on the nursing service, thinking that we must solve the problem of the prisoner soon, doing the service of the doctor, pressured to act according to what the institution tells...The system lacks much of health care.Currently what I feel is the high level of stress in relation to this situation that we are in, without medical care, and without a vision of a solution to it.Difficulty is more an interpersonal issue, the interpersonal relationship I am referring to is not the relation between patient and professional, but among the employees of the security and health area..

. you see that if you are going to direct the prisoner to the emergency room and
In this second theme is expressed the meaning of the work of the nurse within the prison units, their perspectives, the contradictory and latent feelings, the fear and satisfaction of carrying out the care, and the stability of being a public worker.

Theme 2 Meaning of the work of the nurse in Prison Units.
The central ideas identified and their DCS are presented below.

A. It has never been a dream to work in a prison unit
Well, it was never a dream to work in a prison unit, it was not something I thought of my life ... something I never imagined that could happen... N01, N16, N28.

…I had never thought about how a jail worked, or a prison, and in fact it is different from what we imagine… It was a shock having to restrict much of what you learned, to restrain yourself because of security..., now I am already used to it. We end up realizing that our work has nothing
to do with what these people did or did not do and for us they end up being normal people..., there is a certain dangerousness of the prisoner...I am afraid, sometimes, of something happening to me and to my co-workers ...I am afraid of a mutiny, of a rebellion... N01, N06, N07, N11, N19, N28, N29, N35.

C. It's working with the excluded ones and trying to help them recover
...working with the excluded ones, with people deprived of liberty and, in a sense, you are helping and collaborating with their recovery and reintegration of them in society..., which, sometimes, people from different areas, or even the population, do not understand...We take care, in quotation marks, of the scum of society, which are the condemned, which for us are the ones who are being reeducated... N02, N10, N15, N21, N24, N33.

D. Working in the system brings satisfaction working here is not bad, it satisfies me…, and I like to work in public health area, prevention area, in general I like being a nurse…, despite all the negative aspects we face, I think that my work makes difference here inside, because the inmate knows that if they look for the nurse we will solve their problem, … I make difference, we have so much to do for them, and it pleases me a lot… in the prison units, even because of the absence of medical assistance, the inmate see at the nurse the only alternative for health that they have… we can give access and bring the SUS inside of the prison unit
N02, N03, N06, N07, N08, N09, N12, N13, N14, N18, N22, N24, N27, N32, N33.

E. It is like any other job in health area
I consider it as any other job… with no difference, except by the security issues, but for me it is basically this, no difference.We have to take in consideration that we are working with human beings, no matter where they are N10, N11, N16, N19, N20, N22.
serve him within what you think is very complex, you better see the patient, because the prisoner will be waiting escort, and they will be without health services until the other day and will not be forwarded is complicated .

F. It means stability of a public contest
For me it means stability, because it is a public contest…, working in prison unit is my breadwinner, I work here, it is from here that I can survive, although with a salary that is ridiculous, out of date, I can keep myself and my family.Honestly, I came to work here for a simple question, I took a public contest.

Discussion
In the DCS of the interviewed professionals it was possible to identify the challenges faced to perform nursing care in prisons in the State of São Paulo, Brazil.There is the limit to the nurses' work process over rigid safety standards, which impedes actions of health education for care in chronic diseases, prevention of Human Immunodeficiency Virus (HIV), Sexually Transmitted Diseases (STD), smoking, drugs and alcohol, among other demands.
The overcrowding evidenced in the study, is one of the features of the units which participate of the study, with 45.65% above the capacity, is an important variable for the implementation of the assistance.This leads to more adverse conditions for care, being demonstrated by managers [13].
In the analysis of the characterization of the prison units it was evidenced that the number of nurses is insufficient to perform the nursing care.The sizing of human resources is necessary in the different scenarios of professional practice and in the prison units, by the characteristics, this stands out.The peculiarity of care needs to be considered, requiring a sufficient number of professionals and the scientific basis for training teams prepared to meet the health needs of the prison population, in a safe and humane way [14].
It was demonstrated by the data that the variable safety and discipline overlap with the principles of health care, which greatly limits the role of nurses.
There are studies that point out relationship problems and conflicts associated with the tensions imposed in hierarchical, formal and informal relations, which regulate the routine of prisons, especially between these two sectors: health and safety [15][16].According to the data, this difficulty in interpersonal relations interferes in professional actions and generates demotivation and stress for the worker.
The various transfers of prisoners to other units and the absence of the doctor in the health team also impose conditions on the nurse that are unfavorable for assistance.The composition of the minimum staff professionals within the prison units is currently regulated by Administrative Rule 305 of April 10, 2014, which establishes norms for the registration in the SCNES of the teams and services that will be part of the Basic Health Care of Prison and includes in the table of Types of Teams of the SCNES, the types of Health Team in the Prison System (HTPS) [4].
It was evident in several DCS that the deficit of health professionals is one of the difficulties most reported by the interviewees, because it facilitates the reversal of roles, that is, the nurse is expected to attend as if replacing the doctor.There is a legal and ethical implication in not fulfilling the right that prisoners have to receive care and treatment.The reflection and awareness of this conflict cause the nurse great discomfort and also positioning that corroborate with this lack, when taking on, for example, the prescription of some drugs.
The Brazilian Code of Ethics of Nursing Professionals, in chapter I, deals with professional relations and prohibitions and provides the following: "Prohibitions: (...) Art.31-Prescribe drugs and perform surgical procedure, except in cases provided for in current legislation and in emergency situations [17]".It is known that the possibility or not of prescription of medicines by nurses is a complex and controversial subject, both within the prisons and in the social environment outside the walls, being its approach in this work of paramount importance.
In this reality of the prison system what happens is that this population, faced with their needs, looks for the nursery as their only and sometimes last resource, a fact which nurses experience daily.These professionals evaluate and sympathize with the deprived of freedom, person with clinical demand, and propose the care.The practice of nursing has an object, human health, and seeks to transform it, resulting in the final product the care towards the person.Thus, nursing surpasses the technicaloperative dimension of biotechnological knowledge and gains a sense of social practice, which results in maintaining or restoring dignity in all spheres of life, regardless of the context in which care is practiced [18].
Most of the times, the drugs that are delivered by nurses to prisoners belong to the list of Specified Therapeutic Indications and Groups (GITE) and do not need prescription to be sold, they are available in the gondolas of drugstores [19].Faced with this, these professionals, committed to the dignity of the human being, try to soften the deficiencies found, passing on the necessary remedies, but for them this situation of illegality still exists, since they are not covered by a regulatory standard authorizing the recommendation and delivery of those medicines which form part of the GITE [19].
A survey conducted with health professionals from the hospital context that also attend the people deprived of freedom identifies the feeling of empathy, of solidarity and of compassion, evidencing that the health professional abstracts the social condition of the prisoner, but identifies in the other the quality and condition of person, of human [20].In line with this research, this study shows that the nurse identifies with the pain of the other and with the condition of confinement, result that is expressed by the care, although this has implications with the Code of Ethics of the professional category.Thus, this situation needs to be discussed with class entities, inspection agencies and the whole society, because these professionals are at the forefront of caring for an excluded and marginalized population, with precarious health services.
Recognition of the need in the prison system causes the nurse to break with judgments and create values for the construction of their work and their identity, assuming and establishing themselves as a force that generates productivity [20][21].
The data provided here also demonstrate that it was not in principle a desire of these nurses to work in prisons.The health service within the penitentiary system is little known, and in academic training itself this is not included, being extremely necessary the approach of this thematic in the formation.There are also few scientific studies on this subject, and when they do, they generally adopt quantitative epidemiological approaches, which points to the need to produce specific knowledge about the functioning and unfolding of health in the prison system [22][23].
Since care is a structural element in nurses' practice, even greater relevance gains the meaning of care within prisons.Nurses' reports indicate that the assistance denotes "caring for the excluded", conditions that also reveal the vulnerability of the individual and his collective, and the fact that the nurse recognizes and identifies the vulnerability of individuals deprived of their liberty in the context of imprisonment, shows a positive meaning for health care [20].Through the vulnerability referential, it opens the opportunity for an analysis about the professional performance of the nurse and his social role faced with the individual deprived of freedom.
The concept of vulnerability has its origin in the discussion of human rights and citizenship rights of social groups, due to the fragility in the achievement of their rights, the etymology of the word vulnerability derives from the Latin term vulnus, which consists of wounding and expressing, in general, the possibility of a person being injured [24].The vulnerability analysis aims to particularize the different situations of individuals and/or groups for a particular grievance, based on three analytical plans: individual, social and programmatic.For this discussion, the concepts of individual and social vulnerability were addressed.
Individual vulnerability is understood as the principle according to which all people are vulnerable to a particular health condition and involves behavioral as well as cognitive aspects [25].Behaviors are directly related to the degree and quality of information that people have and the capacity to incorporate this information and transform it into preventive attitudes and practices for a given problem [26].
Social vulnerability does not exclusively emphasize collective assessment but focuses on contextual factors that define and constrain individual vulnerability, allowing the understanding of behaviors and practices related to the exposure of individuals to health problems [25].One view common to all cultures is that the human being is vulnerable and needs protection.Consequently, social systems are designed to combat vulnerability in all its plans [27].
When considering these principles, the role of the nurse in the prison system is an agent that through the established social practices, instrumentalizes his knowledge for the practice of caring, taking into account the vulnerability of the individual within the analytical plans discussed here, as an assumption for effective care.This is stated in the actions of the study nurses.
The work that the nurses perform in the prison system has as objective the "caring" of the people deprived of freedom.This is due to the vulnerability in the prison, following a path that seeks to rescue the dignity of the human being, understood that expression in the sense of value of this individual, with the purpose of collaborating in the social reintegration of the person deprived of freedom.This is the essence of caring, as evidenced in this speech: "We end up realizing that our work has nothing to do with what these people did or did not do ..." (N01, N06, N07, N11, N19, N28, N29, N35).Undressed from moral judgments, nurses are placed for care, an essential dimension in the Nursing work process.
However, for some interviewees the meaning of the nurse's work in the prison system is not clearly related to the social practice of nursing or caring, as object in this process; there is also the motivation to hold a state public job.
For nurses who understand the work process as a social practice, the feeling of satisfaction in their activity predominates.It is noticed that beyond the challenges there is the reason and the meaning for their action.Even so, the perception of moral suffering is present, having the clear influence of organizational issues, as also described in a study on the elements that constitute the work process [28].
In this study it was evidenced that the majority of nurses feel satisfied with their work, and that they recognize the object of work when exercising the evaluation and care of the person.Despite the limits, these professionals present technical-scientific knowledge to subsidize their professional practice and, thus, offer assistance to persons deprived of their freedom.

Study limitations
Although aligned with the method, the research participation of 35 subjects consists of the limitation of this study, these nurses in turn, are distributed in 19 prison units of the Coordination of the Western Region of the State of São Paulo, Brazil.

Contributions to the area of nursing, health and public policy
The study provides conditions of apprehension and interpretation of a little studied reality and with an urgent need in the support and realignment of measures coming from the inspection agencies of the profession, class organizations, human rights associations, civil society and the Secretariat of Penitentiary Administration.With this, we can advance in favor of the full professional practice of nursing, resulting in increased health care with quality.That the prison units may consider what is regulated by Brazilian Law No. 7,210 [7] and then allow the conditions for assistance that includes the physical, human, technical-scientific, legal and ethical aspects.

Conclusions
In this study it was possible to understand what are the challenges of nurses and the meanings they attribute to nursing care provided to individuals in situations of prison confinement.The difficulties in attending and the limit of professional autonomy in the prisons of the closed regime of the West of São Paulo, Brazil, are explained.
About the characterization of the prison units it was possible to observe that all units overcrowded and they lack of physicians in most Prison Units, which results in a service overload for the nurses, most nurses are women, with little working time in Prison Unit and little training time.
The aspects related to the valuation of safety and discipline in the penitentiary stand out, which overlaps with health care.Factors such as lack of physician on staff; overcrowding; insecurity and fear of working in prison units; and difficulty in carrying out the reference and counter reference, generate feelings of team discouragement, impotence, revolt, sadness, Suffering and high level of stress, and may compromise the quality of care provided by the nurse.
There are ethical dilemmas with the loss of autonomy in private decisions of nurses when managers delegate assignments to cover the absence of the doctor, also linked to the medicalization of nonprescribed drugs, contrary to the Brazilian Code of Professional Ethics.
Regarding the meaning of the nurses' work process, the empathic look prevails, with compassion towards the person deprived of freedom and the fulfillment of humanistic principles and with the purpose of social practice.
1,777/ MS/MJ, which is currently under discussion in the Secretariat of Health of the State of São Paulo, Secretariat of Penitentiary Administration, Council of Municipal Secretaries of the State of São Paulo and Ministry of Health The implementation of the National Policy for Integral Health Care for Persons Deprived of Freedom in the Prison System.