Yes / Even prior to the conclusion of the European Union (EU) referendum (Brexit), the NHS was showing tremendous signs of strain. Immediately after the outcome was announced, promises of major re-investment of funds saved from payments to the EU were retracted. Since then, hospital closures, cuts and changes to health and social care have been revealed, with regular news broadcasts highlighting the crisis facing the NHS. The uncertainties about post-Brexit relationships, economy, politics and security are likely to further significantly impact the NHS and its sustainability. Higher Education Institutions (HEIs) and the NHS are inextricably linked through research and education of health and social care professionals – changes therefore having implications for both.

Bakgrund: Personer med ADHD har ofta nedsatta exekutiva funktioner, vilket kan försvåra social interaktion. Även vid autismspektrumtillstånd förekommer exekutiv dysfunktion, och där har tidigare studier visat ett behov av att ta hänsyn till detta vid vårdrelaterat bemötande. Det finns begränsad kunskap om hur personer med ADHD upplever bemötande inom hälso- och sjukvården.  Syfte: Syftet var att utforska hur personer med ADHD upplever bemötande inom hälso- och sjukvården. Metod: I studien tillämpas en kvalitativ design med deskriptiv ansats. Semistrukturerade intervjuer genomfördes med åtta personer med ADHD-diagnos. Resultat: Tre huvudkategorier kunde formuleras utifrån intervjumaterialet: Brist på tydlighet, bristande respekt för individ och autonomi samt begränsad kunskap om ADHD hos vårdpersonal. Informanter upplevde otydlighet i kommunikation och struktur och en känsla av att vårdpersonalen inte hade respekterat deras person eller autonomi. De beskriver också hur tidsaspekten blir ett problem: att behöva vänta på olika moment och inte veta hur länge de behöver vänta. Okunskapen om ADHD kändes besvärande. Informanter upplevde att vårdpersonalen hade låst sig vid en begränsad kunskap om ADHD istället för att se personen de hade framför sig. Studiens teoretiska referensram, Joyce Travelbees interaktionsteori, understryker betydelsen av kommunikation och interaktion i omvårdnadssituationen för att adekvat vård ska kunna ges till den unika patienten, och att en förutsättning är att sjuksköterskan vill hjälpa men också har förmågan att göra det.  Slutsats: Informanter i studien upplevde brister inom i huvudsak tre områden: tydlighet i kommunikation och struktur, respekt för deras person och autonomi samt vårdpersonalens kunskapsnivå gällande ADHD. Det är viktigt att patienter bemöts efter sina särskilda förutsättningar. Patienter med ADHD är inte en homogen grupp: graden och omfattningen av svårigheter kan skilja mycket, även mellan individer som uppfyller samma subdiagnos. Sjuksköterskan kan använda dessa kunskaper för att förbättra individanpassningen av bemötande och omvårdnad av personer med ADHD. / Background: People with ADHD often have impaired executive functions, which can hamper social interaction. Also in autism spectrum disorders executive dysfunction occurs, and here previous studies have demonstrated a need to take that into account in health-related personal treatment. There is limited knowledge about how people with ADHD are experiencing personal treatment in health care. Aim: The aim was to explore how people with ADHD are experiencing personal treatment in health care. Method: The study applied a qualitative design with descriptive approach. Semi-structured interviews were conducted with eight people with ADHD diagnosis. Results: Three main categories could be formulated on the basis of the interview material: Lack of clarity, lack of respect for individual and autonomy, and healthcare professional’s limited knowledge about ADHD. The informants experienced a lack of clarity in communication and structure and a feeling that the staff had not respected their person or autonomy. They also describe how the time factor becomes a problem: having to wait for different moments and not knowing how long they will have to wait. Ignorance of ADHD was perceived troublesome. Informants felt that caregivers often stuck to limited understanding of ADHD instead of seeing the person they had in front of them. The study's theoretical framework, Joyce Travelbee’s interaction theory, emphasizes the importance of communication and interaction in the nursing situation to care adequately for the unique patient, and that a prerequisite is that the nurse wants to help but also has the ability to do so. Conclusion: Informants in the study experienced shortcomings in mainly three areas: clarity in communication and structure, respect for their person and autonomy, as well as the healthcare professionals' level of knowledge regarding ADHD. It is important that patients are treated according to their particular conditions. Patients with ADHD are not a homogeneous group: the severity and the extent of the difficulties can be very different, even between individuals who meet the same subdiagnosis. Healthcare professional’s can use this knowledge to improve the personalization of treatment and care of people with ADHD.

Inledning: Patienter med psykisk ohälsa och personlighetsförändringar på röntgenavdelning utgör en grupp av patienter som kan bete sig verbalt eller fysiskt aggressivt. Våld på arbetsplatser förekommer i alla arbetsmiljöer men vårdpersonalen är mest utsatt.  Precis som alla andra vårdtagare har dessa patienter rätt till jämlik och säker vård. Syfte: Syftet med studien var att ta fram praktiska råd som röntgensjuksköterskor kan använda för att bemöta patienter med psykisk ohälsa/personlighetsförändringar och kunna förebygga och hantera situationer med aggression och våld. Metod: Studien utfördes som en allmän litteraturöversikt. Tolv vetenskapliga artiklar analyserades. Resultat: Studien kom fram till tre faktorer som kan bidra till att aggressiva situationer i vårdmiljön uppstår (interna, externa och kommunikativa). Det beskrivs fem typer av signaler som röntgensjuksköterskor ska vara uppmärksamma på för att förutse aggression: vad patienten säger, ändringar i rösten, ansikte, beteende, kroppsspråket och i känslouttryck. Många praktiska råd lyfts fram och de flesta baseras på holistiskt synsätt på patienten. Det är viktigt att bygga upp en förtroenderelation på gemensam basis, respektera patientens val och på så sätt låta patienten ha kontroll över sitt liv. Kontinuerlig utbildning och träning med olika scenario rekommenderas att tillämpa på arbetsplatserna för att öka röntgensjuksköterskors kunskap inför möten med denna patientgrupp. Slutsats: Studien besvarade forskningssyfte genom att lyfta fram faktorer som kan leda till aggression, signaler från patienter som röntgensjuksköterskor ska vara uppmärksamma på och praktiska råd som är viktiga vid bemötande av patienter med psykisk ohälsa/personlighetsförändringar.

Le but de cette étude est de cerner, à partir de leur propre point de vue, la trajectoire d’adaptation de conjoints dont l’épouse est atteinte d’un cancer de l’ovaire. Une approche qualitative, la théorisation ancrée, a été utilisée dans le cadre de cette recherche. Les données ont été recueillies à l’aide d'entretiens semi-structurés effectués auprès de neuf conjoints qui accompagnaient leur épouse lors de leurs traitements dans une unité montréalaise ultra-spécialisée de soins pour les cancers gynécologiques. Nos résultats font ressortir qu’une fois passé le choc de l’annonce du diagnostic, nos répondants se ressaisissent et élaborent toute une série de stratégies de protection pour leur épouse et eux-mêmes, puis d’attaque de la maladie. Au bilan, pour eux, le cancer se révèle une expérience « transformante» aux plans personnel, conjugal et social. Les contrastes observés entre nos résultats et ceux des études antérieures, qui insistent sur le désarroi de conjoints, peuvent être expliqués par la prise en charge efficace de la femme par le réseau de la santé, qui valorise le rôle du conjoint et qui l’outille pour accompagner son épouse. S’ajoutent à cela la force du lien conjugal, trempé par les épreuves passées, certains traits de personnalité des conjoints et l'action du réseau de soutien personnel. En regard de la pratique infirmière, notre recherche met en évidence le bien-fondé des politiques soutenant l’intégration des familles dans les plans de soins et les retombées positives d’une approche concertée entre tous les intervenants de la santé. Répéter une telle étude dans d'autres institutions du réseau de la santé permettrait de cerner encore plus finement son impact sur l’adaptation de conjoints à la maladie. / This research focuses on how nine men recall their adaptation trajectory to their spouses’ ovarian cancer. The qualitative analysis made use of the grounded theory approach; semistructured interviews were conducted with husbands accompanying their spouses during their treatments in an ultra-specialized unit for gynaecological cancers in a Montreal hospital. Our results show that after the initial shock initiated by the announcement, the respondents develop a set of strategies, first to protect their wives and themselves, and then to attack the illness. Accompanying their wives through the experience of cancer proves to be, for the husbands, a transformative experience at all levels: personal,conjugal, and social. The perceived efficacy of the health network and its preoccupation with the husband’s caretaker role may explain the sharp contrast we observe between results from the literature, insisting on the husbands’ helplessness in such a context, and our data, which underline their fighting spirit. Other factors identified are the strength of the conjugal link, forged in common ordeals, personality traits of both husbands and wives, and support from their personal network. Concerning nursing practice, this research suggests that the importance and the support given by the health professionals to the family caregivers is of utmost importance for the couple’s quality of life throughout this experience. Besides, the coordination of the health professionals, throughout the women’s illness, is crucial in diminishing the anxiety linked to the cancer diagnosis. The duplication of such a study in other cancer care units would allow a finer analysis of the impact the health network can have on the adaptation of both spouses to illness.

Background: The rapid diffusion of Novel Psychoactive Substances (NPS) constitutes an important challenge in terms of public health and a novelty in clinical settings, where these compounds may lead to erratic symptoms, unascertained effects and multi-intoxication scenarios, especially in emergency situations. The number of NPS available on the illicit drug market is astonishing: official reports suggest the appearance of a new drug every week. NPS may be enlisted in many different families such as synthetic phenethylamines, tryptamines, cathinones, piperazines, ketamine-like compounds, cannabimimetics and other plant-derived, medical products and derivatives. Therefore, healthcare services and professionals are often called to face this unknown 'galaxy' where NPS users seem to perceive traditional services 'unfitting' for their needs, requiring an attention which is quite different from known classic drug abusers. In this context, the Recreational Drugs European Network (ReDNet), a research project funded the European Commission and led by the University of Hertfordshire, aimed to explore the NPS galaxy and develop information tools for vulnerable individuals and professionals working with them. This initiative reported specific Technical Folders on new drugs and disseminated the collected information through innovative communication technologies (e.g. multimedia tools, social networking and mobile phone services) internationally. Aim and objectives: The aim of this work is to evaluate and contribute to expand the knowledge of health professionals on NPS. The key objectives are: 1) to assess the level of knowledge on NPS amongst a sample of Italian healthcare professionals; 2) to evaluate the effectiveness of dissemination tools developed by ReDNet, including an SMS-Email/mobile service (SMAIL); 3) to understand the clinical impact of NPS by providing four Technical Folders and collecting two clinical cases on NPS. Methodology: According to the objectives, the methodological approach has been articulated in the following three phases. Phase 1: investigating knowledge and preferred channels of information via an online survey among health professionals in Italy. This first Italian study on NPS awareness had been online from February to July 2011, recruiting participants from Departments of Addiction, Psychiatry and other services. Phase 2: evaluating the ReDNet initiative. An evaluation questionnaire was designed and disseminated online to assess the various resources provided by ReDNet project; it had been online from April to July 2013, targeting professionals registered to ReDNet services. This phase also investigated the SMAIL service, a mobile application that was the latest technological tool developed by ReDNet team. Phase 3: promoting evidence based work in clinical practice through the preparation of four Technical Folders and two case reports. Technical Folders followed the methodology optimised during the ReDNet experience, organising NPS data under specific headings, measured for the need of health professionals. Case reports were collected in a Dual Diagnosis Unit in Italy ('Casa di Cura Parco dei Tigli'); assessed patients revealed for the first time the use of NPS; clinical interviews were conducted to collect a full anamnesis while for the first time psychopathological characteristics were measured in NPS abusers, using a psychometric instrument (MMPI-2). Results: In Phase 1 Italian services, in particular interviewees (n=243) from Departments of Psychiatry and Addiction, showed a strong interest for the subject but a poor understanding of NPS: 26.7% of respondents did not know if their patients ever used NPS; at the same time they considered this phenomenon as very relevant to their profession (e.g. psychomotor agitation [75.7%], errors in the assessment [75.7%], management of the clients [72%]); in addition less of a quarter of them had reliable information on new substances. Interviewees also reported the need for easily accessible channels of information to expand their expertise in the field (including emails [70%] and dedicated websites [51.9%]). The ReDNet initiative (Phase 2) reached professionals (n=270) from European countries and various other regions; they appreciated the website above all (48.5%), which provided access to other information (in form of academic papers, news, technical folders, etc.). The integration of technological-based and classic educational resources was used to self-educate professionals (52.6%) and supply information for research (33.7%) with up-to-date and 3 reliable information; in the same Phase the SMAIL service was analysed in its first 557 searches: in the pilot period 122 professionals used SMS inquiries (95%), asking information on NPS while highlighting the increasing number of NPS available on the market. Technical folders (Phase 3) described two new phenethylamines (Bromo-dragonfly and 25I-NBOMe), a novel ethno drug (Kratom) and a new synthetic cathinone (alpha-PVP) whose severe effects were also described in one of the clinical cases. The first case report (Alice) involved a clubber who used mephedrone and other NPS with a severe worsening of her psychiatric disturbances; the second one (Marvin) described a patient who was referred by a psychiatric service and revealed himself as a 'psychonaut' with an intense abuse of alpha-PVP. Conclusions: The exploration of the NPS galaxy is a new challenge for healthcare professionals. In this study, Italian services seemed to be unprepared to face the emergency and requested rapid access to reliable information; the ReDNet project provided both technology-based and traditional resources to expand knowledge on NPS, making professionals more aware of emerging issues and helping especially clinicians working in the field (e.g. via SMAIL service and Technical Folders). Overall, it can be observed that effective information services on NPS targeted at professionals initiatives should include an online interface integrating up-to-date information, describing NPS through specific Technical Folders and disseminating scientific literature; the use of technological tools, including mobile applications, is an important strategy to support health professionals in their activity. Finally, more 'visual' guidelines, possibly in the form of a 'map' of these heterogeneous compounds, could be a useful framework to describe NPS to physicians and other professionals who are often unprepared and unconfident to face such an expanding galaxy.

Orientador: Silvana Artioli Schellini / Resumo: O primeiro atendimento prestado a queixas oftalmológicas no sistema SUS, em geral, é feito por médicos do Programa de Saúde da Família e Comunidade (SFC). Avaliar o conhecimento oftalmológico destes profissionais poderia indicar se há necessidade de treinamento, visando reduzir a demanda oftalmológica nos níveis secundário/terciário, assim como, prevenir a cegueira. Objetivo: Avaliar o conhecimento oftalmológico dos médicos que integram as Equipes de Saúde da Família (ESF) da DRS-VI, visando a melhoria do atendimento oftalmológico. Método: Trata-se de um estudo do tipo transversal, observacional, baseado em questionário eletrônico, visando avaliar o perfil de formação e conhecimento oftalmológico dos médicos das equipes de SFC que atuam na DRS-VI. A coleta de dados ocorreu de outubro de 2018 a fevereiro de 2019. Os dados foram avaliados por meio de análise estatística descritiva. Resultados: Cento e quinze médicos responderam ao questionário completo. Dentre os entrevistados, 81 (70,4%) eram do sexo masculino e 58 (50,4%) cursaram a graduação em instituição pública. A análise comparativa mostrou que o conhecimento oftalmológico não difere entre médicos de sexos diferentes ou entre os graduados em instituição pública ou privada. Apesar do viés de poucos médicos (20% dos entrevistados) terem realizado especialização em MFC, o fato de realizar o curso não provocou efeito significativo sobre a porcentagem de acertos. Segundo os respondentes, 58 (50,4%) relataram atender indivíduo... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Doctors working in the Family and Community Health Program (SFC) in general are the first care providers to ophthalmological complaints within the Brazilian Universal Health System. Evaluating the ophthalmological knowledge of these professionals might indicate if there is a need for training, aiming to reduce the ophthalmological demand in the secondary / tertiary levels, as well as in order to prevent blindness. Objective: To survey ophthalmologic knowledge of doctors working at the Family Health Program (FHP) of our region (DRS – VI), aiming the improvement of ophthalmological services. Method: Transversal and observational study, based on an online questionnaire, surveying ophthalmologic knowledge from doctors of the FHP working at DRS-VI. Data was collected from October 2018 to February 2019 and analyzed through descriptive statistics. Results: One hundred and fifteen practioners answered the questionnaire. Among them, 70.4% were men e 58% had the medical degree in public universities. Comparative analysis showed sex or institution of graduation had no influence in ophthalmologic knowledge. Besides the bias of few doctors (20% of the responders) had specialization in Family Health and Community, the percentage of correct answers was similar in both groups. According to the respondents 50.4% usually assist patients with ophthalmologic complaints. Just 22 (19.1%) practioners considered to have enough knowledge to deal with the main ophthalmologic conditions, 82 (71.3%) jud... (Complete abstract click electronic access below) / Mestre

Introdução: Apesar de o conceito de sofrimento moral ter sido definido há mais de 30 anos, existe uma variedade de definições sobre o conceito e não há consenso sobre as principais características do fenômeno. Embora essa variação seja comum quando os conceitos são inicialmente explorados, tal variabilidade dificulta substancialmente a construção de um corpo coerente de conhecimento. Objetivo: Desenvolver o conceito de sofrimento moral nas situações de final de vida em unidades de terapia intensiva pediátrica (UTIp) e identificar antecedentes, atributos e consequências do fenômeno. Método: O Modelo Híbrido de Desenvolvimento de Conceitos foi aplicado em suas três fases: Teórica, de Campo e Analítica Final. Na Fase Teórica, foram analisados 18 estudos que descreveram o sofrimento moral nas situações de final de vida no contexto da UTIp. A Fase de Campo foi conduzida por meio de entrevistas semiestruturadas, com 10 enfermeiros e 9 médicos que trabalham em UTIp. Os dados da Fase de Campo foram analisados utilizando-se os resultados da Fase Teórica como eixo teórico e a Análise Temática como referencial metodológico. Na Fase Analítica Final, os resultados das fases Teórica e de Campo foram comparados, analisados e integrados, permitindo chegar a uma definição do conceito. Resultados: Os dados evidenciam que sofrimento moral nas situações de final de vida em UTIp é o profissional sentir-se incapaz para agir, realizar ações que esse profissional percebe como inadequadas e manifestar alterações emocionais diante das metas irreais impostas pelas suas crenças e conflitos internos. O sofrimento moral pode ter consequências negativas, como o desejo de abandonar a profissão, e/ou positivas, como criar estratégias de enfrentamento que repercutem na vida pessoal e laborativa do profissional. Considerações finais: A abordagem híbrida ofereceu avanço na exploração do conceito de sofrimento moral nas situações de final de vida em UTIp, ao investigar o fenômeno na prática clínica. Identificar aspectos empíricos de um conceito pessoal, subjetivo e abstrato como o sofrimento moral é um processo complexo. Entretanto, por meio da Fase de Campo, foi possível identificar o componente experiencial que está por trás das condutas dos profissionais ante aos problemas morais nas situações de final de vida em UTIp. Dessa forma, pôde-se compreender como se dá o desenvolvimento do conceito na prática clínica, possibilitando a ampliação dos dados identificados na Fase Teórica. / Introduction: Although the concept of moral suffering has been defined more than 30 years ago, there are a variety of definitions about the concept and there is no consensus on the main features of the phenomenon. Although this variation is common when concepts are first explored, such variability substantially hinders the construction of a coherent body of knowledge. Objective: To develop the concept of moral suffering in end-of-life situations in pediatric intensive care units (ICUs) and to identify antecedents, attributes and consequences of the phenomenon. Method: The Hybrid Concepts Development Model was applied - in its three phases: Theoretical, Field and Final Analytic. In the Theoretical Phase, 18 studies were analyzed that described the moral suffering in the situations of end of life in the context of the PICU. The Field Phase was conducted through semi-structured interviews, with ten nurses and nine physicians working in the PICU. The data of the Field Phase were analyzed using the results of the Theoretical Phase as theoretical axis and the Thematic Analysis as a methodological reference. In the Final Analytical Phase, the results of the Theoretical and Field phases were compared, analyzed and integrated, allowing a definition of the concept. Results: The data show that moral suffering in end-of-life situations in the ICU is the professional feeling unable to act, to perform actions that the professional perceives as inadequate and to manifest emotional changes in the face of the unrealistic goals imposed by their internal beliefs and conflicts. Moral suffering can have negative consequences, such as the desire to leave the profession, and / or positive, such as creating coping strategies - that have repercussions on the professional and personal life of the professional. Final considerations: The hybrid approach offered an advance in the exploration of the concept of moral suffering in end-of-life situations in the PICU, when investigating the phenomenon in clinical practice. Identifying empirical aspects of a personal, subjective, abstract concept such as moral suffering is a complex process. However, through the Field Phase, it was possible to identify the experiential component that is behind the behavior of professionals before the moral problems in end-of-life situations in the PICU. In this way, it was possible to understand how the concept develops in clinical practice, allowing the amplification of the data identified in the Theoretical Phase.

Introdução O objeto deste estudo é a Educação Permanente em Saúde, com foco na avaliação de um programa educativo pautado nas diretrizes da Política Nacional de Educação Permanente em Saúde, em continuidade à pesquisa principal que avaliou as necessidades de aprendizagem e construiu, coletivamente, um programa educativo. A realização e a avaliação deste programa foram realizadas no presente estudo, com os Objetivos de Descrever a realização do programa Refletindo sobre a prática da comunicação no ambiente de trabalho; Avaliar a satisfação dos participantes deste programa; Conhecer a percepção de impacto dos participantes com relação a este programa e Verificar a existência de relação entre as variáveis das avaliações com as variáveis sócio- demográficas e com os grupos. Método Estudo desenvolvido por meio da pesquisa-ação, com abordagens quantitativa e qualitativa, em quatro unidades de saúde do município de Sorocaba/São Paulo; houve participação de 125 trabalhadores da área da saúde, dentre aqueles que integraram as oficinas, estratégia central adotada para execução programa, que responderam a dois instrumentos tipo Likert, a Avaliação de Satisfação e a Avaliação de Percepção de Impacto, aplicados após a realização das oficinas de trabalho. Os dados foram analisados por meio de estatística descritiva e inferencial e a descrição das oficinas foi feita em forma de narrativas. Resultados Durante as oficinas, os participantes se expressaram espontaneamente e pactuaram acordos visando à superação dos problemas identificados. Ao Final, sentiram-se satisfeitos e perceberam que houve impacto no trabalho após sua realização. Conclusões O cumprimento e a repactuação dos acordos geraram o movimento necessário para transformar o processo de trabalho, melhorar a comunicação e as práticas assistenciais. A realização e a avaliação do programa educativo incitaram importantes reflexões sobre o cotidiano do trabalho, pois partiu de problemas reais da prática, na perspectiva da aprendizagem significativa e dos pressupostos da Política Nacional de Educação Permanente em Saúde. / Introduction: The objective of the present study is the Permanent Education in Health, focusing on the evaluation of an educational program based on the National Policy on Continuing Education in Health. The main research evaluated the learning needs and constructed, collectively, an educational program. The program was carried out and evaluated in the present study, with the objectives of Describing the implementation of the program \"Reflecting on the practice of communication in the workplace\"; Evaluate the satisfaction of participants in this program; To know the perception of the impact of the participants in relation to this program and to verify the existence of a relationship between the variables of the evaluations with the socio-demographic variables and with the groups. Method: A study developed through action research, with quantitative and qualitative approaches, in four health units in the city of Soracaba / São Paulo; 125 health workers participated, among those who joined the workshops, a central strategy adopted to implement the program, which responded to two Likert-type instruments, the Satisfaction Assessment and the Impact Perception Assessment, applied after the Workshops. The data were analyzed by means of descriptive and inferential statistics and the description of the workshops was done in the form of narratives. Results: During the workshops, participants expressed themselves spontaneously and agreed on agreements to overcome identified problems. At the end, they felt satisfied and realized that there was an impact on the work after its completion. Conclusions: Compliance and renegotiation of the agreements generated the necessary movement to transform the work process, improve communication and assistance practices. The realization and evaluation of the educational program stimulated important reflections on the daily work, since it started from real problems of practice, from the perspective of meaningful learning and the assumptions of the National Policy of Permanent Education in Health.

O presente trabalho decorre do questionamento sobre a percepção, os discursos e as práticas relativos à loucura no contexto brasileiro de Reforma Psiquiátrica, defendendo a hipótese de que haveria entraves na relação entre aqueles que se aliam ao pensamento antimanicomial e os sujeitos ditos loucos: entraves sustentados por um paradigma clínicopolítico que visamos investigar. A racionalidade que organiza esse paradigma é objeto de análise desta pesquisa, cuja intenção é recuperar as noções de movimento e abertura implicadas na proposição central da reforma psiquiátrica brasileira por uma sociedade sem manicômios , aliando-a à ideia de comunidade que vem. Para tanto, apresentamos e discutimos elementos que compõem e delimitam o pensamento antimanicomial: seus fundamentos, suas narrativas e suas práticas suas formas de luta. Desta análise se observa que a negação do manicômio e a afirmação de um modelo comunitário de atenção em saúde mental, aspectos fundamentais da luta antimanicomial, articulam-se, oferecendo contornos a um pensamento que engendra formas específicas de relação com a loucura. Essa articulação fabrica também fronteiras: limites claros e precisos que distinguem um ideal de comunidade inclusiva de uma sociedade que marginaliza a loucura. A delimitação e o reconhecimento dessas divisas são estratégias importantes, pois permitem visibilizar e tornar pública a violência, os maus-tratos e a exclusão da lógica manicomial, conquistando, assim, o apoio social para a luta. Ao mesmo tempo, trava-se um segundo combate relativo às fronteiras, desta vez em sentido inverso: o confronto é pela dissolução dos limites, pela abolição dos muros reais e simbólicos que segregam a loucura. É nesse desenhar e apagar de linhas que se constituiria uma sociedade sem manicômios. O campo de batalha deste trabalho, enfim, localiza-se também nessas divisas, tendo como objetivo, no lugar de apagá-las ou garantir sua configuração, movimentá-las: muros, fronteiras ou limites, além de aprisionar ou segregar, acolhem, escondem e protegem; ademais, ainda que pareçam claras e precisas, são linhas descontínuas e abertas contêm furos, movimentam-se e produzem movimentos. É nessa mudança de perspectiva que buscamos mobilizar as fronteiras que vêm definindo nossas lutas, nossos ideais de comunidade e nossos modos de relação com a loucura, a fim de romper com suas formas totais / The present work stems from the questioning about perception, discourses and practices related to madness in the Brazilian context of the Psychiatric Reform, sustaining the hypothesis that there are obstacles in the relationship between those who join the anti-asylum thought and the so-called lunatics: obstacles supported by a clinical-political paradigm that we aim at investigating. The rationality that arranges this paradigm is the object of analysis from this research, which intends to retrieve movement and opening ideas involved in the main proposition of the Brazilian Psychiatric Reform for a society without asylums allying it to the idea of the coming community. Therefore, we present and discuss elements that compose and delimit anti-asylum thought: its foundations, narratives and practices - its ways of struggle. From this point, we have noticed that the denial of the asylum and the affirmation of a community-based mental healthcare in which fundamental aspects of the anti-asylum struggle articulate themselves offering contours to a thought that engenders specific ways of relating to madness. This articulation also produces boundaries: clear and precise ones that distinguish this ideal inclusive community from a society that marginalizes madness. The delimitation and recognition of these frontiers are important strategies because they enable to make visible and publicize the violence, the mistreatment and the exclusion of the asylum logic, thus conquering social support for the struggle. Likewise, a second conflict regarding boundaries arises, but this time in an opposite direction: the conflict is for the dissolution of the limits, for the abolition of the real and symbolic walls that segregate madness. It is in this drawing and erasing of lines that it would take root a society without asylums. The battlefield of this work, at last, locates itself also on these frontiers that, instead of erasing them or ensuring their configuration, aim to move them: walls, boundaries or limits, that as well as imprison or segregate, also welcome, hides and protect. Furthermore, even if they seem clear and precise, they are discontinuous and open lines, containing holes which also move and produce movements. It is in this change of perspective that we seek to mobilize the boundaries that define our struggles, our ideals of community and our ways of relating to madness in order to break away from their total forms

Com o intuito de superar os modelos tradicionais de atenção à saúde, caracterizados pela fragmentação e pelo elevado grau de especialização das intervenções, a Estratégia de Saúde da Família (ESF) foi criada como dispositivo prioritário para a reorganização do sistema de saúde. Para tanto, é composta por equipe multiprofissional que deve atuar no desenvolvimento de ações de promoção da saúde, prevenção de adoecimento, tratamento e reabilitação com foco no indivíduo, na família e na comunidade. Com o objetivo de ampliar e apoiar o trabalho da ESF, o Ministério da Saúde criou os Núcleos de Apoio à Saúde da Família (NASF). Tais núcleos são compostos por equipes multiprofissionais que devem operar de acordo com a lógica do Apoio Matricial, trabalhando de maneira conjunta com a ESF. Para isso, os profissionais do NASF desenvolvem algumas ações estratégicas, como discussões de casos, realização de atendimentos compartilhados e ações de educação permanente. A partir da experiência profissional junto ao NASF foi possível verificar alguns impasses e dificuldades relacionados ao desenvolvimento das ações em Saúde Mental e também à integração das equipes de ESF e NASF. Que concepções de Saúde Mental e de cuidado guiam as ações? Como se dá a integração dos diferentes saberes e do trabalho entre os profissionais na construção de projetos terapêuticos? Frente a essas questões, este estudo objetiva discutir o panorama em que se insere a prática e a integração das ações em Saúde Mental desenvolvidas pelos profissionais da ESF e NASF. Para tanto, realizou-se uma pesquisa qualitativa orientada pelo estudo de caso sobre uma equipe de ESF e NASF atuante em uma Unidade Básica de Saúde localizada na região leste do município de São Paulo. O diálogo com os profissionais foi articulado por meio da observação de reuniões de equipe, da análise de prontuários e da realização de grupos focais. Percebeu-se que, embora a implantação do NASF tenha possibilitado alguns avanços no sentido de facilitar a interdisciplinaridade, tanto a prática em Saúde Mental quanto a relação que se estabelece entre os profissionais e entre estes e os usuários expressam os automatismos do agir orientado por uma compreensão patologizante do sofrimento psíquico. As práticas prescritivas repetem os ordenamentos que pretendiam superar. Além disso, os profissionais referem sentimentos de frustração e angústia diante de situações que envolvem o cuidado em Saúde Mental. A integração do trabalho entre os profissionais esteve permeada por questões relacionadas à burocratização, à valorização dos aspectos quantitativos de produção, à gestão verticalizada, às relações de poder e de dominação de determinadas formas de pensar e agir, tudo o que corrobora para que se reproduza o mesmo tipo de modelo da atenção ao qual a ESF e NASF procura substituir. Nesse contexto, considera-se que potencializar espaços de escuta, acolhimento, diálogo e negociação, viabilizando o vínculo a partir do encontro entre os técnicos e entre estes e os usuários seja uma forma de criar brechas para a estruturação de intervenções comprometidas com a complexidade dos processos de adoecimento, subjetivação e produção de vida / In order to overcome the traditional models of health care, characterized by fragmentation and a high degree of specialization of interventions, the Family Health Strategy (ESF) was created as a priority device for the reorganization of the health system. Therefore, it is composed of a multidisciplinary team that must work on developing actions that aim health promotion, disease prevention, treatment and rehabilitation with focus on the individual, family and community. With the purpose of expanding and supporting the work carried out by ESF, the Ministry of Health created the Support Centers for Family Health (NASF). Such centers are composed of multidisciplinary teams that must operate according to the logic of Matrix Support, therefore working jointly with ESF teams. In order to enable such joint action, professional members of NASF develop certain strategic actions such as case discussions, conducting shared visits and activities of continuing education. From the experience with the NASF, it was possible to verify some impasses and difficulties related to the development of actions in Mental Health, as well as the integration of ESF teams and NASF. What conceptions of Mental Health and Care are set forth in order to accomplish such actions? How are the diversity of knowledge and approaches of work among different professionals integrated in the development of therapeutic projects? Faced with these issues, the objective of this study is to discuss the setting in which the practice and integration of actions in the field of Mental Health developed by professionals from ESF and NASF are operated. To achieve such objective, we carried out a qualitative research-driven case study of an ESF and NASF team working together at a Basic Health Unit located in the eastern region of São Paulo. The dialogue with the professionals was articulated through the observation of team meetings, analysis of medical records and conduction of focus groups. It was noticed that while the deployment of NASF has enabled some progress in facilitating interdisciplinary work, both the Mental Health practice and the relationship established amongst professionals, and between the latter and their clients express a pattern of automatic guided actions governed by a potentially pathologysing understanding of psychological distress. Their prescribing practices tend to reproduce the very modus operandi that the teams meant to overcome. Furthermore, professionals express feelings of frustration and anguish in situations involving Mental Health care. The integration of work amongst professionals was permeated by issues related to bureaucracy, appreciation of the quantitative aspects of production, top down management models, relations of power and domination of certain ways of thinking and acting, all of which corroborate to the reproduction of the same model of care to which the ESF and NASF seek to replace. In this context, it is considered that the enhancement of settings that promote a space for listening, receptivity, dialogue and negotiation, allowing for the bonding that stems from such meetings, and from the relation between professionals and clients is a potential means to generate opportunities for structuring interventions committed to the complexity of processes related to mental illness, production of subjectivity and life