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Artigo de Boas Prticas Disponvel em http://dx.doi.org/10.19131/rpesm.

0133

9 REASONING AND PLANNING OF THERAPEUTIC OCCUPATION


ACTIVITIES
| Carlos Melo-Dias1; Amorim Rosa2; Alberto Pinto3 |

ABSTRACT
BACKGROUND: Psychosocial rehabilitation offers the patient the opportunity of reaching the maximum functioning potential in the community
while performing physical, emotional and intellectual skills. Therapeutic Occupation Activities are systematic activities which structure and guide
the participants functional performance, within the interpersonal nurse-client relationship, while promoting autonomy and enabling satisfaction
and accomplishment in both occupation and recreation.
AIM: To explore the reasoning and planning that substantiates the Therapeutic Occupation Activities (TOAs) in Mental Health and Psychiatric
Nursing.
METHODS: Using a concept-based design, the methodological step-by-step framework to build the reasoning will be described, as well as the plan-
ning which substantiates the Targeted Nursing Interventions (TNI) on TOAs.
CONCLUSION: Clinical reasoning in Nursing allows for an updated, adaptive, sensitive and constructive decision-making. The various domains
in which the TOAs are developed reveal the holistic nature of the intervention and the impact of Nursing in the individuals life and health. The
preservation of an optimal well-being and the prevention of relapses and long hospital stays are ultimate therapeutic indications which expand the
philosophies of care and lead to achievable benefits, such as the feeling of social utility and building up the self-esteem and self-image of those in-
volved. The implications for the clinical practice derive from the association between social functioning and personal satisfaction, positive and cor-
rective reinforcement in performance, and from consistency and proportionality of modelling, assertiveness and generalization. The use of clinical
indicators consistent with and sensitive to the Nurses intervention has a clinical influence on the participants performance and outcomes.
KEYWORDS: Therapeutic occupation activities; psychosocial rehabilitation; Reasoning; Targeted nursing interventions

RESUMEN RESUMO
Razonamiento y planificacin de actividades de ocupacin Raciocnio e planificao de atividades de ocupao terapu-
teraputica tica
INTRODUCCIN: La rehabilitacin psicosocial ofrece al paciente la opor- INTRODUO: A reabilitao psicossocial oferece ao doente a oportuni-
tunidad de conseguir el mximo potencial funcional en la comunidad, po- dade de atingir o mximo potencial de funcionamento na comunidade, des-
niendo en prctica las habilidades fsicas, emocionales e intelectuales. Las empenhando habilidades fsicas, emocionais e intelectuais. As Atividades de
Actividades de Ocupacin Teraputica son actividades sistemticas que es- Ocupao Teraputica so atividades sistemticas que estruturam e dirigem o
tructuran y dirigen el desempeo funcional del participante, en la relacin desempenho funcional do participante, enquadradas na relao interpessoal
interpersonal enfermero-cliente, que potencian la autonoma, promueven la enfermeiro-cliente promovendo e habilitando a autonomia e satisfao na ocu-
satisfaccin y el xito tanto en el mbito profesional como en el recreativo. pao e na recreao.
OBJETIVO: Estudiar el razonamiento y la planificacin de las Actividades de OBJETIVO: Expor o raciocnio e deciso da planificao de Atividades de
Ocupacin Teraputica (AOT) en Enfermera de Salud Mental y Psiquitrica. Ocupao Teraputica (AOT) em Enfermagem de Sade Mental e Psiquitrica.
METODOLOGA: Con base en un diseo conceptual, se expone paso a paso METODOLOGIA: Suportado concetualmente, reflete-se passo-a-passo a con-
el razonamiento y la planificacin de las Intervenciones de Enfermera Focal- struo do raciocnio e da planificao necessrios preparao das Interven-
izadas (IEF) necesarias a las AOT. es de Enfermagem Focadas (IEF) em AOTs.
CONCLUSIN: El razonamiento clnico en Enfermera permite tomar de- CONCLUSO: O raciocnio clnico em Enfermagem permite gerar decises
cisiones adaptativas, sensibles y constructivas. Los diversos dominios en los atualizadas, adaptativas, sensveis e construtivas. Os diversos domnios em que
que las AOT se desarrollan revelan el carcter holstico de la intervencin y el as AOT se desenvolvem expem o carater holstico da interveno e impacto
impacto de la Enfermera en la vida y salud de las personas. El mantenimien- da Enfermagem na vida e sade das pessoas. A manuteno do mximo bem-
to del mximo bienestar, la prevencin de las recadas y la hospitalizacin estar e a preveno das recadas e hospitalizao prolongada so extremos das
prolongada son la suma indicacin teraputica que da lugar a beneficios al- indicaes teraputicas e expandem as filosofias de cuidados, gerando benef-
canzables, como el sentido de la utilidad social y la construccin de la au- cios alcanveis, desde o sentido de utilidade social edificao da autoestima
toestima y la autoimagen. Las implicaciones para la prctica clnica provienen e autoimagem de todos os envolvidos. As implicaes para a prtica clnica
de la asociacin entre el funcionamiento social y la satisfaccin personal, del decorrem principalmente da associao do funcionamento social satisfao
refuerzo positivo y correctivo en el desempeo, y de la coherencia y la propor- pessoal, do reforo positivo e corretivo no desempenho, e ainda da coerncia e
cionalidad del modelado, la asertividad y la generalizacin. El uso de indica- proporcionalidade da modelagem, assertividade e generalizao. A utilizao
dores clnicos coherentes y sensibles a la intervencin del enfermero tiene una de indicadores clnicos sintnicos e sensveis interveno do Enfermeiro im-
influencia clnica en el desempeo y los resultados de los/las participantes. plicam-se clinicamente no desempenho dos/as participantes e nos resultados.
PALAVRAS-CHAVE: Atividades de ocupao teraputica;
DESCRIPTORES: Actividades de ocupacin teraputica; Reabilitao psicossocial; Raciocnio; Intervenes de enfer-
Rehabilitacin psicosocial; razonamiento; intervenciones de magem focadas
enfermera orientadas
Submetido em 20-05-2015
Aceite em 30-05-2016

1 Enfermeiro Especialista em Enfermagem de Sade Mental e Psiquitrica; Mestre em Cincias de Enfermagem; Doutor em Enfermagem; Investigador na Unidade de Investi-
gao em Cincias da Sade: Enfermagem; Investigador no Portugal Centre for Evidence-Based Practice: an Affiliate Centre of the Joanna Briggs Institute; Professor Adjunto
na Escola Superior de Enfermagem de Coimbra Plo B, Unidade Cientfico-Pedaggica de Enfermagem de Sade Mental e Psiquiatria, Coimbra, cmelodias@esenfc.pt
2 Enfermeiro Especialista em Enfermagem de Sade Mental e Psiquitrica; Investigador na Unidade de Investigao em Cincias da Sade: Enfermagem; Professor Adjunto na
Escola Superior de Enfermagem de Coimbra Plo A, 3046-851 Coimbra, Portugal, amorim@esenfc.pt
3 Enfermeiro Especialista em Enfermagem de Sade Mental e Psiquitrica; Investigador na Unidade de Investigao em Cincias da Sade: Enfermagem; Professor Adjunto na
Escola Superior de Enfermagem de Coimbra Plo A, 3046-851 Coimbra, Portugal, mpinto@esenfc.pt
Citao: Melo-Dias, C., Rosa, A., & Pinto, A. (2016). Reasoning and planning of therapeutic occupation activities. Revista Portuguesa de Enfermagem de Sade Mental (15),
63-xx.

Revista Portuguesa de Enfermagem de Sade Mental, N 15 (JUN.,2016) | 63


INTRODUCTION Background
The psychosocial rehabilitation offers the opportunity Fields of Use of Therapeutic Occupation Activities
to reach the maximum potential for independent func- The TOAs may be clinically relevant and decisive in the
tioning in the community, teaching the patient how to following domains: Personal and Domestic, Recreation
perform the physical, emotional, and intellectual skills and Leisure, Self-Expression, Psychoeducation, Health
necessary for leading an autonomous life with the high- Education and Interpersonal Relationships.
est level of well-being possible (Melo-Dias, Rosa & Pin- All these domains comprise two dimensions: the tem-
to, 2014). poral dimension and the environmental dimension. The
The Therapeutic Occupation Activities (TOAs) are de- temporal dimension includes the age, the developmen-
fined as systematic and organized activities that struc- tal stage and its role in this phase of life of individual; the
ture and guide the functional performance of the partic- environmental dimension encompasses the structural,
ipant within the interpersonal nurse-client relationship social and cultural variables of the individuals micro/
and the assessment of the Fundamental Human Needs macro environment.
(FHN). Nurses make use of therapeutic techniques
which are selected and prescribed according to the in- Key Features of Therapeutic Occupation Activities
tended objective(s), with psychotherapeutic, psychoed- The following are key features of these Nursing Activi-
ucational, psychomotor, psychosocial, socio-therapeu- ties (Figure 1):
tic and spiritual consequences. They aim to promote, Figure 1 - Key features of therapeutic occupation activities
prevent, empower, maintain and/or recover and devel-
op the individuals skills so as to reach their maximum
potential for performance, autonomy and satisfaction of
their FHN, daily activities, and occupation for achieve-
ment and recreation (Melo-Dias, Rosa &Pinto, 2014).
Clinical reasoning in nursing practice is a thinking pro-
cess based on (theoretical and practical) knowledge and
(professional and personal) experience. It integrates
the complexity, reflexivity, creativity, intuition and cog-
nition of the nurse, the client and the context so as to
systematically select, compare, test, infer and decide
on the clinical evidences of the patients clinical path, Source: Melo-Dias, Rosa, e Pinto, 2014, p. 16
thus leading to decisions and conclusions (Melo-Dias e
Lopes, 2010; Melo-Dias e Lopes, 2011).
The Nurses Role
The clinical decision and reasoning process underly-
ing the TOAs in Mental Health and Psychiatric Nursing The nurses therapeutic role in the TOAs implies a sci-
corresponds to treatment choices in which the therapist, entific intervention in the health area and requires ex-
based on the available possibilities and options, builds a cellent interpersonal skills, knowledge of the cognitive-
model/type of activity directed toward the client(s) and behavioral therapies, enthusiasm with his/her work,
respective needs, while respecting the scientific, ethi- resilience to perform thorough procedures with negli-
cal and esthetical principles (Melo-Dias, Rosa, e Pinto, gible/minor situational feedbacks and also the ability to
2014). use feedback and feedforward processes (Decreto-Lei
n. 161/96; Melo-Dias, Rosa, e Pinto, 2014; Sampaio, Se-
Aim queira, & Lluch-Canut, 2014).
From a well-defined and diversified set of general prin-
The purpose of this article is to explore the reasoning
ciples, the following are highlighted: self-awareness
and planning underlying the Therapeutic Occupation
even during the therapeutic relationship, the ability to
Activities in Mental Health and Psychiatric Nursing.
provide encouragement, flexibility in adaptation and
the promotion of harmony between the professionals
working with the client (Melo-Dias, Rosa, e Pinto, 2014,
p. 16).

Revista Portuguesa de Enfermagem de Sade Mental, N 15 (JUN.,2016) | 64


This active role inevitably includes the management of The satisfaction of needs shows a relative variation in
the therapeutic environment (as milieu therapy) and is an independence/dependence continuum, depending
interpreted in TOAs in their structure and dynamic di- on the level (quality/quantity) of help that the person
mension. The structure and facilities are managed with- requires or needs (Table 1).
in the classic variables (eg. temperature, space, equip-
Table 1 - Independence/Dependence Continuum
ments ...). In the dynamics of interaction between the
different participants, we have the strategies and meth- Independence Dependence
ods intrinsic to TOAs, which confer, shape and ensure Level 0 Level 1 Level 2 Level 3 Level 4 Level 5
the management of personal and social functioning of Meets own Needs Needs Depends Depends Fully de-
needs rela- someone someone on some- on some- pends on
participant in a therapeutic manner. tively so as to to teach so as to one to one to someone
ensure homeo- how to follow perform perform to satisfy
stasis. main- the the tasks the tasks his/her
Autonomous Nursing Interventions tain or treat- necessary necessary needs or
Nursing clinical practice is focused on the interperson- Follows a recover ment to satisfy to satisfy comply
treatment regi- indepen- properly needs or needs or with
al/therapeutic relationship between a nurse and an indi- men properly dence or use comply comply treat-
vidual/group, which is distinguished by the training and or uses techni- and technical with with ment, as
cal assistance ensure assis- treat- treatment, Is not
experience of the nurse who develops his/her skills in a without help. homeo- tance, as ment, as has a able to
partnership (Ordem dos Enfermeiros, 2001). Therefore, stasis. can only as has a minimum partici-
as autonomous interventions, the nurses are responsible partially limited participa- pate.
partici- partici- tion.
for prescribing and implementing the TOAs. pate. pation.
Source: Phaneuf, M. (2001) Planificao de cuidados: um sistema integrado e per-
Receptive, Processing and Sending Skills sonalizado. Quarteto, Coimbra.

The following tree types of skills are identified: Receptive


Skills (to interpret relevant cues or signals efficiently); About the Planning Process
Processing Skills (to assess the information received, the The human responses to development and disease pro-
objectives and the planning of a behavioral response); cesses, and also the length and type of hospital stay, the
Sending Skills (adequate verbal, non-verbal and para- cultural and demographic characteristics, the life proj-
linguistic behaviors) (Coelho e Palha, 2006). ects and expectations, the disruptions caused by the
new roles, the pain and the (physical, mental and social)
About Reasoning suffering, the adaptation difficulties, and the cognitive
In Social Learning, the consequences of the behav- impairment have a general and specific influence on the
ior affect its repetition, and the observation of external design of nursing interventions in TOAs (McGurk et al.,
models accelerates the learning process more than if 2013; Melo-Dias, 2014; Rainforth & Laurenson, 2014).
that behavior had been performed by the apprentice Also, the Nurse, as leader and rater is in a position of
himself/herself. This assertion is based on the four de- co-territoriality, because is emotionally and rationally
terminants: Attention Process; Retention Process; Re- integrated in the situation, while maintaining a techni-
production Process; and Reinforcement Process. cal distance (Melo-Dias, 2009).
Observation is also a key process in the TOAs. Although
it does not have an end in itself, this process is subject to Determinants of Therapeutic Occupation Activities
each individual and their complex processes of bringing in Mental Health and Psychiatric Nursing
intelligibility to reality, providing the necessary empiri-
cal data for further critical analysis and critical assess- There are several key variables that determine the type
ments (Melo-Dias, 2009). of TOA to be prescribed, such as: Stigma, Standards and
Philosophy of Care, Nurses Motivation, Funding Dif-
Virginia Hendersons Nursing Need Theory ficulties, Emotional and Behavioral Deficits, Impaired
Communication Skills, and Learning difficulties.
In the Virginia Hendersons model, the concept of
The therapeutic indications for prescribing TOAs in
Need is defined as vital for the individual, who will
Mental Health and Psychiatric Nursing (MHPN) are
have to meet his/her needs in order to preserve his/her
physical, psychological, social or spiritual balance, thus (Figure 2):
ensuring his/her development and growth (Phaneuf,
2001).
Revista Portuguesa de Enfermagem de Sade Mental, N 15 (JUN.,2016) | 65
Figure 2 - Therapeutic indications for prescribing TOAs Table 2 - Planning Model of Occupation Therapeutic Activities
in Mental Health and Psychiatric Nursing
PLANNING MODEL of THERAPEUTIC OCCUPATION
ACTIVITIES
Title / Theme = ...
Place, Date, Time and Duration = ...
Aim (Overall Objective) = ...
Specific objectives of the participants = ...
Participants (Selection Criteria) = ...
Necessary resources = ...
Methodologies and Strategies = ...
Assessment Indicators = ...
Ethical aspects to be considered= ...
Persons Leader = ...
Responsible Rater/s = ...
for the Activity
Collaborators = ...
Model of Indicators Assessment Grid
Source: Melo-Dias, Rosa, e Pinto, 2014
Assessment Indicators
Participants Indicator Descrip- Outcome Measure-
Benefits of Therapeutic Occupation Activities in tion ment and Record
Mental Health and Psychiatric Nursing Method/Strategy
The following benefits for the clients are correlated with Participant A = ...
Indicator X... ...
the specific objectives (Figure 3): Indicator Y... ...
Indicator X... ...
Figure 3 - Benefits of Therapeutic Occupation Activities Participant B
in Mental Health and Psychiatric Nursing Indicator Y...
... ... ...

Title / Theme
100% Creativity + 100% Specificity. It will be read by
several audiences: health care professionals, potential
clients and other interested parties (e.g., the family). The
title will be descriptive, represent the activity which will
be performed and, at the same time, captivate partici-
pants.
Source: Melo-Dias, Rosa, e Pinto, 2014
Place, Date, Time and Duration
Setting a time and place will ensure that the activity is
Methods, Reasoning and Clinical Decision properly integrated in the dynamics of the health care
The clinical reasoning and decision process applied to team. The item duration should take into account the
TOAs in MHPN corresponds to the treatment decisions participants invitation, the immediate preparation of
and choices, in which the therapist builds a model/type the environment, and the duration of the activity itself.
of activity directed toward the client(s) and respective
needs, while taking into account the available possibili- Aim (Overall Objective)
ties and choices and respecting the scientific, ethical and The objectives of the TOAs need to be previously out-
esthetical principles (Melo-Dias, Rosa, e Pinto, 2014). lined, as they are structural activities aimed towards the
The planning of TOAs is focused on the individual individuals functional performance which is partially
needs, while respecting preferences and lifestyle and or totally impaired. This section presents the Nurses
concomitantly maintaining the clinical appropriateness main purpose of developing the TOA session/s.
on a properly informed client, thus ensuring its thera- Example: To Promote to Empower to Improve ... to
peutic potential and clinical utility. Reduce or to Develop
Revista Portuguesa de Enfermagem de Sade Mental, N 15 (JUN.,2016) | 66
Specific Objectives of the Participants Third with inclusion one mean tuning base skills be-
The specific objectives are focused on the participant tween clients, so the activity is thus developed in pairs
and his/her performance, behavior, action and func- or subgroups, bringing together more and less skilled
tioning, which are inherent in the Sensorimotor, Cogni- participants, in order to potentiate and empowering
tive, and/or Psychosocial dimensions. By associating so- both. Fourth with exclusion one mean the assumption
cial functioning and personal satisfaction, the definition that in that clinical moment participation on TOA didnt
of objectives will enable the participants to be successful constitute therapeutic benefit for that specific client. Fi-
in every session. nally, could be pertinent the definition of the maximum
It is always complex to turn a desire into an intention amount of clients participating in TOA session, to be fit-
and, in turn, that intention into the actual fulfilment of ted with the areas of facilities and equipments, and also
the objective(s), a process which should necessarily take because of the management response to ensure the suc-
into account the degree of desirability and feasibility. cess of the activity with all and each one of the clients.
This equation becomes even more complex when the
objectives are outlined by others. As a result, the Nurse Necessary Resources
should evaluate together with the client the willingness The resources can be analyzed from a simpler perspec-
to perform the action, making sure he/she has under- tive (like academic learning environment) to a more
stood the purpose of the objectives. The Nurse takes complex one (like organizational environment and/or
on the responsibility of supporting the client in case of calls for funding/tenders). The selection of the available
anxiety about the unknown and anxiety related to the resources to support the performance of the activity, as
emotional demands of the experience and the clients well as its continuity (if that is the strategy), depends on
perception and understanding that the situation may or that level of complexity, ensuring always an sustainable
not be out of her/his control. cost-benefit balance. There diverse resources could be
As a general rule, the objectives should be quantifiable/ human, proficiency, materials, equipment, structural,
measurable and explain what is intended to be reached financial and organizational resources.
within a given period of time.
The following SMART mnemonic is acknowledged as Methodologies and Strategies
effective: S= Specific, M=Measurable, A=Attainable, The task of explaining objectives and actions to another
R=Realistic, T=Timebound (Doran, 1981). person requires that those explaining them have both
There are three key dimensions for objectives construc- the ability to adequately analyze the skills and motiva-
tion/creation: Coherence and integration in the pro- tions of those who will be accomplishing them, and the
posed activity; Proportionality between the expected ability to communicate in a consistent and coherent way
results and the available time and resources; and Focus with that analyzes. Within this process, the nurse-client
on the priority/main results of the performance (Melo- relationship should be as consolidated as possible in or-
Dias, 2012). der to consume less energy in the persuasion process of
both performers: nurse and client, and consume more
Participants: Selection Criteria energy on the client to accomplish goals.
Whenever possible, inclusion and/or exclusion criteria Patients can learn relatively complex material despite
are established to support and ensure the therapeutic their transitions of health and illnesses, as also can
dimension of the TOA. It is important to have a deep meaningfully improve the continuity of their own care
knowledge about the participants to select them, name- by participating in these structured recovery and devel-
ly through a previous assessment of their FHNs, prefer- opment programs (Melo-Dias, 2015).
ences and lifestyle. There are some decision principles These Targeted Nursing Interventions (TNI) compre-
that should also be respected. First, the criteria should hend the action Nurses make by identifying and fo-
not be excessively strict, for instance, to facilitate the cusing its interventions direct toward the core areas of
participation of clients who may have borderline level client functioning/performance, such as interpersonal
skills. Second, the criteria should ensure balance among relationship, burden of symptoms, cognitive function-
the group of participants, for example by selecting those ing, coping with disease and treatments, generalization
who will benefit from the activity in the short and in the and social integration, contributing to reduce and/or
long term and those who have different skill levels. problem resolution.
Revista Portuguesa de Enfermagem de Sade Mental, N 15 (JUN.,2016) | 67
The implementation of the activity using the teaching- Verbalizes a coherent message; Handles written com-
learning methodologies together with the human re- munication; Recalls immediate information accurately;
sources/space management and decision-making strat- Self-initiates goal-directed behavior; Engages in effec-
egies is presented by chronological order of use. Every tive exercise routine; Performs tasks or activities; Walks
stage of implementation of the TOA will be described with effective gait.
with the necessary details (it may even include the esti- The following is an example of a Likert scale: Extremely
mated duration of each stage), so as to enable its replica- compromised=1; Substantially compromised=2; Mod-
tion and continuity in similar settings and with similar erately compromised=3; Mildly compromised=4; Not
participants. compromised=5.
Example of Methodologies: Oral presentation, Brain- The indicators are sensitive to Nursing interventions,
enabling Nurses to document the effects of their inter-
storming, Simulation.
ventions and to be individually and collectively held
Example of Strategies: Modeling, Assertiveness, Coach-
accountable for the care delivered to patients (Moor-
ing, Generalization.
head et al., 2010, p. 71). Open-ended questions. Ad-
vantages: (free) expression of the participant; indicate
Assessment Indicators that the trainer is interested in the participants opinion;
The participants performance is assessed through cri- increase the participants share of responsibility in the
teria or indicators in line with specific objectives sen- assessment. Disadvantages: increase complexity in ana-
sitive to the Nurses intervention, translating into clini- lyzing the answers (content analysis); subjectivity (with
cal quantitative/qualitative results (Melo-Dias, Rosa, e personal content); require writing and reflection skills;
Pinto, 2014). and require more time spent writing the answer.
The selected indicators arise from the specific knowl-
edge and experience put into the intervention by each Ethical Aspects to be Considered
Nurse (or team). The free informed consent is the core concept in these
t$BMDVMBUJPOT TPMWJOHTUBHFTTUFQT
 relationships. Although it coexists with a typical envi-
Example: How many self-massage steps did perform? ronment of tensions, these should be aimed towards
How many breathing cycles per minute? continuing to build a free, democratic and pluralist so-
t %JDIPUPNPVT BOTXFST UXP NVUVBMMZ FYDMVTJWF BMUFS- ciety based on an agreement established between those
natives). who are part of it (Melo-Dias, 2003).
Example: Says the persons name, yes or no; Throws the The Nurses interventions are concerned with protecting
ball, yes or no? the freedom and the dignity of the human being and
t-FWFMTPGQFSGPSNBODFBOEPSCFIBWJPSBMFYQSFTTJPO the Nurse. Thus, responsible freedom and the capac-
Example: What is level of anxiety observed: mild, mod- ity of choice aiming at the common good are univer-
erate, high? sal values to be pursued in the professional relationship
Example: In the six-level dependence-independence (Decreto-Lei n. 104/98). The informed consent may
continuum, what is the current level regarding the need be an autonomous action or an institutional authoriza-
tion. In this case the focus is on the autonomous ac-
x / problem x / focus of attention x? (Phaneuf, 2001).
tion, for it gives the Nurse permission to intervene (or
According to Moorhead, Johnson, Maas, and Swanson
to investigate) with a therapeutic plan, complying with
(2010), a nursing outcome indicator is a specific vari-
the following conditions: (a) a reasonable knowledge of
able that is responsive to a nursing intervention. It cor-
the client; (b) the absence of third party control; (c) the
responds to a state, behavior, feeling or expression of clients intentionality, and (d) the permission for Nurses
observable perceptions or assessments reported by the action (Melo-Dias, 2003). Regarding the ethical aspects
client classified in a specific level. Each outcome is as- to be considered in the TOAs (as in other Nursing inter-
sessed on a five-point Likert type scale that quantifies ventions), we believe that an informed consent requires
a continuum from least desirable (1), to most desirable more than a mere signature; it entails the acknowledge-
(5), and provides a rating at a point in time. ment of the clients autonomy and of a free, voluntary
The following are examples of NOC outcomes: Inter- and intelligent decision made by an autonomous adult
acts with other appropriately; Expresses emotions dur- person in full possession of his/her mental faculties,
ing play activities; Difficulty concentrating; Verbalized giving permission for something proposed by another
anxiety; Irritability; Respiratory rate; Pulse pressure; person to be accomplished (Melo-Dias, 2003).

Revista Portuguesa de Enfermagem de Sade Mental, N 15 (JUN.,2016) | 68


Therefore, we have two forms of expressing consent: psychosocial functioning, burden of psychotic symp-
tacit consent (the clients behavior or verbalizations ex- tom, health, cognitive functioning, empowerment,
press his/her approval) or express consent (documen- long-term competitive work/employment/occupation,
tary expression of consent). and quality of life (Mueser & Gingerich, 2011; Van-
Meerten et al., 2013; Svedberg, Svensson, Hansson, &
Persons Responsible for the Activity Jormfeldt, 2014).
This section is important to hold the nurses accountable Benefits in improved functioning revealed also that the
implementation of these psychosocial rehabilitation
for the technical-scientific procedures responsibility,
programs to persons who had been hospitalized was
both when leading the session and when assessing the
associated with decreased duration of hospitalizations
participants performance.
and costs savings of all inpatient that had participated
(VanMeerten et al., 2013; Melo-Dias, 2015).
CONCLUSION It is also important to emphasize the use of indicators
Therapeutic Occupation Activities (TOA) are orga- in tune and sensitive to the Nurses intervention and
nized to promote, prevent, enable, maintain and/or re- translated into quantitative/qualitative clinical results.
cover and develop the individuals skills to holistically They enable the Nurses to document the effects of the
express his/her Fundamental Human Needs (FHN), interventions made available to the clients (Melo-Dias,
thus responding to nursing problems / focus of atten- Rosa, e Pinto, 2014; Bulechek, Butcher, Dochterman,
tion. These activities are prescribed, implemented and & Wagner, 2013; Moorhead et al., 2010; de Cordova
assessed by nurses based on the nursing diagnoses and et al., 2010), while holding them accountable for the
clinical reasoning (Melo-Dias, Rosa, e Pinto, 2014). technical-scientific procedures responsibility, and also
of crucial impact on social media exposure of Nursing
The clinical reasoning emerges in the complexity, re-
autonomous outcomes.
flexivity, creativity, intuition and cognition of the nurse,
client and context, making it possible to draw updated,
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