Report of the Use of California Florals in Extension Projects Carried out at the Ana Nery/Ufrj Nursing School

Integrative and Complementary Health Practices (ICHP) have been recognized by the World Health Organization since the 1970s. In 2006, the Ministry of Health launched the National Policy on Integrative and Complementary Practices (PNPIC) in the SUS. PICs use the integral approach of the person based on individual needs considering the physical, mental, social, spiritual and emotional aspects. These practices contribute to the increase of well-being, promote support in the relationship with society and stimulate the self-care of people in treatment [1]. 

Floral Therapy was created by Dr. Edward Bach, an English clinical physician and homeopath. He devoted himself to developing a simpler and more natural therapeutic method aimed at curing the causes and not the symptoms which would treat the individual, not the disease. Floral essences help in the work of balancing emotions with better discernment for decision making [2]. At the Anna Nery School of Nursing / Federal University of Rio de Janeiro (EEAN/UFRJ), we have the Integrated Research and Care Program (PIPA) where several extension activities are carried out. Within PIPA we have two projects with floral therapy: "Technology applied to the care of people living with HIV/AIDS" and "Technology applied to the care of teachers, administrative technicians and Undergraduate and Graduate students". 

The project entitled "Technology applied to the care of people living with HIV/AIDS" is aimed at the care of HIV-infected men and women at various times of infection (recent and late diagnosis). With another focus, the project entitled "Technology applied to the care of teachers, administrative technicians and undergraduate and graduate students" is aimed at serving the general public with emphasis on the members of the Social Body of EEAN/UFRJ.

Thus, nursing professionals using complementary therapies in PLWHA can have a relevant impact on quality of life, personal empowerment and the way this individual relates to the world. Thus, nursing actions in relation to the practices of complementary therapies to the person living with HIV/AIDS may be based on the nursing theories of Myra Levine and Sister Callista Roy, who respectively advocate nursing as a promoter of the conservation of structural, personal and social energy in the face of the dynamic interaction between the being and the environment; and nursing providing the adaptation of this public in the physiological fields, in the self-concept of identity, in interdependence and in the performance of its role in society [3]. 

In this context, this study aims to identify the meaning of complementary therapies in the lives of people with HIV/AIDS, to verify the main changes after treatment with complementary therapies and to discuss the effect of these therapies on the lives of people with HIV/AIDS. That way, this research seeks to contribute to the incentive of the training of health professionals focused on complementary therapies in the expansion of the number of care and access to complementary practices by the SUS, with the inclusion of Bach's Reiki and Floral therapies in the National Policy of Integrative and Complementary Practices (PNPIC); and thus enable comprehensive health care and improvement in the quality of life of PLWHA.

The aim of this article is to identify the meaning of complementary therapies in the lives of people with HIV/AIDS, to verify the main changes after treatment with complementary therapies and to discuss the effect of these therapies on the lives of people with HIV/AIDS.

This is a research with a qualitative approach; therefore, the information collected is subjective and expresses different values according to the analysis. This approach seeks to understand the opinions, beliefs, values, motives and attitudes of certain groups, segments and small realities in order to understand relationships, processes and phenomena [4]. 

The method used as theoretical reference was Life Narratives as proposed by Daniel Bertaux, which is based on a statement of the testimony of life experience by the intention of knowledge of the researcher who records it. Thus, previously, the intention of knowledge to the testimony must be explained and clarified so that it is understood, accepted and internalized, so that an implicit filter is established that will select only the semantic universe that corresponds to the expectations of the researcher [5].

Data collection was performed in the space of the Integrated Research Assistance Program (PIPA), where the extension project took place - People Living with HIV/AIDS and Floral Therapy and Reiki: Actions to enhance treatment adhering located in the Thompson Motta Pavilion, at the Anna Nery Nursing School, Federal University of Rio de Janeiro. 

This extension project allows the access of people living with HIV/AIDS (PLWHA) to receive fortnightly care of floral therapies and Reiki. The PLWHA participating in the project should be performing regular HIV treatment in a health unit and participate voluntarily. This project started in March 2013. In relation to the sample, ten people living with HIV/AIDS (PLWHA) were selected as members of the extension project who participated in the project in a period of more than one year, of both sexes, older than eighteen years and who agreed to participate to the research. 

The signing of the Free and Informed Consent Form was requested prior to the interview, where the participants were informed about the research and invited to authorize the use of the information granted for the preparation of the information under free approval. The project was approved by the Ethics and Research Committee (CEP) of EEAN/HESFA/UFRJ with caae number 61087416.0.0000.5238. All participants signed and received the Free and Informed Consent Form (TCLE). The data was obtained from March 31 to June 16, 2017, through a recorded interview containing two open questions: "What does it mean for you to have access to complementary therapies?" and "What were the changes in your life throughout this year that you have been doing complementary therapies?".

The technique used for data analysis was thematic analysis as proposed by Bardin, which consists of a set of communications analysis techniques conducted through systematic and objective processes to describe the information expressing the analytical content targeted by the researcher. This analysis is fundamentally divided into three phases: Pre-analysis; Exploitation of the material; e Treatment of results, inference and interpretation [6].

In the first phase of Bardin's thematic analysis, the Pre-analysis was transcribed, the audios collected in the interviews and the "floating reading" of the material were constituted, where the first impressions of the transcribed material of each interviewee were constituted, which during this research are anonymously titled as 'Participants' and the number corresponding to the order of the interviews [6]. 

From the floating reading, we sought to understand the interviewees' discourse by observing the priority of enunciated ideals, the vocabulary used, the explicit and implicit meaning of the discourse and the thematic distancing of the answer to the right-hand question. Thus, it was possible to conceive the research corpus and elucidate the interviewees' opinions, beliefs and views on the subject [6]. In the second phase of the thematic analysis, the Exploration of the Material, the analysis of similar and discrepant discourses occurred; the ratification of the thematic frequency of the reports, and consequently the denotation of the most relevant theme; and the deepening of the research corpus. Therefore, the raw data of the transcribed discourses were organized and classified into thematic categories [6]. 

Thus, the treatment phase of the results, inference and interpretation, consisted in the exposure of significant and real results, where the material was interpreted and discussed according to the limits of the general and specific structures of the research [6].

When analyzing the reports of experience of PLWHA on the use of complementary Bach and California systems therapies in a period of more than one year, the following thematic categories were elaborated in the Material Exploration phase: Self-Esteem/Self-Confidence; Interaction with the project team; Valorization of self-care and perceived changes and evaluation of the project. 

Complementary therapies can act in different spheres in the promotion of human health. Therefore, when asked about what were the changes in the participants' lives over the course of a year by doing complementary therapies, the following thematic categories were identified: Self-Esteem/Self-Confidence; Interaction with the project team; Valorization of self-care and changes perceived by the participants. 

Self-esteem/Self-Confidence 

In this thematic category, the participants' statements revealed that from the use of complementary therapies there was an improvement in self-esteem/self-confidence, associated with personal empowerment and a greater acceptance of their HIV-positive condition, as can be seen in the following statements: 

I got the highest self-esteem, became more self-confident. I'm much freer, I recognize that I'm not just a black woman, I'm an important being on this earth. Interviewee 1

With a little more harmonization in my life I was able to see myself, I saw myself as a very sick person, very limited, [...], but before and after (of complementary therapies) is a better person, more aware of me, in many aspects of my life. It did me very well! Interviewee 5 

Complementary therapies allow an improvement in self-esteem and sociability, reflecting on an active behavior, of greater disposition for daily activities. The improvement of these aspects is of great importance for PLWHA, because often this public is in situations of prejudice, generating a low self-esteem and feeling of loneliness [7]. 

Interaction with the project team 

The establishment of a bond between the health professional and the service user is fundamental for the effectiveness of health actions and for the professional-user co-responsibility for the quality of the health service for the population [8]. Likewise, the relevance and appreciation of the study participants in the interaction with the extension project team is denoted, as noted in the following reports: 

Coming to the service is already good, because it lives with nice people, who give themselves to us and this is very important, I feel loved, welcome always, with smile, this does a bad good. Interviewee 2

Coming only in Floral Therapy and Reiki, every fortnight or monthly, I was in consultations with you guys and it helped me a lot because I really felt cared for. Interviewee 7 

There are nursing theories that focus on care and interaction between nurses and health service users, since this relationship directly influences the quality of the health service provided. For example, Joyce Travelbee's Theory of Interpersonal Relationship aims through interpersonal relationships and holistic care to help the individual and the family cope with the disease and suffering [3]. 

Valuing self-care 

The nursing theory of Self-Care, conceived by Dorothea Orem, refers to the act of promoting self-care a therapeutic action to sustain life and health in the recovery of the disease, injury or coping with its effects. Therefore, the practice of promoting and valuing self-care are fundamental changes and of great relevance for the improvement of the health of PLWHA [9]. In the statement below, it is remarkable the development of self-care from floral therapy: 

It improved to say no, on account of the Florals, I feel transformed, I started to look more at me than for everyone right, if not I do not realize, or I look for myself or everyone, there as far as possible right, because I have three children .... Now I'm more selfish, my whole life taking care, there comes, now it's my time, do what I like, nothing holds me anymore, no. Interviewee 2 

However, this thematic category had a smaller number of statements that mentioned this change. This fact can be attributed to multiple factors, such as simply the difficulty of the human being in implementing self-care. Therefore, it can be said that this category is considered less relevant in relation to changes in the use of complementary therapies. 

Perceived changes in daily routine 

First, regarding this thematic category, it can be said that it was the category with the highest number of statements, therefore it was designated as the most relevant theme and consequently the corpus of the research. First, regarding this thematic category, it can be said that it was the category with the highest number of statements, therefore it was designated as the most relevant theme and consequently the corpus of the research.

Among the various changes perceived after the use of complementary therapies in a period of more than one year, the participants highlighted the significant improvement in emotional balance, which was also reflected in aspects such as coping with adversities with more serenity; the improvement of personal relationships and the improvement of health in general. 

Complementary therapies, such as Reiki, encourage the individual in its emotional and psychological restructuring, because they stimulate the immune system and the maintenance of homeotase in the body in the long term, promoting changes in behaviors related to health maintenance [10]. The improvement in coping with adversities with greater serenity and enthusiasm due to emotional balance can be exemplified through the following reports: 

It has changed well-being and quality of life. Before I was more paranoid, stressed, agitated, more wrong with life. Now I'm more balanced, more focused, more optimistic, more responsible, more concerned with life and waiting for things to happen so that the sum and good things will happen. Interviewee 9

What helps a lot are the Florals, they attend to me in various things like anxiety, what happens inside. We expose and have therapy to help win the stages. Interviewee 2

The fact that we have HIV associated with another disease of greater strength, has helped me a lot (the therapies) to process this information in my mind and I think I control a little bit of my mental confusion. Reiki has improved this situation a lot, it's given me more strength, it's been helping me to get up in a few moments. Interviewee 6 

Another reported change, derived from emotional balance after the use of complementary therapies, was the improvement in interpersonal relationships. This change can be attributed to a greater understanding, patience and tolerance in the way of relating as another and with oneself. The following reports illustrate the change in relationships: 

I have a lot of personal problems with mom, I still do, but it's improved a lot. And with each floral formula I feel the change, the difference, I come into contact with myself every day [...]. Changed the cycle of friendships, relationships; now I stopped a little to take care of me, to come someone with the same harmony as me. Interviewee 1 

Complementary therapies with energy techniques, cause multiple physical and emotional effects beneficial for the improvement of health, such as the reduction of sympathetic nervous system activity, anxiety, stress, as well as the stimulation of homeotase in the body, these effects favor the reduction of blood pressure and heart disease [10]. Following statements address aspects of health improvement after the use of complementary therapies:

Before I went to the therapies, I had panic, my immunity (CD4) did not increase at all, even taking the medications. After I started doing reiki and floral therapies went to 900 cells/mm³ and it was 400 cells/mm³, increased immunity. Interviewee 3

I felt that it improved concentration, overall health, I feel very healthy and my tests show as if I did not have HIV. Triglycerides and cholesterol have improved since therapy, I do physical activity, I feel more energy. Interviewee 7 

The relationship of access to floral therapies and Reiki: an evaluation of the Project 

This thematic category refers to the question: "What does it mean for you to do complementary therapies?". The results obtained through the experience reports showed that Bach and California florals therapies mean for participants a comprehensive treatment, a complete care, and a therapy that treats not only HIV, but also the person. The excerpts below are examples of the statements that refer to this concept. 

I really liked the project, of great importance for those who live with HIV because usually doctors treat only through medicines, does not treat the self, to people themselves. Interviewee 1

And this therapy is very important to me because I do not have a psychologist, here is a complete care, I do not feel the need for a psychologist and these therapies have met all my needs, thank you. Interviewee 7 

In answering the first question mentioned above, the PLWHA also attributed the meaning of complementary therapies to an improvement in mental, emotional and social aspects, as the following reports illustrate: 

I think everything is much better and I do not know if I would be without, I feel a very great need to come here and enjoying all the benefits it brings. Floral therapy has improved several aspects of my life, I point out the issue of menopause, PMS and memory. I've had more concentration and improved my speech. Interviewee 7

I had a range of options after I started Reiki that before I did not see, as you look at life, give more value as a human being even. Interviewee 11 

Some interviewees also expressed a feeling of gratitude for the extension project when asked about the meaning of complementary therapies. In addition, they also verbalized the desire to continue treatment through complementary therapies, the lack they feel when they cannot attend the service and the desire to stay in the project. 

I really like therapy, I want to continue, I don't want the project to end. I like to come here, I wake up knowing that I'm going to have a few quiet moments, and I get a lot of energy from reikians and I'm using that energy in the days that come before me, I feel good. Interviewee 7

Complements, but is an important complement to me, and still being, I even miss it. There are moments that I miss and I remember and the feeling during Reiki and help. In the floral, by the goal I had to let go and improve assertiveness I improved. Interviewee 10 

In agreement with the results of this thematic category, complementary therapies are obtaining greater recognition of the population due to the holistic approach of the illness process, both in the integral care of the individual itself and in the construction of a link between healer-patient. The holistic approach of the individual in health care achieves a greater satisfaction of the population when compared to the low comprehensiveness of biomedical care [11]. 

In addition, complementary practices encourage the individual to rebalance his 'inner self' with the 'external self' through the care techniques that each therapy provides, in order to contribute to health promotion and the natural healing process. However, establishing this therapeutic process becomes difficult to implement for scientific knowledge/practices that follow the biomedical care model [11]. 

Thus, based on the experience reports of the interviewees in this research, complementary therapies showed multiple positive results in the bio-psycho-social aspects, besides not presenting records of side effects, contraindications and physical or psychic dependence. Thus, the implementation of complementary Reiki and Floral Bach therapies in the SUS, at all levels of complexity of health care, are extremely beneficial for the population, because in addition to presenting numerous advantages in the association with conventional treatments, they require a simple structure and low cost to be performed [12]. 

However, it is essential to invest organizations that finance research in complementary therapies, seeking to determine the effectiveness, safety and cost-effectiveness in the SUS, because one of the main obstacles to the implementation of these therapies in the SUS is the scarcity of financial resources [12]. Therefore, for the insertion of complementary therapies in the SUS, there must be an incentive from the government through investment in comprehensive health policies, since these therapies act in health promotion, prevention of risks and diseases, maintenance and recovery of health, contributing to the development of a health model compatible with the principle of Integrality of the SUS [12].

In general, the use of complementary therapies, Reiki and Bach Florals for PLWHA, meant mainly to acquire an integral treatment, focusing on the holistic improvement of the individual. In addition, improvement in mental, emotional and social fields was also designated, leading research participants to express a feeling of gratitude for the extension project when asked about the meaning of these therapies. 

Thus, it is possible to affirm that after the use of Reiki and Bach Floral therapies, PLWHA obtained positive and significant changes in their lives, especially with regard to self-esteem and self-confidence; appreciation of self-care and emotional balance, which resulted in improved health, personal relationships and coping with adversities with more serenity. 

Therefore, it is concluded that the implementation of complementary Reiki and Floral Bach therapies in the SUS becomes too important and beneficence for PLWHA, and it is necessary to invest in comprehensive health policies, with greater adherence to complementary therapies, as well as funding in research related to the implementation of complementary therapies in the SUS.