ORIGINAL ARTICLE

 

To take care and being cared: opinion of nursing students on a mental health project

 

Cuidar y ser cuidado: la opinión de académicos de enfermería sobre un proyecto de salud mental

 

 

Marcelle Paiano^I; Beatriz de Carvalho Ciaciare^II; Maria Angélica Pagliarini Waidman^III; Lílian Cristina Bento^IV; Bruna da Costa^V

^IDoctoral student, Universidade Estadual de Maringá, Maringá, PR, Brazil
^IIRN, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
^IIIPhD, Adjunct Professor, Universidade Estadual de Maringá, Maringá, PR, Brazil
^IVRN
^VUndergraduate student in Nursing, Universidade Estadual de Maringá, Maringá, PR, Brazil

Correspondence

 

 

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ABSTRACT

This study aimed to capture the opinions of nursing students who participated took part of the project "Nursing Mental Health Assistance" on its importance to their professional training. The qualitative and descriptive research was performed with 42 students. The data were presented in two themes: "Talking about mental health" and "Understanding others and yourself from interpersonal relationships." We have found that the student feels happy to be taken care and that this concept of happiness comes with competence, so we can say that anyone who takes good care of itself is more prepared to care for others.

Descriptors: Mental Health; Delivery of Health Care; Nursing.

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RESUMEN

Se objetivó aprehender la opinión de los académicos de enfermería que participaron del proyecto "Asistencia a la Salud Mental del Académico de Enfermería" sobre la importancia de eso para su formación. El estudio, descriptivo de naturaleza cualitativa, fue realizado con 42 académicos. Los datos fueron presentados en dos categorías temáticas: "Hablando de la salud mental" y "Comprendiendo el otro y a sí mismo desde las relaciones interpersonales". Verificamos que el académico se sienta feliz al ser cuidado y que en ese concepto de dicha viene a embutida la capacidad, por eso podemos decir que quien cuida bien de sí tiene mejores condiciones de cuidar del próximo.

Descriptores: Salud Mental; Prestación de Atención de Salud; Enfermería.

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Introduction

The formation of a competent professional for the practice of nursing has been one of the objectives of undergraduate courses. We have realized that the major students' concern during the course is related to their technical skills, but we believe that proper training is also necessary to develop other skills such as empathy, communication, interpersonal relations and others.            

It is possible to understand that many scholars find it difficult to develop care activities, both in relation to each other as to the patient, and often these difficulties are linked to personal issues. Concerned with this problem, in 1998, the State University of Maringá (UEM) has developed a teaching project "Mental Health Care of the Nursing Student" which intended to offer to the scholars the opportunity to express their difficulties, knowing they will be understood in their uniqueness avoiding, thus, the commitment of their mental health.

Regarding what we have observed in contact with these students, sometimes they have problems which affect their mental health and in certain cases they need to be referred for treatment, while others manage to overcome this condition simply by participating of the project.

The central focus of this project is the care⁽¹⁾, activity on which Leininger, a nursing studious, researching on care, has identified 175 different types, showing that this concept varies among different cultures. In this study we will adopt the concept of care that includes: "To assist others; to be authentic; to get engaged; to be present; to comfort; to care; to be considerate; to be compassionate; to express feelings, to make something for someone and with someone; to touch; to love; to be patient; to protect; to respect; to share; to have technical skills; to demonstrate knowledge and security; to appreciate others value; to be responsible, to use silence; to get related spiritually and to listen carefully"⁽¹⁾.

From this conception of care, reflecting on the quality of the professional who are graduating, we have concluded that it is necessary to form a competent nurse, capable of care.  On the other hand, if care is all we mentioned earlier, we believe that this student needs to have the experience of being cared in order to feeling happy to further care satisfactorily.

The concept of happiness that we have adopted and which we refer to brings in itself the technical, scientific and human competence, as when people are happy, they perform their activities with love, responsibility and ability⁽²⁾, qualities or skills that are essential for the proper performance of care.

By providing to the students the opportunity to reflect and to discuss their way of relating and the difficulties encountered in their living process, we offer them the opportunity to know themselves to be able to have a well relation with others in a satisfactory way, with order to better care for themselves and each other.

In the nurses' training process the search for self-knowledge is critical, because the student, as a human being, experiences several crises or potential crises, and these experiences, willing or not, can influence them with their clients⁽³⁾. Included here, there are all existential problems, unresolved conflicts and many other difficulties to be overcome but with no subsidies offered by the course.

Therefore, this study aims at understanding the opinions of nursing students who participated in the teaching project "Nursing Mental Health Assistance" on the importance of this project in their formation.

 

Material and Methods

In this descriptive with qualitative research study we interviewed 42 students enrolled in all Nursing grades of the UEM, in 2007. For this, we interviewed students who participated of the project in 2005 and 2006.

For data collection we used a semi-structured and self-explainable plan developed by the authors, which requested information on age, gender, family data, entering university, data on housing, relationships, physical and leisure activities, mental health understanding, reason for participation and opinion on the project. The questionnaire was given to the students who participated in the project in the stipulated period. For data collection, which occurred in March 2007, it was programmed and conducted an individual meeting with each participant student.

For the analysis we used as reference the content analysis⁽⁴⁾, considered as an excellent method to analyze and interpret messages. This analysis is understood as a group of technique analyses for messages, whose concern lies behind the manifest content, i.e., it is more than it is being communicated. The content analysis may involve three stages: 1) pre-analysis; 2) material exploration; 3) processing and interpretation of results. This was an exhaustive and complex part and it was attempted to obtain the data subjectivity necessary for the interpretation and inference required for this type of study.

Initially the data were placed in a worksheet in which there was a  space for researchers to make relevant notes. In the first analysis we carried out a preliminary reading, paying attention to the points that were of highest interest and meet the objectives of the study. Next, there was a second reading, which was mindful regarding the relevant points and the parties of interest were underlined. In the third reading, there were written words next to the speeches, called code, which should, in the next phase, refer to the expressed content. After, these codes were grouped, analyzed and interpreted, generating two categories: 1) Speaking of mental health and 2) Understanding you and others from interpersonal relationships.

There were taken into account all ethical precepts required by the Resolution 196/96 of the Ministry of Health⁽⁵⁾, i.e., all participating students signed informed consent accepting to participate. The project was authorized by the Ethics Committee of the State University of Maringá, (n. 0349/98). In the presented speeches the students are identified by numbers (Ac1, Ac2...), to preserve their anonymity.

 

Results and Discussion

From the students interviewed, 15 were under 19 years; 26 were from 20 to 23 years and one was more than 24 years; 17 were in the first year of the course; 12 in the second year; nine in the third year and four were in the fourth year. Regarding gender, 38 were female and four were male. Regarding their origin, 11 were from Maringá and lived with their families; 26 were from other cities and lived alone in boarding houses or shared apartment with colleagues and/or relatives; five omitted this information.

The fact of being away from home led the students to seek assistance in the project, demonstrating that the absence of the family has contributed to the increase of the difficulties encountered at the university, which would or not related to relationship problems. [...] It was very nice because of change issues (city, course and new friends) [...] because there was all the difficulties that a nursing student goes through [...] (Ac1). We can speak about things here... (Ac12).

Entry into university in pursuit of a career is an important step in the human being's life and it has been happening earlier. We have verified that most students participating in this study (22 students) entered the university between 17 and 18 years; 12 between 19 and 22 years, and the other, over 23 years. We believe that the uncertainty related to immaturity can often lead these scholars to suffer for the decisions that sometimes they need to take and, in some cases, the distance from family or trusted people with whom they can share their difficulties exacerbates the situation. It is observed, thus, that they found in the project a space to discuss their anxieties and fears and talk about issues that afflict them, including problems related to their profession and to the academic life.

Talking about mental health

From the analysis of the messages we have found that when mostly students talk about their mental health they talk about a state of physical and mental well-being associating that feeling to life conditions. It is when they are well with themselves and with others. It is when they are able to deal with problems without interfering their social life (AC8). It is the maintenance of mental well-being, which favors the whole organism. I believe this is fundamental for everything else to work well (Ac17).

Mental health is defined as a simultaneously success at work, love and creation, with the ability to make mature and flexible decisions of conflicts, consciousness, others significant people and reality; or as a dynamic state in which it is demonstrated thoughts, feelings and behaviors consistent with age and social and cultural norms⁽⁶⁾. Health of thought and mind, a way of organizing our feelings and deal with them (Ac30).

We have observed during the implementation of project activities that most students refer to performance in college. This stress creates anxiety, depression, difficulty sleeping and tiredness. Some students also refer not eating well and it is observed, in the project groups, that some have lack of affection, crying, and heightened sensitivity, among others.           

The students consider the project as a space where they can talk about issues, fears and anxieties related to their personal, academic and professional lives. They further state being comfortable, because they can talk, be heard and understood by the groups: [...] We can talk about problems without fear of a negative reaction"(AC14).

They reveal a trust relationship, which is due to [...] how the teacher has approached the group, giving them an immense care and attention to each one [...] (Ac19). There is companionship and attention, because no one was concerned about if the other was right or not, but simply listened and tried to understand (Ac20).

The interviewed have indicated that the attention from teacher and classmates help them in their own mental health, teaching them to know themselves better, to deal with their problems, and that the project activities can help to reduce the stress imposed by the university reality. [...] Talking about some things in here is good to relieve some stress and worry because of tests and internships"(Ac5).

They have also reported that the project helps them to better understand their and others' reality, allowing them to, thus, take care of themselves and each other. [...] It is very important to take care of ourselves ... therefore, we are able to care for others [...] (Ac11).

Knowing how to listen or listening reflectively is an active process and requires attention and concentration. It is necessary to try to understand between the lines; by hearing it is necessary to be careful not to judge⁽⁷⁾, it is try to understand the other person and have empathy as a therapeutic tool. This listening skill is developed by all participants when they agree to be with their colleagues, in the group. We believe that it is in this listening and communicating learning process that the student grows up and understands himself.

All participants have rated their mental health as good, and to keep it, during spare time they watch television, date, sleep and go out with friends. As for physical activities, 30 interviewers have reported not playing sports and attribute it to lack of time caused by the extensive workload at the university, which involves full time classes.

Understanding themselves and others from interpersonal relationships

Communication and interpersonal relationships are processes and communication skills between individuals and groups with the purpose of adjustment, integration and development⁽⁸⁾.

Our experience is based on several theorists who study relationship, however, Joyce Travelbee has been chosen because of her extensive approaches on the subject. In this study, interpersonal relationship is defined as "[...] un proceso interpersonal mediante el cual la enfermera ayuda a una persona, familia o comunidad con el objeto de promover la salud mental, prevenir o afrontar la experiencia de la enfermedad y el sufrimiento mental y, si es necesario, contribuye a descubrir un sentido a estas experiencias...constituye un proceso interpersonal que se ocupa de personas. Estas personas pueden ser pacientes individuales, familias o grupos que necesitan la ayuda que la enfermera puede oferecer"⁽⁹⁾.

Thus, based on the adopted reference, by offering to the students the opportunity to express their feelings, we have found that it helped them to improve their mental health and to overcome their relationship, as reported below. [...] It helped me to solve behavior and relationship problems with the people I live with (family, boyfriend and friends) (Ac3). [...] It helped me to understand some things differently, about dealing with people and issues that involve them more comprehensive, although it is very difficult to completely change the way each person thinks (Ac7).

It also offered self-acknowledgement to the students, and for participating in a group, sharing their experiences and views on different issues and even about life, made them ​​to grow up as human beings. It helped me to realize simple things like interpersonal relationship, and to appreciate the simplicity of a hug and much more [...] (Ac12). [...] This project helped me to feel better and happier, made me give more value to doing good things than the bad; it helped me to relieve some stress and worries of tests and internships (Ac15).

Communication with oneself is the proper way that the individual has to be part of a group, because this process helps him/her to a better understanding, to know his/her limits and strengths that interact within him / her⁽¹⁰⁾.

The activities developed in the project (group) were highlighted by the students, who reported that the techniques and dynamics were well received, allowing them to manifest their problems in a natural way. The identification of common problems among participants is also a factor of cohesion and closeness. According to their statements, the problems perception they experience were the same as other colleagues of the same age faced, and in the same situation it has helped them to face the situation with less suffering. In some cases, when someone noticed that a colleague problem was more serious, he/she encouraged the colleague not to be discouraged and realize that it was being given a high value to certain things that did not deserve so much investment and psychological suffering.

Support or therapeutic groups have as main objective to assist participants to deal with emotional stress, focusing in relationships that can lead to mental health problems⁽¹¹⁾. The group is not only a sum of individuals, on the contrary, it is constituted as a new identity, with its own and specific mechanisms, and to be considered as a group all individuals that are part of it must be gathered around a commitment or a common objective. Although the group has a common identity genuine, it is essential to be clear that the identity of each member of the group should be preserved⁽¹¹⁾. [...] I see that I started thinking more about things [...] working in a group is a rich experience, because we share many ways of looking at the same situation. The diversity of thoughts tends to add several ways of seeing life and I seem to feel less alone (Ac24).

Another problem pointed out by the students who live together with other students is the initial difficulty of being away from family and learn to live with what is different (other people, other city, other customs). They report that the project activities, group dynamics and discussions on intrapersonal and interpersonal relationship helped them to overcome the difficulties. [...] Crying, anxiety, are due to homesickness I got of home and my family. When I started, I expected the project to help me find answers to these problems, because in this project other people with my similar situation would also participate, it was an opportunity to exchange ideas (Ac29).

The value system of an individual is established at the beginning of his/her life and has its bases on the principle of values ​​accumulated during life⁽⁶⁾. This value system is sustained by cultural beliefs, customs and attitudes, because the clarification and recognition of the values ​​and customs lead humans to become aware of them and accept their condition of life⁽⁶⁾. We believe that, when speaking of living difficulties with what is different, the student begins to reflect on his/her life, which leads him/her to respect and understand the uniqueness of each human being and develop activities with utmost care and responsibility so that he/she really takes care⁽¹²⁾, ensuring his/her and others well-being⁽¹³⁾.

Another point emphasized by students was the exchange of experiences among the students from the communication and the relationship developed during the activities of the project group (eight encounters, one a week). They have reported that the advice and guidance given by peers or teachers have provided them personal growth and balance. They have stressed that this experience is likely to ease their ability to care for, making their professionals who value ​​the human being in its uniqueness and completeness. [...] A greater understanding of myself and how we need to relate well with people, because we need a harmonious coexistence with those who are around us (Ac15). [...] I see that it is very important to take care of ourselves before we take care of other people [...] (Ac33). [...] This project helps us to think better about ourselves and the actions we take; it helps us to have a good mental health, so we may be able to care for others (Ac42).

It is possible to observe that the students themselves recognize that the project is the place for them to know themselves and others, and thus, live an empathic experience and growth, because empathy is the ability of humans to use their knowledge about relationships and put themselves in other people's position, but do it without ever losing their identity as a human being⁽⁷⁾.

This growth experience and development is also part of caring, as the essence of care is to help each others to grow and achieve their objectives. In this process, tanking care is to be with the person in his/her world, which is promoting growth and development of the other person, which involves friendship and above all the ability to make the other person happy⁽¹³⁾. It is essential to understand that the human being lives the meaning of its own life, and that when it cares, it is being taking care. In the relationship between the person and the other, both of them need each other, however, for this to happen, it is necessary to develop a relationship based on trust, not on the use of power, recognizing the needs and rights of those involved and making them become responsible for the care given or received.

The human being needs to be aware of its need for growth (self-care), in order to seek the fullness of its condition. Caring of others is the antithesis of manipulation to get its own pleasure. The main items of care are: knowledge, alternating rhythms, patience, honesty, trust, humility, hope and courage⁽¹³⁾. Thus, from what it has been surveyed along with the students we believe that they, in their experiences in the project, have managed to care and be cared for, always seeking the ability to be happy and make other people happy from the abilities and skills acquired in their professional training.

The students have shown they consider the Project as a caring environment and a means to learn to care, which corroborates with the perception of students from a previous research, which found the care environment as the foundation place of caring and providing interactions among the subjects of giving and receiving care, with unique characteristics that are linked and complement each other⁽¹⁴⁾.

In this sense, we agree with other authors⁽¹⁵⁾ when refer to the adoption of a non-excluding practice and actions that promote mental health are fundamental in basic training of nurses, which refers to the need for convergence between education and practice. This reinforces the importance of the project conducted and analyzed by the interviewers and the importance of having a place at university to receive a care that can be applied to practice, because from the data presented here we can infer that the experience of being cared for gives future professionals awareness that they must take care of each other with the same quality that cared for themselves.

 

Final consideration

The purpose of this Project is to give to the students the opportunity to express their difficulties knowing they will be understood in their uniqueness and that their identity will not be compromised. It also aims to support the nursing students' with relationship difficulties, with the belief that this could influence the teaching-learning process. Nevertheless, according to the students' perception, the objectives were achieved beyond those proposed, because they could ponder about their existence as caregiver and receiving care.

We also note that the students are happy to being care of in the way proposed by the Project, and we found in some speeches and observations made ​​during the groups' meeting that competence is part of this concept of happiness; so we can say that with the assistance of the Project it is possible to form most qualified professionals in interpersonal relationships and better capable to care for themselves and others.

It was observed that it is possible to make students to realize that all of us have anxieties, fears and insecurities and we need to speak and be listened to with care and attention, in order to relieve these feelings and then, work to overcome them.

The students have reported that many things seen and done during internships (practices) are not discussed and worked properly during this phase of training and that causes anguish, anxiety and suffering. In their opinion, the space that the Project offers them to talk of their lives is configured as a place where they can reveal, share fears and anxieties related to personal, academic and professional issues, and that, directly or indirectly, helps them to improve their lives, reflecting both in scientific learning (notes, knowledge building) and the personal aspect (improved relationships, maturity).

Among the limitations of this study it can be pointed out the fact that it reflects reality, investigated in a qualitative perspective, preventing generalizations. However, as health professionals who work in Higher Education Institution, we have found, in these seven years, period of this Project, which we contributed to an integral formation of the students; this is why we recommend that other institutions offer to their nursing students spaces like this.

 

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Correspondence
Marcelle Paiano
Universidade Estadual do Maringá
Av. Colombo, 5790
Jardim Universitário
CEP: 87020-900, Maringá, PR, Brasil
E-mail: marcellepaiano@hotmail.coma

Received: Oct. 13^th 2010
Accepted: Jan. 25^th 2013