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SMAD. Revista eletrônica saúde mental álcool e drogas

versão On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.15 no.2 Ribeirão Preto abr./jun. 2019 

DOI: 10.11606/issn.1806-6976.smad.2019.000377


Situational strategic planning in a psychiatric institution: contributions and challenges


Planificación estratégica situacional en una institución psiquiátrica: contribuciones y desafios



Francisca Fabiana Fernandes LimaI; Nadyelle Elias Santos AlencarI; Márcia Astrês FernandesI; Elaine Cristina Carvalho MouraI; Fernando José Guedes da Silva-JúniorI

IUniversidade Federal do Piauí, Teresina, PI, Brazil




OBJECTIVE: to aplly the situational strategic planning in the nursing service of a psychiatric institution.
METHOD:  action research in a psychiatric hospital of Northeast Brazil, during the period of December/2015 to June/2016, when 34 nursing staff participated. Enterviews and meetings were conducted, which were recorded/transcripted and content analysis performed.
RESULTS: the priority problems were inadequate staffing, insecurity, failures in the material management and deficit in the comprehensive care provided. Besides that, the difficulties to implementation were- low governability, poor communication and staff desmotivation.
 situational strategic planning is useful to delineaction of actions in mental health and its efficacy depends on the envolved actors commitment.

Descriptors: Health Planning; Mental Health; Hospitals, Psychiatric; Nursing Service, Hospital.


OBJETIVO: aplicar la planificación estratégica situacional en un servicio de enfermería de una institución psiquiátrica.
MÉTODO: investigación/acción en hospital psiquiátrico del nordeste brasileño, período entre diciembre de 2015 y junio de 2016, participación de 34 profesionales de enfermería. Realizadas las encuestas y las reuniones, que fueron registradas y transcritas, y se hizo análisis de contenido.
RESULTADOS: los problemas primeros fueron la dimensión insuficiente de personal, inseguridad, faltas en la gestión de los recursos materiales y el déficit en la atención integral proporcionada. Incluso, las dificultades para la aplicación- baja de gestión, mala comunicación y baja motivación profesional.
CONCLUSIÓN: planificación estratégica situacional es útil para la delineación de acciones en salud mental y su efectividad depende del compromiso de los actores ivolucrados.

Descriptores: Planificación en Salud; Salud Mental; Hospitales Psiquiátricos; Servicio de Enfermería en Hospital.




The movements of psychiatric reform began in Europe in 1970 and reflected in other countries, especially in Brazil, where there were already changing ideals led by psychiatrist Nise da Silveira(1). These actions strengthened, from 2001, with the creation of Law 10,216, which proposed a new organizational model for the Brazilian psychiatric services and promoted the care redirection and humanization, in addition to social reintegration of institutionalized patients(2).

In Brazil, the reform process represents a challenge for managers, professionals, users and society, since the program advocated by higher levels is not always experienced in the daily practice of psychosocial network. The psychiatric hospitals still have remnants of the traditional care model, have a deficiency in multidisciplinary integration and, in addition, professionals reveal that the unhealthy work environment described by the presence of grids, crowded infirmaries, noise and odor, generates frustration and limits the practices of health(3).

In this context, despite the regulamentation of the psychiatric reform in Brazil in 2001, the mental health care is still adapting to a new reality. The process of deinstitutionalization is relatively recent, the psychiatric hospitals still have high rates of occupation and the assistance lacks organization(1). In addition, since the nursing team represents the largest contingent of workers at hospitals, studying the challenges faced by them is of utmost importance(4)

Thus, in the face of organizational conflicts and shortcomings that permeate the reality of care in mental health, the application of Situational Strategic Planning (SSP) becomes a viable option in the construction of appropriate solutions, because it is based on the choice of priority problems and collective construction of solutions(5). However, the whole process of planning requires time for correct situational diagnosis and its success depends on the ability of articulation, motivation and leadership of those involved(6).

Based on the above, the present research aims to: apply the SSP in the nursing service of a psychiatric institution; discuss the priority problems of the service; and reveal the difficulties implementing the plan.



This is a qualitative, action-research type study(7). This type of research can follow various methodological paths and use other methodological tools to operationalize the development of the study(8). In this sense, the SSP guided the methodology of this research. SSP is an alternative method to traditional planning, designed by the chilean Carlos Mattus in the 1970’s(9)

This method occurs in four classic moments (explanatory, normative, strategic and operational-tactical) (9) and its operationalization involves 10 steps that address the definition of the actors, listing of problems, definition of the determinants (causes and consequences), prioritization of the determinants and problems, construction of the action plan and analysis of its viability, implementation/management and continuous assessment(10).

The study was conducted at a public psychiatric hospital, state reference in providing care to patients with mental disorders, located in a Northeastern Brazilian capital. The institution has 160 beds and offers outpatient service, emergency treatment and full hospitalization. This study included professionals members of the nursing team working in the aforementioned psychiatric hospital for a period equal to or greater than one year, after the vocational adaptability. The exclusion criterion were those on vacation or on leave for any reason.

Data collection covered all the moments of the SSP and occurred in the period from December 2015 to June 2016. In the exaplining moment, interviews were conducted with professionals from the nursing team, which allowed recognizing institutional problems and characterizing participants (gender, age, professional category, time working in the institution and specialization/update in mental health). The interviews ended when the information obtained replied to the study objective, with a final sample of 34 professionals.

According to availability, interest and influence in the service, of all participants, nine professionals (six nurses and three nursing technicians) represented the team in the three following moments of the SSP. In the normative and strategic moment, they participated in the construction of the plan of interventions and analysis of its viability and, in the operational-tactical moment, in the development of actions, and evaluation of the results obtained.

In this context, all interviews and meetings were recorded and transcribed immediately. The participants’ reports and data about the implementation of the SSP were recorded, since the definition of the actors until the evaluation of interventions. Such records were interpreted based on the content analysis method(11). After analyzing the data, three discursive categories emerged: "From situational diagnosis to construction of the action plan ", "Planning in action" and "Difficulties implementing actions".

The Research Ethics Committee of the Federal University of Piauí approved the study, opinion 1,252,857 , dated 30 September 2015. The study respected all ethical precepts of Resolution 466/12 of the National Health Council. The participants’ anonymity was guaranteed by numbering in order of participation , P-1 through P-34.


Results and discussion

Fourteen nurses participated in the survey and 20 nursing technicians/assistants, with predominance of females, aged between 30 and 71 years and time working in the institution from 1 to 42 years. Most interviewees had worked for more than 20 years in the hospital and report having update/specialization course in the mental health area.

According to the chronology of actions, the main results of the study will be discussed. Firstly, the priority problems of the psychiatric hospital in question will be presented, and then, there will be the discussion on the proposed interventions, the construction of the action plan and the interventions carried out. Finally, the main difficulties faced during the whole process will be discussed.

In the first moment of the  SSP (explanatory), the nine representatives of the team participated in the situational analysis and election of the priority problems of the hospital (Figure 1).



The problems identified by the professionals corroborate the existing literature. A survey conducted at a psychiatric hospital in the Federal District-Brazil also identified poor interprofessional communication, evidenced by the difficulty to work in a team and little integration. Furthermore, it also mentions other problems: lack of resources, absence of a network of effective psychosocial services and maintenance of traditional medical practice, focused on productivity(3).

The precarious physical structure, the weak support of human and material resources and overcrowding were the main difficulties for professional activity in the mental healthcare network in the state of Rio Grande do Norte-Brazil(12); and, in Rio de Janeiro-Brazil, the neglected integral care and the resistance of older professionals to the proposed changes stood out(4).

In this context, even after introducing changing ideals, the mental health practice in Brazil is still linked to many structural and ideological problems. However, other countries have raised the quality of psychiatric services and reveal successful experiences. For example, a study developed in Germany compared the assistance in psychiatric hospitals, in the years 1999 and 2011, and pointed to improvements regarding the ability to offer protection, with reduction of its association with repressive and inhuman treatments(13).

As above, the reality of Brazilian psychiatric hospitals is marked by heterogeneous problems and, thus, it is important to prioritize them in order to direct the planning of changes. Therefore, in relation to the planning, after defining the problems, these were prioritized according to the criteria of governability, urgency, importance, confrontation and desire(10).

In this way, four priority issues were elected: inadequate nursing staff dimensioning, insecurity in relation to the person with a mental disorder in conflict with the law, flaws in material resources control/distribution and neglected integral care. To finish the first moment of the SSP, the determinants (causes and consequences) of each one of the four problems were identified and prioritized. During the second moment (normative), interventions were proposed based on the determinants (Figure 2).

In the strategic moment, the action plan (expected results, proposed actions, term, responsible actors, necessary resources and viability) was built and the last moment (tactical-operational), which involves the intervention and the continuous monitoring of results, will be discussed below.

The implemented actions based on the problems reported by the participants (P-1 through P-34). The first intervention refers to the inadequate amount of nursing professionals, classified as the main service problem.

The professionals reported previous attempts to solve it and reinforced the difficulties exercising a quality assistance considering the reduced number of professionals, which also interferes with the professional’s quality of life and social life.  [...]We have an employee for 50 patients (P-23); [...]There is no nursing dimensioning, the Regional Nursing Council is aware of it, the technical board is aware, we have already requested more professionals and we have been waiting until today (P-1); [...] It brings many consequences, fatigue, stress, malaise, we end up mistreating our family at home, because of the stress (P-20).

Nursing represents the largest professional category at hospitals, and, since its actions are developed for the patients’ vital care, it faces stressful situations in the work environment that reflect on nursing professionals’ own health. In this sense, an Indian study involving 693 nurses from 33 health institutions pointed out that the conflicts in the work environment, arising from the care and managerial demands, interfere negatively in nurses’ family relationships(14).

On the other hand, a study developed in the Brazilian northeast shows discordant data, since professionals working in mental health services revealed a low level of overload, with greater impact at work for those with techinical/fundamental level, aged 25 through 39 years and with less time working(15).

In the reality studied, the physical and mental wear of the interviewees was related to inadequate staff dimensioning and high work load. In this perspective, the dimensioning was the key point of discussion, because it is direct or indirect cause of other problems identified. With the reduced number of professionals, work overload, presenteeism, stress and professional dissatisfaction, which limits the quality and systematization of nursing care (SNC). [...]The quality of care is also linked to human resources because, with few employees, how will a quality assistance be held? (P-34); [...]The consequences are greater for the patient himself because a single person has to take care of many patients, who are not cared for, only looked at, right? (P-3).

The inadequate management of human resources was also considered a limiting factor in health practices organized by a study conducted with 32 nurses, in three hospitals of Minas Gerais-Brazil. The proper dimensioning was described as the first step in the process of change, because the reduced scale affects the quality of care provided, restricts the SNC and generates negligence in professional practice(16).

Given the first exposed problem (reduced number of professionals), the dimensioning calculation was performed, which, according to the team, had already been done, which was presented to the institution board and forwarded to the Regional Nursing Council. The hospital has 160 beds, with average occupancy rate of 87.13%. The nursing team is composed by 19 nurses and 62 nursing technicians/assistants, with weekly work load of 30 hours.

According to decree GM 251/2002(17), which establishes guidelines and norms for hospital care in psychiatry, the current dimensioning of the hospital in question has a deficit of 16 nurses (46%) and 50 nursing technicians/assistants (45%).

This is a macroproblem, which involves the action of governmental entities and demands financial resources, below the governability of actors involved in this planning. The report built was considered an important tool in the theoretical foundation to enforce the law.

The same occurs in relation to the lack of security personnel trained to operate in sectors that provide assistance to patients with mental disorder in conflict with the law (second priority problem). This is because, since the closing of the state custody hospital, this psychiatric hospital began to receive high demand from the prison system and, with it, the (in)security became a point of discussion. [...]The problem is serious and they keep treating as if it were simple, but it is not, we have had a case of a patient who was murdered by another here inside and, by coincidence, the patient who murdered was involved in justice and the other was not. The staff responsible for the security does not have the police power, they are not prepared to do this. (P-32)

The institutions that provide care to patients with mental disorder in conflict with the law must rely on prison officers or guards(18). On the other hand, in the hospital under study, there is a deviation of functions, because the professionals who provide general services are responsible for the safety of the sector. The problem was presented to the hospital board which revealed another vision of the problem, when considering the professional’s prejudice in relation to patients originated from the prison system, since incidents can occur with any psychiatric patient.

Data reinforce the idea that there is fear in psychiatric patient care, since the fear of being attacked was considered the aspect that impacts the work in mental health. This fear is more common among professionals of techinical/fundamental level and stresses in the early years of practice in the area(15).

In relation to the flaw in the control and distribution of material resources in the sector of laundry/clothes/janitors (third problem), based on the professionals’ speeches, there was a poor communication between the different sectors and impingement to define the responsibilities of each professional in the hospital context. [...]The night staff complainsabout few bad sheets... there is only one sheet at night and during the day, there is not. (P-18); [...]There is no lack of material, the problem is distribution. Because the employee of the sector does not want to go there to pick it up because he thinks he is not responsible for it. (P-28).

The whole professional work is guided by rights and duties and, in the institutional context, managers can intervene in formalizing the responsibilities of each profession. Thus, communication is fundamental in this process. Either through verbal or non-verbal means, effective communication is a skill that guides good professional practice and enriches the multidisciplinary relationship(19).

As action in the short term, the non-verbal communication was stimulated through the proposal of a form for control and registration of items daily dispensed, which, despite the initial resistance, are in use. The hospital does not have documents to determine the responsibilities of each professional. In addition, organizers were prepared for the patients of the female sector, as a pilot project, in order to stimulate the individual control of hygiene items and patients’ autonomy.

Strategies were defined according to the characteristics of the institution, its professionals and users. However, the attempt of changes revealed problems regarding the employees’ lack of commitment and resistance to change. Faced with this situation, the nurse should be able to intervene in relation to difficulties and pursue the knowledge as well as the skills and attitudes inherent to the profession, which make them a potential manager(20).

Regarding flaws in the integral care to the patient (fourth priority problem), there is need to condict improvement and update courses on mental health. [...]There should really be a recycling course, preparing professionals to work with them, because they are sensitive and are here to receive attention, mainly from nursing. (P-6); [...] What we need in a psychiatric hospital is the largest assistance with patients, making groups, directed activity [...]and we see here that they give only medications, there is no real care. (P-24).

Faced with the scarcity of courses for professional updating and flaws in the integral care to the patient, educational lectures and activities were carried out to stimulate awareness of professionals regarding the importance of care integrality. The professional’s behavioral change occurs slowly, and, in the studied situation, the demotivation, the deficit of professionals and the absence of an educational nucleus limit this process.

In the same sense, a study conducted in the state of Paraná-Brazil, with 13 nurses, stressed that the main obstacles faced in the adoption of educational strategies are: the little professional commitment, shortage of human, financial and physical resources, as well as a lack of support from the management(21).

In relation to difficulties implementing the SSP, in the international literature, the analysis of unsuccessful strategic planning enabled the identification of four situations that make the planning process ineffective: starting the process without planning, conducting planning without a plan, planning and no execution, and performing actions that do not produce an impact (6).

In the present study, the aforementioned situations did not occur, since, all the SSP steps were followed and the proposed interventions were accomplished, with satisfactory results. Nevertheless, there were other difficulties, such as: low governability of the actors in the face of some of the problems, lack of support from management, poor interprofessional communication and demotivation of professionals faced with the institution reality. [...] I see it as a lack of interest of the hospital management itself, so much that I think they see the problems, but do not want to solve them. Because we have a lot of problems. (P-12); [...] I’m realizing discouragement of employees with respect to assistance, I do not know whether it is tiredness...because they are working the extra extra.  (P-24).

Since they had been working for so long in the institution, most interviewees showed discouragement regarding the proposed changes. There was inertia of professionals who, faced with a reality taken as immutable, expressed little hope for change. Such demotivation affects the delivery of professionals in the institution and, therefore, limits the quality of care offered. [...] I have been working here for 28 years, I already want to retire, there comes a time when we get tired. We see the problems, but we no longer have that strength, that energy to start everything. (P-24); [...] I have already asked to be transferred from here three times and nobody listens to also come to impugn your work place, because it is unhealthy for you work in a place like this. (P-12).

According to the results found, a survey conducted in Switzerland, with 1647 nurses, addressed the satisfaction at work and concluded that several factors influence the dissatisfaction in the nursing professional practice, including low remuneration and unhealthy conditions, which contribute to lack of motivation, and even desire to change the work place(22).

On the other hand, the actions implemented had a positive effect by stimulating the collective discussion about the priority problems of the hospital and by encouraging the empowerment of professionals in the process of change. [...] The wheel of conversation with the government worker (professional) is important, so that they also indicate the difficulties, problems, seek solutions. (P-30).

The context of the Brazilian psychiatric reform is marked by doubt of deinstitutionalization. In the state of Piaui, Brazil, the psychiatric hospital continues to be the center of reference to the urgency and emergency mental health care, the number of psychiatric beds in general hospitals is paltry regarding the demand and the focus of the mental health training continues to be the psychiatric hospital. Thus, since the resources destined to psychiatric hospitals reduced and substitute strategies are weak, their maintenance is precarious in the face of a psychosocial network totally dependent on their services(23).

Based on the above, the main problem faced by the nursing service of the psychiatric hospital was the deficit of professionals, which represents an obstacle for the assistance, overloads the professional, affects their quality of life and generates dissatisfaction at work. Furthermore, the deinstitutionalisation represents a breakthrough for the mental health care, especially in what concerns the user’s reintegration into society. Nonetheless, as long as there is no adequate means to this strategy, psychiatric hospitals will continue to provide care in mental health and, therefore, must have sufficient mechanisms to offer appropriate assistance to patients.



The Situational Strategic Planning is useful to solve problems through the delineation of strategic actions, but its effectiveness depends on the participants’ degree of involvement.

The implementation of this tool revealed the four priority problems of the nursing service of the psychiatric hospital, allowed formulating shared goals and designing specific actions. All interventions were accomplished; however, implementing a participative methodology reveals difficulties in integration and commitment from the actors involved in this process.

Some limitations of the research were: the short period available for implementing the actions, low governability power facing some problems and demotivation by some professionals, facing the experienced reality, with low expectations of changes.

This study may contribute to the existing scientific literature and encourage the development of new studies addressing the situational strategic planning, particularly in the context of mental health actions. Although this study restricted to nursing team professionals, SSP is a flexible tool that can be adapted to various health services and even involve an entire institution.



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Received: Mar 10th 2017
Accepted: Dec 7th 2018

Corresponding Author:
Márcia Astrês Fernandes

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