ORIGINAL ARTICLE

 

The perception of health professionals regarding the care for the elderly with mental disorders^*

 

 

Maria Giovana Borges Saidel; Claudinei José Gomes Campos

Universidade Estadual de Campinas, Faculdade de Enfermagem, Campinas, SP, Brazil

Corresponding author

 

 

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ABSTRACT

OBJECTIVE: to understand the perceptions of the staff of a Psychosocial Care Center regarding the care for the elderly with mental disorders.
METHOD: qualitative study with a theoretical and methodological framework: Theory of Social Representations. The field of study was a Psychosocial Care Center in the state of São Paulo. Convenience sampling was used, and the sample consisting of 12 professionals was determined by saturation. Data were collected by semi-structured interviews and analyzed by thematic content analysis.
RESULTS: three categories emerged, and they showed contradictions regarding the professionals' perceptions of the CAPS' role. Such contradictions may be supported on the representations concerning the difficulties reported in the care for the elderly, which overlap with those in the care for individuals with mental disorders. The lack of strategies for routine care is discussed, and professional education is mentioned as important although it is non-existent. The burnout of mental health professionals emerges, and the perception of the lack of human resources is revealed in the discourses. These problems bring about a representation of insufficient practices that will reflect on the care for the elderly with mental disorders.
CONCLUSION: the study contributes with clarifications to be addressed in intervention studies in order to strengthen heath care change.

Descriptors: Manpower; Mental Health Services; Old Age Assistance; Mental Disorders; Geriatric Psychiatry; Community Health Services.

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Introduction

The Psychiatric Reform movement worldwide has enabled a significant change in the mental health care model. Care provision has been redirected to open community services in detriment of asylum practices and hospitalization services, in addition to the development and application of concepts related to prevention in mental health. Such reality brings with it the imminent urgency to instrumentalize professionals and specialized services that are articulated with the care for people with mental disorders^(1-2).

Human resources for mental health care in developing countries are a reason for concern that is clearly presented in international studies. Such concern stems from both staff dimensioning and professional education for health care provision^(3-4). This fact produces an overload to professionals in this specialty^(5-6).

In an attempt to solve this problem, global efforts have been made, aiming at developing strategies to deal with the widespread lack of workers in those countries. Such efforts have resulted in the description of a basic structure to help mental health care managers to obtain effective and sustainable human resources. In that structure, articulated items that are necessary for the development of human resources are presented, namely policies, workforce management, financing, education, partnerships and leadership. In order to address these issues in mental health services, an interdisciplinary and systemic approach with the participation of various sectors is required. Such approach should take place with the participation of governmental, non-governmental, research and professional-education institutions, health care teams and system users^(7-9). The articulation of these initiatives would be the beginning of a transformative work to reach the objective of extending and improving the care for individuals with mental disorders⁽¹⁰⁾.

These difficulties in mental health care are intensified when they occur with specific populations showing great many particularities. Elderly individuals with long-term mental disorders experience a chronic condition, and this imposes long relationships to professionals in health care services that are filled with anguish and adversities. There are two major challenging specialties in the contemporary world: mental health/psychiatry and gerontology⁽¹¹⁾. Therefore, studies on human resources in mental health, particularly on the care for the elderly, are relevant due to the priority of this topic on the agendas of governments around the world for that population.

In face of the impasses concerning human resources in mental health pointed out in the literature and by the teams providing care to the elderly with mental disorders, the following study question was asked: what are the social representations of the staff at a Psychosocial Care Center (CAPS) of the care for the elderly with mental disorders? In view of this research question, this study aimed at understanding the perceptions of the staff at a CAPS concerning the care for the elderly with mental disorders.

 

Method

This is a qualitative study with a theoretical and methodological framework based on the Theory of Social Representations (TSR). TSR is articulated with the research starting from the construction of the processes of anchoring and objectification as well as from the construction of meanings attributed by means of the consensual and reified universe⁽¹²⁾. Thus, the theoretical and methodological framework highlights the constant relationship between social structure and the subjects; and among the subjects with one another, resulting in the construction of social representations.

The study was conducted at a Psychosocial Care Center in the state of São Paulo. Data were collected by semi-structured interviews with the following guiding question: what is your perception of the care for the elderly with mental disorders?

Data were collected over a period of eight months, from November 2013 to July 2014, thus achieving prolonged engagement⁽¹³⁾ (acculturation period). The inclusion criteria were: professionals with professional practice in the field of study and minimum experience of one year in the psychosocial care network (RAPS), and the exclusion criteria were: professionals who, for any reason, were away from the service. Convenience sampling was used, and the sample was determined by saturation, that is, all the professionals on the CAPS staff were interviewed. The interviews were conducted on different days and at different times, with a minimum of three days between the meetings, which allowed for adequate temporal triangulation⁽¹³⁾. Several professionals of different categories and levels of schooling were interviewed, thus allowing for personal triangulation. In order to preserve anonymity of the subjects the acronyms SE and HE were used for secondary education and higher education, respectively, followed by the number of the interview.

The interviews were audio recorded and fully transcribed integrally. Thematic analysis was used to analyze the data. This method is used in different theoretical structures with the following steps: familiarization with data, generation of initial codes, search for themes, analysis of themes, definition and attribution of themes and report production⁽¹⁴⁾.

The study project was submitted to the Ethics and Research Committee of the State University of Campinas (UNICAMP). After approval, the processes of acculturation and subsequent data collection were started with the consent from the subjects by means of the Informed Consent Term. The subjects' anonymity was guaranteed by alphanumeric coding, and transcripts that could indicate identities were omitted. The Committee's approval report was registered with number 342.202.

 

Results

The final sample consisted of 12 health professionals, comprising nine women and three men aged 29 to 46 years (two nurses, one physician, two nursing technicians, one social worker, two occupational therapists, one monitor, one administration assistant, one general service assistant and one psychologist). The interviewees' length of employment in psychosocial care ranged from 3 to 31 years and that in the field of research (CAPS) from 3 to 8 years.

The thematic categories that emerged after data analysis are described below so that the staff's social representations can be understood.

Theme 1: Representation of the antagonism of the role played by the Psychosocial Care Center in the care for the elderly with mental disorders

The professionals expressed the representation of this service anchored on issues that caused apprehension and restlessness to the team. Their discourse showed concern regarding the role currently played by the service in relation to the care for the elderly with mental disorders. I am concerned about the institutionalization of CAPS. This is a day care center; literally a substitute for hospitalization and this is not what CAPS is for; it shouldn't be this" (HE01); People use CAPS as a day care center; the family comes and leaves the elderly person here to spend the day, so that they can work (HE02).

The purpose of the service is understood; however, reality is contrary to policy guidelines. This place should not be a day care center; there is a time for admission and a time for discharge even if such discharge does not mean an ultimate dismissal from the mental health care service (SE03).

In addition to questioning the team's conduct and the professionals' individual work. I don't understand certain actions taken here; some of the elderly patients are removed from projects because 'their behavior is not as expected', but wait a minute! What is our role? We must teach the patients to deal with it, but I realize that my voice is repressed (SE01).

Theme 2: Representation of the lack of development and improvement strategies for the care for the elderly with mental disorders

A representation that the team was insufficient for the care to be provided to the elderly with mental disorders was observed in addition to the perception that such population is more demanding than others. I think the team is too small; I think there should be a lot more staff; the work is stressful, the elderly are more difficult; they stress us at times (SE04); We do not have enough staff to think about this [specific practices for the elderly with mental disorders]; it's hectic, every day, it's very difficult (SE02).

In addition to the perception of a lack of human resources, the team also represents dissatisfaction with the absence of interprofessional education for the care for these elderly people. We do not have any courses; we do not have anything that can help us to better care for these elderly people; it is difficult (HE04); Since I've been here [3 years] I've never heard anyone even mention it, so we can better care for the elderly with mental disorders, and we do have elderly people here, but I've never taken a course, nothing (SE04).

In the team's account, there was the representation of RAPS' responsibility to provide such training. We don't take courses, the Network has never offered us anything, and we feel it's necessary because we need to update our knowledge, and the Network should provide it, shouldn't it? (SE03); We don't have any training to deal with the elderly with mental disorders. Since I've been here I've never had any training on the subject; I think the (Health) Department should provide such courses, some support, you know? (HE07).

Theme 3: Representation of the weaknesses and potentiality of networking in the care for the elderly with mental disorders

There is a clear representation of the team's perception of networking, and this understanding is anchored on situations that are considered to be irrelevant when they occur to the elderly in primary care. Networking is not comprehensive enough because most often when a patient comes for admission or triage, the family reports: 'Ah, but he's been like this for so long; we thought that was normal' until a breakdown occurred. The Family Health Program (PSF) didn't play its role, do you understand? (HE05).

The lack of standardized procedures is indicated as a possible cause of disagreements in the network. There is a chronic problem in the services that are not specialized in mental disorders, which is the lack of protocols. Not only that, of course, but it would help (HE06). The lack of a network added to the lack of resources is also pointed out as an obstacle to performing the activities. Firstly, an adequate network is one that - whether run by the federal, municipal or government - gives us a financial incentive because, today, without money, we do nothing. I find this place awful; the patients do not deserve to be here, the physical structure ... (SE02)

However, among the innumerable adversities of the work processes, the professionals perceive the possibilities of improvement and objectify them in partnerships. We are trying to develop other partnerships; we are starting to have a little more contact with basic care, the Family Health Unit, although with some resistance, but it is a little better (HE01); There are times when we need help from CRAS [Social Work Reference Center], from PSF, anything will help a great deal. The problem is that the patient is dumped here, and no one wants to know about it anymore; it is complicated (SE03).

 

Discussion

In the presentation of the results for the first category, contradictions regarding the CAPS's role in the care for the elderly with mental disorders are shown. These representations cause anguish, which can often lead to a feeling professional identity loss. Such finding raises another question: if CAPS, in the representation of workers, loses its strategic rehabilitation role, then what role does it play in this context?

These social representations were constructed from internal and external instruments experienced by these professionals. Such constructions have an impact on the daily practices of the service, since the individuals act through their representations stemming from the consensual universe⁽¹²⁾. Therefore, when CAPS is objectified as a day care center, the elderly become children and can be cared for as such.

CAPS is an open, specialized, community service and a substitute for the hospitalization of people with mental disorders. It is considered a strategic device in the movement of the Psychiatric Reform movement due to the potential for change and care actions for people undergoing psychic suffering⁽¹⁾. The work performed by CAPS' professionals should be articulated with the service's proposal described in its policies. It is necessary to create spaces for reflection which will allow for the construction of effective actions during this work process^(2-4). These actions should be based on the following guidelines: the individual's rehabilitation and autonomy generation, reduction in the need for hospitalization, reconstruction of identities through therapeutic relationships and promotion of users' mental health^(15-16).

Resuming the representation of CAPS as a day care center and, consequently, that of the elderly as children, it can be inferred that there is a difficulty in looking at and caring for the elderly with mental disorders. The elderly in psychic suffering are already described in the literature as the object of multiple stigma, since, in addition to psychic suffering, they are 'old'. This view may constitute barriers in the care relationship⁽¹¹⁾. When objectification occurs with the representation of a day care center/children, there is the formation of the figurative nucleus and a process of unconscious naturalization by that team⁽¹²⁾, thus limiting the feelings of anguish⁽⁷⁾. However, it is necessary to overcome that representation so that workers can play their role without figurative elements that make the construction of effective care processes difficult.

The reality described in the first category is articulated with the representations that originated the second category. The team represents that the difficulty in providing care to the elderly with mental disorders is anchored on the lack of strategies that can help in the improvement of the professional practice in addition to the scarcity of human resources.

The work processes performed by the interprofessional team in specialized mental health services have advanced in the construction of a model of contemporary psychosocial care. However, professionals working in the psychiatric environment are more exposed to physical and psychological exhaustion⁽¹⁶⁾ and thus show contradictions and numerous problems inherent to the implantation of health equipment, from which exactly those that emerged from the results in this study stand out: scarcity of human resources and lack of professional education. These issues have repercussions in the configuration of work processes, in the relationships among players and in the workers' care dynamics^(16-19).

The fact that these social representations emerged in the interviews shows a cognitive process, demonstrating emancipated representations. In their discourse (language), the group constructed unconscious explanations that justified some obstacles related to the care for the elderly with mental disorders⁽¹¹⁾.

This movement of formation of the social representations can be viewed in a positive way, as it shows that there are solutions to the problems and that such solutions are in the existing human resources. While in the first theme the creation of reflexive spaces is suggested, for the second theme it seems more appropriate to create partnerships with research and training institutions.

These partnerships articulated with the needs of the mental health care team could result in accurate educational processes. Educational processes by themselves do not constitute practice transformation; however, they can bring important components for it

In the last thematic category of the results, the representation of the fragilities and potentialities of RAPS is observed. The team blames the health devices that make up the network for the failures in the admission of the elderly with mental disorders. They point out and perceive the lack of procedures that can help with this classification and objectify the need for protocols. With this regard, the group's representation of the lack of protocols suggests an understanding through the reified universe of social representations. Such understanding can be objectified as a possible strategy thought by professionals to solve some problems concerning the lack of networking. This dialectical movement provided by interviews is substantial for paradigm change.

Studies on the work processes and evaluation of CAPS show that the institutions and the professionals should be articulated so that the reorientation of the mental health care model is effective. Networking is a necessity, and a strategy addressed by the study is the simultaneous conduction of the therapeutic projects by CAPS and other health services. This action would be an indicator that aims at understanding interprofessional and intersectoral work^(20-21).

Numerous innovations are underway around the world in order to measure and improve the quality of mental health care. These initiatives combine advances in care provision technology as well as provide the possibility of constructing measurable indicators. The goal is to achieve mental health care that is constantly evaluated and improved. Therefore, another strategy would the construction of indicators to evaluate the team's representations of the lack of networking and protocols based on such representations^(1,10,20).

With the results, more accurate strategies could be designed in specific points of the network to increase its efficiency. An example would be the referral strategy, training for schedule application and the design of protocols for admission and care provision^(20-21).

Work efficiency at RAPS is fundamental to the quality of the care provided to the elderly with mental disorders. Many comorbidities may cause inaccuracy at the initial admission to primary care and be attributed only as peculiarities of the aging process. This confusion would then lead to neglect and delays in the treatment of mental disorders at the specialized services or even in other network devices, depending on the repercussion and psychological distress in the life of those elderly individuals.

Qualified professionals in health management and support are vital to supervise the implementation of strategies so as to achieve better care provision levels in mental health^(6,10). It takes investment to increase management capacity in psychosocial care networks. In addition, it is necessary to design protocols and train the staff for their execution in daily practice^(17,21).

The evaluation processes are also important actions. Professionals and health services need a list of indicators with validated results centered on the individual, the service user, as well as for special populations⁽¹⁰⁾, as for instance, the elderly. There is a need for an evidence base for quality measures through practical guidelines and continuous monitoring carried out by predefined groups that will provide strategies to incorporate quality improvement where necessary and reduce the overload perceived by professionals^(5,10,21).

This study is limited to the understanding of the team's social representations of the care for the elderly with mental disorders, so this discussion can contribute to a naturalistic generalization in similar contexts. The international literature is relevant, but in contexts that have already overcome the challenges represented by the professionals in the present study. It does, however, provide guidelines for skilled care with the use of instruments that improve mental health care.

 

Conclusion

The findings in this study showed that the care for the elderly with mental disorders in the specialized service as represented by the interprofessional team is complex and faces numerous adversities. Such complexity is diluted in three major propositions: the challenges concerning the identity of the specialized community mental care health service at contemporary times; the lack of competencies and skills by professionals to care for this specific population and the insufficiency of RAPS to adequately manage these cases.

It is necessary to confront and overcome the obstacles that are present in the process of caring for this population. Teams must incorporate dialectical moments in the services with practical and feasible guidelines concerning the daily practice of this peculiar care, which shows a tendency to grow, as well as partnerships, the design of evaluation instruments and indicators and investments in RAPS. It is necessary to improve the construction of knowledge on this subject, without reducing the concepts, thus expanding the praxis and incorporating the subjects' subjectivities. This practice is challenging, but fundamental to achieving the team's broader understanding and practice for comprehensive and effective care for the elderly with mental disorders.

Understanding these changes in the practice contexts, adequate monitoring in health devices and the implementation of the strategies mentioned in this article can make possible fundamental movements for a future transformation of the care for the elderly in mental health.

 

References

1. Tavares CMM, Muniz MP, Silva T. Priorities for research on mental health and the transformation of care model. RPESM. [Internet]. 2015; (esp2):107-12 [cited Sep 3 2018]. Avaliable from: http://www.scielo.mec.pt/scielo.php?script=sci_arttext&pid=S1647-21602015 000100018&lng=pt&nrm=iso&tlng=pt.         [ Links ]

2. Saias T, Laurentine VCD, Xavier B. Prevention in mental health: Social representations from French professionals. Health Sociol Rev. [Internet]. 2014;23(2):159-64 [cited Sep 3 2018]. doi: https://doi.org/10.1080/14461242.2014.11081970        [ Links ]

3. Alves SR, Santos RP, Oliveira RG, Yamaguchi MU. Mental health services: perception of nursing in relation to overload and working conditions. J Res Fundam Care Online. [Internet] 2018;10(1):25-29. doi: http://dx.doi.org/10.9789/2175-5361.2018.v10i1.25-29.         [ Links ]

4. Marcolino TQ, Fantinatti EM, Gozzi APNF. Community of practice and mental health care: a systematic revision. Trab Educ Saúde. [Internet] 2018;16(2):643-658 [cited Oct 4 2018] .doi: http://dx.doi.org/10.1590/1981-7746-sol00112.         [ Links ]

5. Souza IAS, Pereira MO, Oliveira MAF, Pinho PH, Gonçalves RMDA. Work process and its impact on mental health nursing professionals. Acta Paul Enferm. [Internet] 2015;28(5):447-453 [cited Oct 5 2018]. doi: http://dx.doi.org/10.1590/1982-0194201500075.         [ Links ]

6. Kakuma R, Minas H, Van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, Saxena S, Scheffler RM. Human resources for mental health care: current situation and strategies for action. Lancet. [Internet] 2011; 378(9803):1654-63. [cited Oct 14 2018]. doi: https://doi.org/10.1016/S0140-6736(11)61093-3.         [ Links ]

7. Bee P, Brooks H, Fraser C, Lovell K. Professional perspectives on service user and carer involvement in mental health care planning: a qualitative study. Int J Nurs Stud. [Internet] 2015;52(12):1834-45. [cited Oct 14 2018]. doi: https://doi.org/10.1016/j.ijnurstu.2015.07.008.         [ Links ]

8. Ivbijaro G, Patel V, Chisholm D, Goldberg D, Khoja TA, Edwards TM, et al. Informing mental health policies and services in the EMR: cost-effective deployment of human resources to deliver integrated community-based care. East Mediterr Health J. [Internet] 2015; [Acesso Oct 14 2018] 21(7):486-92. Avaliable from: http://www.who.int/iris/handle/10665/255241        [ Links ]

9. Van Ginneken N, Maheedhariah MS, Ghani S, Ramakrishna J, Raja A, Patel V. Human resources and models of mental healthcare integration into primary and community care in India: Case studies of 72 programmes. PLoS One. [Internet] 2017;12(6) [cited 14 Oct 2018]. doi: https://doi.org/10.1371/journal.pone.0178954.         [ Links ]

10. Kilbourne AM, Beck K, Spaeth-Rublee B, Ramanuj P, O'Brien R, Tomoyasu N, Pincus H. Measuring and improving the quality of mental health care: a global perspective. Wld Psychiatry. [Internet] 2018;17(1):30-8 [cited Oct 15 2018]. doi: https://doi.org/10.1002/wps.20482.         [ Links ]

11. Medeiros B, Foster J. Mental ill health in the elderly: medical students' social representations in the United Kingdom. Rev Esc Enferm USP. [Internet] 2014; 48(esp2):132-8. [cited Nov 02 2018]. doi: http://dx.doi.org/10.1590/S0080-623420140000800020        [ Links ]

12. Moscovici S. Representações sociais: investigações em psicologia social. 8ª ed. Rio de Janeiro/Petrópolis: Vozes; 2011.         [ Links ]

13. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. [Internet] 2006;3(2):77-101 [cited Nov 5 2018]. doi: https://doi.org/10.1191/1478088706qp063oa        [ Links ]

14. Pedrosa TB, Moreira MIB. Mental health and justice: network care challenges. Rev Bras Pesq Saúde. [Internet] 2017;19(2):73-82 [cited Nov 05 2018]. doi: https://doi.org/10.21722/rbps.v19i2.18864.         [ Links ]

15. Brolese DF, Lessa G, Santos JLG, Mendes JS, Cunha KS, Rodrigues J. Resilience of the health team in caring for people with mental disorders in a psychiatric hospital. Rev Esc Enferm USP. [Internt] 2017;51:e03230 [cited Nov 6 2018]. doi: http://dx.doi.org/10.1590/s1980-220x2016026003230.         [ Links ]

16. Clementino FS, Miranda FAN, Martiniano CS, et al. Satisfaction and work overload evaluation of employees' of Psychosocial Care Centers. Rev Fund Care Online. [Internet] 2018; 10(1):153-9 [cited Nov 06 2018]. doi: http://dx.doi.org/10.9789/2175-5361.2018.v10i1.153-159.         [ Links ]

17. Pinho ES, Souza ACS, Esperidião E. Working processes of professionals at Psychosocial Care Centers (CAPS): an integrative review. Ciênc Saúde Coletiva. [Internet] 2018;23(1):141-52. [cited Nov 6 2018]. doi: http://dx.doi.org/10.1590/1413-81232018231.08332015.         [ Links ]

18. Ohlsson R. Diagnosis as a Resource in the Social Representation of Mental Illness. Papers Soc Representations. [Internet] 2016;25(1):153-59 [cited Nov 6 2018]. doi: http://dx.doi.org/10.9789/2175-5361.2018.v10i1.153-159.         [ Links ]

19. Onocko-Campos R, Furtado JPereira, Trapé TL, Emerich BF, Surjus LTLS. Evaluation Indicators for the Psychosocial Care Centers Type III: results of a participatory design. Saúde Debate. [Internet] 2017;41(spe):71-83 [cited Nov 6 2018]. doi: http://dx.doi.org/10.1590/0103-11042017s07.         [ Links ]

20.Twomey C, Prina AM, Baldwin DS, Das-Munshi J, Kingdon D, Koeser L, et al. Utility of the Health of the Nation Outcome Scales (HoNOS) in Predicting Mental Health Service Costs for Patients with Common Mental Health Problems: Historical Cohort Study. PLoS One. [Internet] 2016;11(11):e0167103 [cited Nov 6 2018]. doi: https://doi.org/10.1371/journal.pone.0167103.         [ Links ]

 

 

Corresponding author:
Maria Giovana Borges Saidel
E-mail: mgsaidel@unicamp.br

Received: Jan 24^th 2019
Accepted: Apr 16^th 2019

 

 

Authors' contributions: Research conception and design: Maria Giovana Borges Saidel, Claudinei José Gomes Campos. Data collection: Maria Giovana Borges Saidel, Claudinei José Gomes. Data analysis and interpretation: Maria Giovana Borges Saidel, Claudinei José Gomes. Statistical analysis: Maria Giovana Borges Saidel, Claudinei José Gomes. Funding acquisition: Maria Giovana Borges Saidel, Claudinei José Gomes Campos. Manuscript writing: Maria Giovana Borges Saidel, Claudinei José Gomes. Critical revision of the manuscript: Maria Giovana Borges Saidel.
All authors approved the final version of the text.
Conflict of interest: The authors have stated that there are no conflicts of interest.
* Paper extracted from doctoral dissertation “Social representations of professionals at a Psychosocial Care Center on the care of the elderly with mental disorders: qualitative case study”, presented to Universidade Estadual de Campinas, Faculdade de Enfermagem, Campinas, SP, Brazil.