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SMAD. Revista eletrônica saúde mental álcool e drogas

versión On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.17 no.3 Ribeirão Preto jul./set. 2021

http://dx.doi.org/10.11606/issn.1806-6976.smad.2021.174632 

ORIGINAL ARTICLE

 

Psychiatric Nursing, Mental Health and the National Curriculum Guidelines for the Undergraduate Nursing Course*

 

 

Amanda Márcia dos Santos ReinaldoI; Girliani Silva de SousaII; Belisa Vieira da SilveiraIII,IV

IUniversidade Federal de Minas Gerais, Departamento de Enfermagem Aplicada, Belo Horizonte, MG, Brazil
IIUniversidade Federal de São Paulo, Escola de Enfermagem. Departamento de Enfermagem Clínica-Cirúrgica, São Paulo, SP, Brazil
IIIUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
IVScholarship holder at the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil

Corresponding Author

 

 


ABSTRACT

OBJECTIVE: to analyze the recommendations for the reformulation of the National Curricular Guidelines of the Undergraduate Course in Nursing (Resolution No. 573 of January 31, 2018) regarding the teaching of Psychiatric Nursing and Mental Health in the formative process of nurses.
METHOD: this is a documental study. Data was collected from a textual search on the theme in different research sites. The data were tabulated using Web Qualitative Data Analysis software and submitted to Content Analysis. The categories found were Nursing care in mental health is a right for all; Nursing care in mental health considers the singularity of the subject.
RESULTS: the recommendations strengthen the teaching of Psychiatric and Mental Health Nursing, bringing protagonism to the area in the context of health care.
CONCLUSION: the recommendations address contemporary issues associated with mental suffering in populations. Nursing education should address social, political and market issues, considering the social determinants in health and mental health.

Descriptors: Graduate Programs in Nursing; Psychiatric Nursing; Curriculum; Nursing Education.


 

 

Introduction

In the international year dedicated to Nursing, a pandemic caused by COVID-19 highlighted the essential work of the Nursing team in health systems in the line of care for the screening of infected people, the treatment offered to mild and severe cases of people infected by COVID-19 and in the assistance to people in mental distress.

The necessary and indefinite social isolation of millions of people around the world has contributed to highlight the fragility of the population regarding issues related to mental health, its promotion, protection, and care. Nurses in the front line of care and in the rear of the services have sought and offered psychosocial support to face a serious health situation with unfoldings that cannot be measured in the short term(1-4).

This reality draws attention worldwide to the need for quality education for the development of professional Nursing competencies in order to provide care for a pandemic caused by a virus that still has unknown causes and effects on individuals(5-7).

Nursing, in this sense, was faced with challenges in different work fronts that depended on its knowledge and the quality of its training. In this context, the training of nurses in the world followed the history of health, public policies, and social movements that modified, created, and consolidated health systems, such as, in the case of Brazil, the Sanitary Reform, the Psychiatric Reform, and the creation of the Unified Health System (UHS)(8-12).

The elaboration of the National Curricular Guidelines for Undergraduate Nursing Education, in 2001, is configured as a powerful strategy for directing the training of nurses in the UHS and for the UHS. In its scope, the NCGs outlined the profile of the professional appropriate and possible at the time of its elaboration; they also defined the general and specific competencies that should guide the political pedagogical projects and curricula of nursing schools in Brazil(13).

The publication of the NCGs brought advances and direction for training, although, for some authors, they have distanced themselves from knowledge of the human sciences, leaving the humanistic training of nurses in second place(8,14-17).

The NCGs are the reference for the elaboration of Political Pedagogical Projects and Nursing Curricula. These documents are revised according to the guidelines, expanding the actions of nurses and forming a structure for the teaching of nursing in tune with the labor market, good health practices based on evidence, the epidemiological profile of the populations, their social and economic determinants and conditioning factors in health.

In Brazil, the challenges for quality in the training of generalist nurses involve: the social division of labor; the positivist model of health care; the curricula organized into disciplines; the expansion in the number of nursing schools in the country; the difficulty in assessing the quality of education in these institutions and the discussion around distance learning (DL), which can weaken the profession as a field of health knowledge(18-21).

The generalist formation of nurses is based on general and specific competencies and skills that support their practice in different points of care(22-24).

In 2018, Resolution No. 573, dated January 31, approved Technical Opinion No. 28/2018 containing recommendations from the National Health Council (NHC) to the proposed NCGs for undergraduate Nursing courses(17).

It is observed, in relation to the teaching of Psychiatric Nursing and Mental Health, an advance between the NCGs (2001) and the proposal approved in Resolution No. 573 of 2018. In the 2001 document, there is no textual mention of care issues in Psychiatric Nursing and Mental Health in the 33 Nursing competencies described and in its text in general, lacking textual accuracy regarding an important area of comprehensive health care and that interfaces with other areas, among them, the area of alcohol and other drugs. It is identified, therefore, a contemporary character in the resolution regarding the health needs of the population in relation to mental suffering.

The need for the generalist nurse to develop skills for care in Psychiatric Nursing and Mental Health, in the different care settings, is crucial in face of the contemporary panorama arising from the pandemic for COVID-19 with the increase in cases of depression, sleep disorders, anxiety disorders, suicide risk, use of alcohol and other drugs, stress, domestic violence and associated causes in the general population.

It is emphasized that these competencies are necessary for the establishment of strategies to support the population and health workers such as: online service; the production of informative materials; the initiatives of organizations linked to culture and leisure; the protocols of care; the recommendations to be developed and made available in order to help in the management of uncertainty, fear, isolation and loneliness(1-2,25). In Brazil, such activities are still incipient when compared to the social, economic and psychological demands of people.

In this sense, this study aimed to analyze the recommendations for the reformulation of the NCGs of the undergraduate course in Nursing (Resolution No. 573 of January 31, 2018) regarding the teaching of Psychiatric Nursing and Mental Health in the formative process of the generalist nurse.

 

Method

This is a documentary analysis study. The primary sources of analysis were Resolution No. 573 of January 31, 2018, which addresses the recommendations for the reformulation of the NCGs of the undergraduate course in Nursing; the NCGs of Nursing (2001); Law No. 10,216 of April 6, 2001, which provides for the protection and rights of people with mental disorders and redirects the mental health care model and the World Health Report 2001 "Mental health: new conception, new hope"(26).

The research comprised the identification, verification, and analysis of documents that are related to the investigated object, allowing the theoretical discussion of the theme in question. The documents were submitted to Content Analysis, systematized by Bardin, and comprised (1) Pre-analysis; (2) Exploration of the material and (3) Treatment of the results(27-28). The data collection was carried out in the month of May 2020 from textual search on the web about the theme in different free access research sites.

Other studies and documents were used as secondary sources of information, including scientific articles, reports from health organizations, and resolutions on the professional practice of nurses issued by the Federal Council of Nursing (COFEN).

The data were tabulated using Web Qualitative Data Analysis (WebQDA) text, video, audio, and image analysis software. The system is organized in three areas: 1. Sources - where the system is fed with the research data and organized according to the researcher's needs; 2. Questioning - the researcher creates the dimensions and/or categories that will be analyzed according to previously elaborated analysis models for each of them(29).

Thus, the documents were attached to the platform integrally (Source) and key words were defined in relation to the theme so that the system could identify them in the texts, namely: mental health; Nursing; Psychiatric Nursing; alcohol; drugs; teaching; evaluation; care; health promotion; prevention; treatment; comprehensive care; integrality; social determinants of health; person; subject; patient and community (codification). Finally, the previous categories were added according to an analysis model created from the initial reading of the documents.

The categories listed were: (1) Nursing care in mental health is a right for all; (2) Nursing care in mental health considers the uniqueness of the subject.

The article is a section of a larger study entitled 'Study and Research in Good Practice in Psychiatric Nursing and Mental Health', which addresses mental suffering as something intrinsically linked to the social conditioning and determinants of health and mental health, associated with the training of generalist nurses through primary care in mental health, the technologies of care and the validation of the necessary skills for generalist nurses to work in the care of the suffering person in different settings.

 

Results and Discussion

Nursing care in mental health is a right for all

Nursing care is a right for all, as assured by the NCGs for Nursing(30). Resolution No. 573, dated January 31, 2018(17), corroborates this right. In this sense, the recommendations of the National Health Council (NHC) to the proposed guidelines bring advances to the training of the graduate by textually incorporating the need for the professional in training, meeting individual and collective needs, and respecting mental diversities, human plurality, the uniqueness of the human being and the basic principles of therapeutic action, among them, the biopsychosocial conditions.

The Psychiatric Reform has as its legal landmark Law No. 10,216 of April 6, 2001, which guaranteed the right of the person in mental distress to information about the mental disorder and its treatment, access to quality treatment in community mental health services according to their needs and the autonomy of the person in mental distress as a citizen with rights, free from stigma, prejudice, abuse and exploitation(31).

The Psychosocial Care Network (PSCN) and its devices support the care of people in mental distress throughout the national territory, regardless of its complexity in the UHS, which is also the largest employer of nurses in mental health(32-33).

Networking in mental health is complex and dynamic. The mental health user moves inside and outside his territory, calls on services of other networks, uses primary, secondary and tertiary care, calling on health professionals to reinvent themselves in the face of a user who previously did not circulate in the public space. The psychosocial care model in the country, from a time-space perspective, is young. Only 19 years separate the psychosocial care model from the exclusionary, institutionalized, and legally supported psychiatric asylum.

The nursing student, in the formative process of graduation, should have mandatory curricular disciplines in Psychiatric Nursing and Mental Health that develop competences for the approach in primary care in mental health, in the community and psychosocial model, based on the assumptions of the Psychiatric Reform, acting in the triage and identification of cases and using care technologies that enable it to provide integral and humanized care to people in mental suffering(18,21,24,34).

The reorganization of the educational projects of undergraduate nursing courses is emergent, considering that the contents covered and the practice fields should prepare the nursing student for the development of empathy, therapeutic communication and interpersonal relationships with the team, users and families within the territory at the various care points that make up the PSCN.

However, the literature points out the difficulty in training professionals for psychosocial care. The educational institutions adopt, in their educational projects, a reduced workload for the disciplines of Psychiatric Nursing and Mental Health. In many, there is a lack of integration of the mental health contents, as a transversal theme, to the other disciplines. In addition to the offer of disciplines that do not dialogue with the reality of people in mental suffering assisted in the PSCN, there is the presence of teachers without training in the area and the realization of practice and/or internship developed in psychiatric hospitals or services that maintain the asylum logic of care, preventing or hindering a quality training in mental health in undergraduate education. The literature suggests that it is unlikely that nursing courses develop competencies and skills necessary for nurses to provide primary care in mental health, given the limited attention to Psychiatric Nursing and Mental Health in these programs(18,35-38).

A study on the evaluation of the quality of teaching in mental health by nursing students pointed out that teachers should have training in the area. When teachers are generalists or specialists in other areas, the teaching is fragile and the student, at the end of the course, does not feel prepared to act minimally in primary care in mental health(39).

The teaching-learning experiences in poorly structured services, where nurses are not trained for mental health care and adopt authoritarian postures consistent with the asylum model, signal to students that nurses, in this context, do not need specific training. Students stay away from the specialty because they do not perceive the necessary competences for nursing work in mental health. Hildegard Peplau stated that knowing and understanding the profession and its work is a prerequisite for the care of the other and consequent emancipation(40-41).

Regarding practical activities, it is pointed out the need to be developed in mental health services of the PSCN and/or in primary care with adequate supervision and contact with professionals trained in primary mental health care. In mental health services, the nursing team must have training in Psychiatric Nursing or Psychosocial Care(42).

The impact of practicing in poorly structured internship fields, especially in psychiatric hospitals, and observing the care of mental health users, conducted by unqualified professionals with supervision by non-specialist professors, is reflected in the deficit of psychiatric nurses in some countries. A minority of students feel attracted to the specialty because they understand that they can somehow help the mental health user to "save" him/her from inadequate and unprepared nursing care. Another important point is the perception that the performance of psychiatric nurses is limited to watching and punishing patients, curtailing rights and imposing rules of behavior that are not consistent with the psychosocial model of care(43-45).

Teaching methodologies for mental health nursing have been applied in different countries, such as positional rotation in services, early contact with the mental health user through sharing stories and experiences inside and outside services, use of simulated care and real-time anamnesis applications, teaching by recording and making decisions considering behavioral algorithms. There is special investment in the experience of students listening to and engaging with the life stories of mental health users(36,39,46).

Some points are defended as essential for the formation, among them: the knowledge of national and local public policies for the area; the study of social determinants and conditioning factors in mental health; the issue of financing the care networks; the teaching of care technologies, with special focus on primary care; the systematization of care; evidence-based nursing; good practices in Mental Health Nursing and quality practice scenarios for student training(47).

Studies point out that, in the PSCN care devices, the integral care in Nursing presents fragility, although Resolution nº 0599/2018(42) of COFEN has minimized this issue, with special attention to the daily practice of nurses and the definition of their space and role in the team.

The nurse assumes activities that sustain his actions related to the management of the nursing team, but, at the same time, he distances himself from the care of the user. For the trainee nurse, one of the possible directions to enhance the teaching of mental health nursing is the presence of a teacher specialized in the area, with the ability to perform the necessary readings and evaluations of the context in which the student is inserted, to facilitate the construction of knowledge in a reflective and critical manner. Additionally, the integration of teaching-service, with the construction of content in an articulated manner with the technologies used in the PSCN, and the nurses who work in them enable the student to think and reflect on the practice, forming professionals committed to qualified nursing care being a right for all(48-49).

Nursing care in mental health considers the subject's singularity

Human integrality and care relationships in the mental health dimension, including interdisciplinarity, are contemplated in Resolution No. 573, dated January 31, 2018(17), which recognizes communication and welcoming as technologies of the Nursing work process with different social groups in life cycles.

Mental health care implies bonding and co-responsibility. To establish the bond, nurses use care technologies, including communication and welcoming, both mentioned in the resolution. The welcoming, interpersonal relationships, and therapeutic communication are related to the theoretical and practical field of mental health, although they are tools that can and should be used in other clinics, with good results, when correctly applied(50-51).

Care relationships belong to the field of soft technologies of care, are sensitive to the processes of interaction with others, are procedural and are built in the daily work in health. Studies show that students who learn and apply these tools tend to realize that mental health is an interdisciplinary area that cuts across health as a whole, and start using the techniques learned in other areas of nursing practice(35,52-53).

Diluting the contents of Psychiatric Nursing and Mental Health in a transversal way in the curriculum has incurred weaknesses in different experiences in Brazil. The cross-sectionalism can be harmful from the moment the student cannot locate mental health as an area, when the workload allocated to the subject in other disciplines is derisory or when the teachers specialized in other areas take over the teaching of the specific content of Psychiatric Nursing(18,21,24,54-55).

The WHO identified mental disorders as occupying the fifth position in a ranking of ten causes of disability, which totals 12% of the global burden of disease with progressive increase, generating social and economic costs. The nurse has a privileged position in the health field, because the care relationships are established from the bond, which demands time and quality of interaction. In different countries, studies show that the time spent caring for people by nurses is greater than that of other health professionals(23,28,56-57).

The care relations take place individually and collectively, respecting the individual and collective singularity of specific groups, whether in the context of health services, or in the family, community, and society. In this sense, it is important that Resolution nº 573(17) has made explicit in its text a chapter destined to the curricular contents and educational projects, which includes the human and social sciences as a basis for the understanding of individual and collective care dimensions.

The human, political and social sciences contribute to the critical understanding of the determinants and conditioning factors of health, as described in the text of the resolution. A curriculum that is not concerned with the integral humanistic formation of the nurse is close to the formation of technique for technique's sake and adds little to the citizen formation of the future professional(16).

Also important is the reference to the person with mental disorders as the subject of nursing care. These are necessary advances that can contribute to correct distortions in relation to the workload destined to the disciplines of the area of mental health in the nursing curricula in Brazil(38,56,58-59).

The weakness in training is one of those responsible for the logic of referral and not listening to the demands of the mental health user; another point is stigma and prejudice. In relation to stigma, especially, the mental disorder is associated with unpredictable behavior, violence and aggressiveness, and difficulty of management outside the clinic of Psychiatry. People are classified as patients belonging to Psychiatry. The subject becomes an object for belonging to a certain clinic and professionals. Nursing care is broad and integral, and training must reaffirm the uniqueness of the person, consciously and responsibly directing the demand for health(35,60-61).

The concepts of stigma and prejudice should be worked with students, sensitizing them to the vulnerability of people in mental distress and their demands, which go beyond delusions and hallucinations. The stigma towards people in mental distress disqualifies them as subjects of rights and justifies asylum practices, as well as promotes the defense of exclusion and internment in the asylum. Beyond this issue, stigma hinders the diagnosis of people in mental distress in health services(35,62).

The technology for diagnosis and treatment and the domain of intervention techniques are indispensable in the health field. In care relationships, especially in mental health, the encounters between health professionals and health users are mediated by the use of the reception as a health technology. When allied to communication, the reception can give visibility to users' demands(32,53).

Studies indicate that the Psychosocial Care Center (PSCC) becomes the only possible place for health care for this population. The PSCC is the service that organizes the Psychosocial Care Network and can be confused with a center for specialties and emergency care for any demand of the mental health user when it is not clear that the mental health user has the right to comprehensive care(39,63).

The mental health practices and/or internships can include, in their fields, the community services of the PSCN, such as psychiatric beds in general hospitals, psychiatric wards that have articulation with the territory, PSCC, Community Center (CECCO) and Family Health Strategy (FHS). It is noteworthy that, although the Psychiatric Reform law is almost two decades old, the existence of psychiatric hospitals signals that the asylum model is still a challenge to be overcome. In this sense, there are educational institutions that perform their practices in those spaces, which, therefore, weakens the training of nurses within the psychosocial model(18). In addition, it should be noted that there may be attitudes and care exercised by health professionals in the PSCN in the asylum model and this requires attention and development of quality indicators by teachers for the selection and articulation, together with the municipality, of health services that can be fields of practice.

An investigation in 89 public educational institutions in Brazil revealed that only (24) 23.3% of teachers conduct mental health teaching only in primary health care with strategies for home visits, educational actions and active search for mental health cases. This reality reveals that the teaching of mental health is still centered in specialty settings, which makes it difficult for the formation process of generalist nurses to include competencies to provide primary care in mental health, to identify early subjects in mental distress and to act in the treatment of stable psychiatric conditions, in the prevention and promotion of mental health(64).

To address contemporary issues and strengthen Nursing as an autonomous field of knowledge committed to the assumptions of the Psychiatric Reform, the Brazilian Association of Nursing, with the creation of the Department of Mental Health, sought to politically strengthen Psychiatric Nursing in defense of psychiatric reform, the deinstitutionalization of knowledge and practices associated with the logic of asylum, positioning the Brazilian Nursing in relation to the defense of the rights of this population to a dignified and quality treatment, giving visibility to the area(59).

Ressignifying madness in a political, social and cultural way is a strategy that can be used to displace the training of undergraduate nursing students from the institutionalizing and excluding care model and to have as an instrument the therapeutic relationship and the qualification of mental health care by nurses.

 

Final Considerations

The recommendations for the reformulation of the NCGs of the undergraduate course in Nursing signal necessary and bold changes to meet social, political, and market demands in contemporary times. For Nursing, such reformulations present important advances in the formation of the generalist nurse.

It is understood that it is up to nurse teachers, as educators at the forefront of the training process, to discuss the impact on the evaluation and reformulation of political pedagogical projects and curricula of nursing schools throughout the country.

The basis for the development of a profession in the health area is quality training implicated with the social well-being and quality of life of individuals and populations. Psychiatric and Mental Health Nursing, in face of epidemiological data and projections of mental suffering for the world population, will be urged to assume general and specific mental health care, expanding an area of Nursing knowledge that has little attracted future nurses. The proposed changes in the training field meet the needs that present themselves now and in the future.

The need for studies that identify mental illness as something intrinsically linked to the social conditioning and determinants of health and mental health, as well as in the field of primary care in mental health in undergraduate education, identifying the technologies of care and the necessary skills for generalist nurses to work in the care of people in mental distress in different settings.

 

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Corresponding Author:
Amanda Márcia dos Santos Reinaldo
E-mail: amandamsreinaldo@gmail.com

Received: Oct 14th 2020
Accepted: Feb 10th 2021

 

 

Author's contribution
Study concept and design: Amanda Márcia dos Santos Reinaldo.
Obtaining data: Amanda Márcia dos Santos Reinaldo, Girliani Silva de Sousa, Belisa Vieira da Silveira.
Data analysis and interpretation: Amanda Márcia dos Santos Reinaldo, Girliani Silva de Sousa, Belisa Vieira da Silveira.
Drafting the manuscript: Amanda Márcia dos Santos Reinaldo, Girliani Silva de Sousa, Belisa Vieira da Silveira.
Critical review of the manuscript as to its relevant intellectual content: Amanda Márcia dos Santos Reinaldo, Girliani Silva de Sousa, Belisa Vieira da Silveira.
All authors approved the final version of the text.
Conflict of interest: the authors have declared that there is no conflict of interest.
* The publication of this article in the Thematic Series "Human Resources in Health and Nursing" is part of Activity 2.2 of Reference Term 2 of the PAHO/WHO Collaborating Centre for Nursing Research Development, Brazil.

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