TWENTY YEARS OF THE BRAZILIAN PSYCHIATRIC REFORM: MEANINGS FOR PSYCHIATRIC AND MENTAL HEALTH NURSING

VEINTE AÑOS DA LEY DE REFORMA PSIQUIÁTRICA EN BRASIL: SIGNIFICADOS PARA LA ENFERMERÍA PSIQUIÁTRICA Y EN SALUD MENTAL

ABSTRACT

Objective

to develop arguments supporting Psychiatric and Mental Health Nursing as a baseline force of qualified and indispensable work in the evolution of mental health care and policies.

Method

argumentation of a reflective nature, considering the path of Psychiatric and Mental Health Nursing over the twenty years of the legal framework of the Psychiatric Reform, as well as the publications pertinent to discussion of the topic in vogue.

Results

two topics emerged, namely: From Psychiatric Nursing to Mental Health Nursing: a change of paradigm; and Mental Health Nursing: a new praxis.

Conclusion

Psychiatric and Mental Health Nursing presents itself as a resilient and sustainable practice despite the crises caused by institutionalizing policies implemented at the governmental level. The profession, increasingly politicized and attentive to the relevant guidelines of the Unified Health System, struggles and reinvents itself in its way of caring, in line with the reform guidelines, not subjected to stigmatizing regressions or outside the community territory.

DESCRIPTORS
Mental health; Psychiatric Nursing; Mental health services; Nursing; Professional practice; Psychiatric Reform

RESUMEN

Objetivo

desarrollar una argumentación que sustente a la Enfermería Psiquiátrica y en Salud Mental como una fuerza base de trabajo calificado e indispensable para la evolución de la atención y las políticas de salud mental.

Método

argumentación de carácter reflexivo, considerando el trayecto de la Enfermería Psiquiátrica y en Salud Mental a lo largo de los veinte años de vigencia del marco legal de la Reforma Psiquiátrica, al igual que las publicaciones pertinentes al debate del tema en boga.

Resultados

se presentaron dos temas: de la Enfermería Psiquiátrica a la Enfermería en Salud Mental: un cambio de paradigma; y Enfermería en Salud Mental: una nueva praxis.

Conclusión

la Enfermería Psiquiátrica y en Salud Mental se presenta como una práctica resiliente y sustentable con respecto a las crisis originadas por políticas institucionalizantes implementadas al nivel gubernamental. La profesión, cada vez más politizada y atenta a las pautas relevantes del Sistema Único de Salud, lucha y se reinventa en su forma de ofrecer atención, alineada con las directrices de la reforma y no sujeta a regresiones de carácter estigmatizante o fuera del territorio comunitario.

DESCRIPTORES
Salud mental; Enfermería psiquiátrica; Servicios de salud mental; Enfermería; Práctica profesional; Reforma psiquiátrica

RESUMO

Objetivo

desenvolver argumentação sustentando a Enfermagem psiquiátrica e em saúde mental como força-base de trabalho qualificado e indispensável na evolução da assistência e políticas em saúde mental.

Método

argumentação de natureza reflexiva, considerando o percurso da Enfermagem psiquiátrica e em saúde mental ao longo dos vinte anos do marco legal da Reforma Psiquiátrica, bem como as publicações pertinentes à discussão do tema in voga.

Resultados

apresentam-se dois tópicos: da Enfermagem Psiquiátrica à Enfermagem em saúde mental: mudança de paradigma; e, Enfermagem em saúde mental: uma nova práxis.

Conclusão

a Enfermagem psiquiátrica e em saúde mental se apresenta como prática resiliente e sustentável a despeito das crises originadas por políticas institucionalizantes implementadas em nível governamental. A profissão, cada vez mais politizada e atenta às pautas relevantes do Sistema Único de Saúde, luta e se reinventa na sua forma de cuidar, alinhada às diretrizes da reforma, não estando sujeita a regressões de caráter estigmatizante ou fora do território comunitário.

DESCRITORES
Saúde mental; Enfermagem psiquiátrica; Serviços de saúde mental; Enfermagem; Prática profissional; Reforma psiquiátrica

INTRODUCTION

The year 2021 made it possible to reflect on the psychosocial field, as it marked twenty years since enactment of Federal Law N^o.10,216/01, known as the Paulo Delgado Law, which conferrer legal character to the Brazilian Psychiatric Reform. Such law, recognized as a result of the anti-asylum movement initiated in the 1970s, which brought to light the incompetence of psychiatric hospitals, which only responded as an asylum, excluding, prison-like and institutional reference in treatment of these people, was widely supported by users, their family members and professionals imbued with the concept of mental health, who, since then, have remained firm in the struggle for the effective guarantee of the rights of people in psychological distress in Brazilian society1.

This framework is also a reason for celebration for Nursing, as the Paulo Delgado Law (Psychiatric Reform) provided, through the creation of different mental health care devices, a change in the way of caring for people with mental disorders, which exerted a direct impact on the Nursing practice in the area1.

Since 2001, this model, previously limited to psychiatric hospitals, has been replaced by territory-based services, with restructuring of mental health care in the following topics: funding of beds in general hospitals, hospitalization time restricted to the minimum necessary, psychosocial assistance and rehabilitation for users discharged from long psychiatric hospitalizations, and regulation of the Psychosocial Care Network (Rede de Atenção Psicossocial, RAPS)2.

The RAPS, created by MS/GM Ordinance N^o.3,088/2011, legally establishes these services and restructures a more expanded place for psychosocial care in its various components and points of care, characterized by community health services, inserted in the social context and open to the population, within the scope of the Unified Health System (Sistema Único de Saúde, SUS)3.

The Psychosocial Care Centers (Centros de Atenção Psicossocial, CAPS) were the first devices to replace asylums, established in 1987 and with a strategic organizational function in the territory. For the users, it was a path towards freedom, dignity and, mainly, to the rescue of citizenship. In addition to opening a door to its corresponding territory, where treatment started to be devised jointly and co-responsibly, it sought to develop a possible autonomy through deinstitutionalization, comprehensive interprofessional care and psychosocial rehabilitation strategies4^-5. Therefore, the CAPS meet and are compatible with aspirations for the treatment of people with mental disorders, which are linked to psychiatric reform precepts, in increasing development2.

Thus, an unprecedented transformation was generated in the history of Brazilian Psychiatry, with closing of asylums and creation of other care devices, in addition to the CAPS, such as the following: Residential Therapeutic Services (Serviços Residenciais Terapêuticos, SRTs), Shelter Units, Street Clinics, Living Centers and Reserved Beds in General Hospitals, among other modalities, provided that they guarantee users appropriate alternatives in mental health services, without restricting their freedom, which was once the only option for anyone who manifested any type of psychological distress or abuse of alcohol and other drugs, requiring some specific form of treatment1^-3.

Such transformations were directly reflected in mental health professionals' knowledge and actions, mainly in Psychiatric Nursing care, which had to be reconfigured in the face of the new practices and knowledge required in the construction of care proposed by the territorial model of psychosocial care. Therefore, the care previously performed in the hospital by the physician/nurse dyad is now proposed, in mental health devices, together with a multiprofessional team, in an interdisciplinary and interprofessional nature. Thus, organization of the networking process faces the challenges of promoting mental health, preventing, protecting, recovering and rehabilitating situations of psychological distress in people, whether in childhood or at another life phase, in the family environment and necessarily expanding to the community space to generate autonomy6^-7.

Evidently, over these last twenty years, health teams still have some members who are resistant to the changes proposed by Law No. 10,2016/01 and other subsequent legal frameworks. However, thanks to the efforts of many professionals, users and their family members, who continued with the anti-asylum movement, it is possible to visualize the Psychiatric Reform guidelines as a reality in mental health devices spread across the Brazilian municipalities. In this way, surveillance and the struggle for rights represent a constant and necessary stance for those who aim at a qualitative evolution in mental health care and assistance in contemporary social institutions1^-2.

In this context, Nursing and other team professionals reorganized mental health care, based on psychosocial assistance, having two pillars supporting its objectives: joint creation of coping strategies and the greatest possible autonomy for people with mental disorders in their families, considering everyday life situations, users' uniqueness, resources and devices available in different social and economic contexts. All of the above to be built from the singular therapeutic project, developed in a co-participatory way between the user, the family and the reference professionals of the services inserted in the territory8.

The Nursing team, in its most recognized peculiarity, which is to be present in a continuous and uninterrupted way in the hospital, needed a reinterpretation of its professional Psychiatric Nursing practice, instituted since the creation of the first Brazilian asylum and reasserted for more than a century within similar institutions8^-9. This reinterpretation of the Nursing practice in the psychiatric field, which since the 1950s has been well-defined as specialized Psychiatric Nursing care, was qualified to become essential also in the field of mental health.

Thus, the preference of some authors for using the term “Mental Health Nursing” instead of “Psychiatric Nursing”, in no way interferes with the constitution of the established knowledge in the specialty, as it persist as fundamental in the devices intended for the care of the people with severe and persistent mental disorders, requiring the participation of a specialist nurse in the area and defining the main theories and procedures of this care: Psychiatric Nursing. History should not be put out but serve as an example to prevent repetition of the practices evidenced as futile for care. Therefore, it can be said that the Psychiatric Nursing specialty has expanded and subsidized Nursing practices in mental health, which are applicable in different care settings, and can (mental health) be spread even to the non-specialized professionals who work in Primary Health Care, in order to allow for greater coverage of Nursing care in the territory and organization of access for people with mental disorders to the RAPS devices.

Thus, over these twenty years, Psychiatric and Mental Health Nursing care has evolved and its professionals are willing to do it with, and not for, the user. In this sense, professionals, specialists, researchers, Masters and PhDs produced important scientific evidence that consecrated their contributions to the elaboration of a theoretical-practical framework, aiming at psychosocial care as the core of Psychiatric and Mental Health Nursing8^,10.

Undergraduate courses have improved, graduate courses (lato and stricto sensu) have expanded and Psychiatric and Mental Health Nursing, as a specialty, started to be better recognized, without failing to bring to light the gaps in the training of qualified human resources and the challenges to be faced both in the practice and in the elaboration of public policies in this area, which often suffer attacks translated as setbacks to the recommendations set forth by the Psychiatric Reform11^-12.

As an example, in the period between 2016 and 2019 there is a series of edited regulations, related to the "New Mental Health Policy", nomenclature given to technical note No. 11/2019 of the Ministry of Health. In fact, the “New Policy” is a counter-reform that places psychiatric hospitalization, whether in a general hospital, a psychiatric hospital or even in a therapeutic community, as an advantageous possibility for funding mental health as a commodity1. This leads to remembrance of what happened in the 1970s, to what is known as the “madness industry” or “madness commodification”, as the “New Policy” also authorizes funding the electroconvulsive therapy (ECT) procedure, currently regulated by the Federal Council of Medicine, requiring anesthesia and equipment, which increases the amount charged for it, which is added to the high cost of psychiatric medications and the high amounts paid for Hospital Admission Authorization (Autorização de Internação Hospitalar, AIH) in Psychiatry. If not supervised in its use, all of the above can be manipulated to enrich the pharmaceutical industry and the owners of psychiatric clinics1^-2.

Also in the same perspective, while the financial resources for hospitalizations and maintenance of long-term hospitalization beds increased, the budget for CAPS, SRTs, Shelter Units and Beds in General Hospitals was reduced, which reflects the intention of making a way back or counter-reform, being directed to mental health professionals and users1^-2.

It is about this sudden transformation, over twenty years and from the perspective of history, that this article deals with, with the objective of developing arguments supporting Psychiatric and Mental Health Nursing as a baseline force of qualified and indispensable work in the evolution of mental health care and policies.

In justifying this reflection, it is considered, above all, that in twenty years of the Psychiatric Reform Law, Nursing represents a prominent and uninterrupted presence with users of the Health Services in different institutions and management bodies, always attributing new meanings and transforming their practices for the sake of quality and excellence in care. Thus expanding the focus, previously only focused on bureaucratic, administrative and technical duties, to new direct actions with users and family members in mental health, through evidence-based practice, technological innovations, scientific knowledge, light technologies and integrative practices.

Application of the Nursing Process in a systematic way is also added, with qualified therapeutic listening, welcoming, bonding, development of therapeutic workshops, preventive interventions and education in health, home visits, Nursing consultation, crisis management and matrix support, among other psychosocial care strategies, in the various devices that comprise the RAPS, assuming a role of resistance and confrontation with retrograde and institutionalizing movements.

METHOD

An argumentation of a reflective nature, which considers the path of Psychiatric and Mental Health Nursing over the last twenty years of the legal framework of the Psychiatric Reform, as well as the publications pertinent to discussion of the topic in vogue. The references were selected both for their relevance in the field of Psychiatric Nursing history (teaching and practice) and for discussions by researchers who critically address the Psychiatric Reform movement.

RESULTS

The changes resulting from and guaranteed by the Psychiatric Reform allowed Psychiatric and Mental Health Nursing to advance through new paths, including the following: expansion of the demand for specialization in the area; increased awareness and political action in the face of constant threats and setback policies in the area; production of studies on topics pertinent to the reform, corroborating for the dissemination of the work done by the category in the area; and greater insertion of the Nursing team in the different mental health devices, not reducing their know-hows only to hospitals.

Thus, this reflection was presented in two topics, as follows: 1) From Psychiatric Nursing to Mental Health Nursing: a change of paradigm and Mental Health Nursing: a new praxis; and 2) Psychiatric and Mental Health Nursing after twenty years of the Psychiatric Reform: challenges to avoid setbacks.

From Psychiatric Nursing to Mental Health Nursing: a change of paradigm

Historically, Psychiatric Nursing had difficulties defining its role in the context of interdisciplinarity and the paradigm of biopsychosocial care in mental health. This fact is justified by its trajectory in the area which, initiated as a charitable practice, progresses towards its professionalization, initially focused on the interests of Psychiatric Medicine, which starts to manage large hospices13.

Although they were called “nurses”, only a small percentage of this group had some professional training, and psychiatric “care” was performed by anyone, regardless of study or qualification for such purpose. It is necessary to acknowledge that work in these asylum institutions required “Nursing” to deal face to face with people in psychological distress, without having undergone any technical training or in therapeutic procedures or humanized care protocols. In addition to that, most of the times, people are hospitalized against their will and subjected to punitive, standardizing and imprisoning “treatments”10.

This situation lasted from periods in which moral treatment was in force, going through the biological therapies, until the advent of psychotropic drugs (1950) and the implementation of non-pharmacological therapeutic practices, from 19709^,13. Until the 1960s, few nurses were included in psychiatric institutions, and it was only in 1975 that the first graduate course in Psychiatric Nursing was created in the country11.

In view of this, despite having been diverted for a long time from its role of caring, Psychiatric Nursing has developed certain ability to adapt to new care modalities and theoretical-practical and scientific knowledge to improve the profession and qualify its performance8. The justification for its scientific and technological advances in the psychosocial field, even considering only twenty years since enactment of the law that for the first time consolidated the principles and guidelines of the Psychiatric Reform in Brazil, is the replacement of Nursing practitioners by nurses, nursing assistants and technicians over time10.

Without disregarding the role of Public Health Nursing (1930-1950) which, based on mental hygiene, acted as another agent of psychiatric care outside the hospital due to its educational capacity in the prevention of mental illnesses10; Psychiatric Nursing has particular importance in the Psychiatric Reform, as it invested in theoretical-practical improvement, production of scientific knowledge, training of resources, or even in the social devices for control and formulation of public policies, it restructured itself and broke with the asylum paradigm to work in qualified promotion of mental health care8^-9.

In the deinstitutionalization process, still within the psychiatric hospital, Psychiatric Nursing promoted care to make it possible for hospitalized people to be discharged, actively participating in the reduction of beds. Anti-asylum movements took place both inside and outside the institution. In the latter, Nursing worked to give a minimum of autonomy for these people to go out to socialize in their homes or SRTs.

Through the creation of mental health devices in the community and improvement of teaching in the area, the professional knowledge of Psychiatric and Mental Health Nursing could, in fact, be validated, trained and implemented, establishing autonomy and competence of these professionals for the care to be offered based on the Psychiatric Reform. Therefore, Psychiatric and Mental Health Nursing even surpassed the teaching model of Nursing schools which, for many years, was based on traditional psychiatry and pharmacological treatments, understood as the only way to achieve the “cure for madness”7^,9^,12.

In this context, with the advent of the SUS, the hegemony of medical science over other health practices encouraged parallel and concomitant movements to those of the Psychiatric Reform on the part of the health professions, so that, critically, the disciplines, including Medicine itself, set themselves out to exchange knowledge and share interventions and care.

Thus, Psychiatric and Mental Health Nursing extended itself in society with the Psychiatric Reform to be incorporated into the psychosocial care model, understood as a paradigm that includes mental health in the interdisciplinary field, while keeping in itself specialized care inherent to the profession. In this way, it came to understand the health-disease process as a result of complex social processes that demand an interprofessional and intersectoral approach, with the objective of achieving comprehensive care, from the perspective of the SUS. Mental health is defined as “well-being in which the individual develops their personal skills, is able to cope with the stresses of life, works productively and is able to make a contribution to their community”14^,15^:25.

This is because Psychiatric and Mental Health Nursing has a range of knowledge that allowed it to work in the psychosocial paradigm, where the work process is horizontal and no single professional assumes leadership. In addition, it has been taking place without its bases, as a specialty, being left aside, as they are the ones that continue to support care for people with severe and persistent mental disorders. The advances are evident and marked by the presence of Nursing in all the RAPS devices.

The current investment of Psychiatric and Mental Health Nursing needs to be in tune with a studious professional composition and full of projects suited to the service it proposes to provide to society where it serves. The multiprofessional team proposal, with an interprofessional approach, is to have several professionals working cooperatively, with collaborative practices and teamwork shared with social workers, nurses, physicians, psychologists, nursing technicians and occupational therapists, among other professionals. All centered on care quality and on certain advanced results, with a focus on care in freedom and extended to an increasingly comprehensive social exchange4^,16^-17.

Interprofessionality in mental health presupposes horizontality of the team and this implies criticizing inflexibility in relation to multiprofessional and intersectoral dialog. It has strategies capable of offering care to a greater number of people in the SUS and of reducing lack of access to mental health services. Intersectoral dialog depends on professionals potentially prepared to develop communication within the team and across services, for better articulation of common and specific competences of each professional16^-17.

As nurses are recognized professionals, not only, but mainly, for their permanence and proximity to users and their families to provide Nursing care, they are always linked to the work of other professionals. Therefore, their performance is integrated with that of the other members of the health team, usually turning them into an important articulating member of the team3^,17^-18. This place is not only occupied by nurses, as it must circulate among the different members of the mental health team, allowing for the effective participation of everyone in provision of the service, which is encouraged by the Nursing team.

However, these changes that fostered efforts to reconfigure diverse knowledge and practices made difficulties and resistance emerge in multiprofessional teams. In addition, not all members of these teams had the skills or were willing to follow the advances made by the anti-asylum movement8. This is one of the factors that may have led some Nursing professionals to distance from the care logic of the territorial mental health service, with centralization of their performance in bureaucratic activities, professional identity crisis, and limitation in the development of Psychiatric and Mental Health Nursing.

However, several studies point out the relevant contributions of Nursing and, in particular, of professional nurses, who came to reconfigure their outdated knowledge and managed to build their own mental health praxis based on the science of Nursing and human rights, having as a premise the therapeutic relationship and the uniqueness of each person for the development of appropriate and more comprehensive ethical and professional care, meeting the parameters set forth by the SUS8^,18^-19.

Thus, the Psychiatric Reform also boosted Psychiatric and Mental Health Nursing to develop and apply some tools, now perceived as fundamental, in order to go beyond the technicist model (task performer) towards an autonomous and creative model, sensitive to the improvement of new care strategies and coping with unexpected situations, always seeking dignity and greater autonomy in people with mental disorders in their psychosocial context, making these professionals essential for consolidation of the reform6^-7^,14.

By integrating the RAPS services, the Nursing team contributed to the implementation of devices that had services capable of identifying clinical demands beyond the symptoms of mental illness, highlighting in this process the therapeutic interpersonal relationships as a primordial tool, applicable in any health care setting to provide mental health care. With a vital role, Nursing has articulated resources and devices to promote due attention and care to each person's needs, considering their multidimensionality18^-20.

It is also important to highlight the evolution of the Nursing Process towards implementation of a list of resources for care based on interpersonal and therapeutic relationships20^-21. In the new mental health devices, Nursing has gone beyond the care of a person, individually, covering their entire life and health scenario. It also worked in the production and updating of scientific knowledge in the mental health area, with a significant number of articles, from 2001, indexed in the most relevant databases. This allows us to more clearly identify the expansion of Psychiatric Nursing into Mental Health Nursing in the last 20 years22.

Psychiatric and Mental Health Nursing after twenty years of the Psychiatric Reform: challenges to avoid setbacks

In this look at the path of Nursing in the last twenty years, after the legal framework of the Psychiatric Reform, it permeates the political scenarios that exerted profound influences on the elaboration of guiding policies for mental health care in the country. In this context, the participation of this working class in the health sector also advances in the movements and conflictive decision-making situations in the direction of institutionalized and deinstitutionalized practices. Regarding the changes that accompany the path of the Reform, investments in professional training and scientific production focused on and articulated to a care model in mental health and integrality of the human being are also revealed.

Historical Nursing studies, motivated by the path of the Brazilian Psychiatric Reform, start from experiences in psychiatric hospitals, contributing to the knowledge and appreciation of the changes experienced by the workers in the institutions22^-23, as well as by mental health users, inside and outside of institutions; what shed light to the perception of the mental health problem in society was realizing that mental health is a need for all and not a problem for some, influencing the directions of professional training24.

A study represented the behavior of the way of caring, which followed the interactions of the social and political world since the 1970s, from within the institutional space to the space outside the walls, given the relationships of the people who provided care and managed hospitals25. Thus, the second half of the 20^thcentury was decisive to attribute a new meaning to global mental health, which had new communication resources to spread ideas and theoretical conceptions on this topic, causing, in different parts of the world, critical reflections on what influences psychological distress: the life context of people who suffer26.

In this sense, in the national reality with the creation of the CAPS in Brazil, Nursing entered the interprofessional care context, with a focus on psychosocial rehabilitation and mental health care, with specific demands that required intersectoral articulation to implement the extramural policy proposal, made as opposed to the asylum system. Thus, it is acknowledged that it has always been challenging to promote a new care model for mental health, both by the CAPS teams and by the mental health services in territories, according to the realities of the municipalities. In this way, the actions by Nursing in mental health find in the Family Health Strategy a number of possibilities and challenges in the implementation of practices for deinstitutionalization and expansion of the perspectives of network care, with the purpose of capillarizing practices in the territory with the existing social devices27.

Thus, the role of Nursing in the CAPS is characteristically represented by the way of organizing the work process of the Nursing team, with basic care and grounded on specific competences. This requires dialog between nurses' exclusive activities, in addition to interactions and shared care with the interprofessional team, means by which individual, family and collective practices are developed, both at the and community levels18^-28. Given the complexity of mental health care, the importance of interprofessional work in recognizing the collective identities and interprofessionality in the devices and resources available is essential, considering the national policy and the current context of the Brazilian Psychiatric Reform17^,20.

In addition to that, theoretical-practical approaches aimed at assistance in psychopathology and psycho-symptomatology are also emphasized as difficulties in nurses' work, which reflect gaps in professional training or even in permanent education. A challenge pointed out in the literature is the persistence of non-definition or lack of clarity about the position and space of nurses' work, clinically, in the multiprofessional team, which can be related to the hegemonic psychiatric model in its treatment modalities and to the scarcity of opportunities to update the professionals working in the substitutive services8^,18.

This is because the determinants for the transformation of Psychiatric Nursing teaching and the interest in the field of coverage in Mental Health did not only involve curricular changes but also studies on the way in which Nursing teaching appropriated these determinants for the development of the are in Nursing training6^,9^,11; many of them evidenced and consolidated from the evolution of care and theoretical-practical advances developed in the health services from the territory. In view of this, the transversality that can become more present in mental health within the scope of Nursing education is highlighted, as the Psychiatric Reform advances with its respective care actions towards the territory. And, thus, coverage of people in psychological distress becomes more present in health care environments, regardless of the specialty offered by the service.

Another important challenge has been high turnover in the services, especially in those that comprise the RAPS, such as CAPS and SRTs. One of the arguments pointed out for this turnover was the hiring of other professionals instead of those approved in a public tender for the SUS. A study18 identified in the literature the disagreements in the deinstitutionalization process, when observing the working conditions of mental health teams in the territory and their representativeness in the CAPS for the interprofessional work process in the therapeutic and productive scope of the activities performed in these services4^,18.

Thus, even considering the relevant advances implemented in Nursing care in mental health, from the perspective of the reform, health professionals, Nursing courses (university and technical), professors and researchers in the mental health area are often isolated. Even if they participate in scientific events in the area, their performance is limited to the debates in dialog and decision-making spaces.

There are still worrying limitations, such as isolation of the Nursing team in wards, especially in psychiatric hospitals, the little voice of the Nursing team in closed institutions that maintain the old medical-centered treatment dynamics, and intense workloads that hinder articulation with other categories. All of this represents obstacles for a better organization of the category in the sense of broadening their views to the multidisciplinary dialog of care and expanding conversation and insertion with other groups, both inside and outside the mental health area29.

This situation is expressed in the Letter of Mental Health Nursing, documented during a plenary session at the 3^rdBrazilian Colloquium on Mental Health Nursing (2021), emphasizing that national partnerships at this current historical-social moment could provide a greater scope of actions, broad involvement of other actors and decentralization and territorialization of proposals, as well as offering greater investment in the Mental Health Nursing training in the action-transformation perspective with the students, effectively articulating teaching, research and university extension in research-intervention-action29.

Despite so many challenges, some of them herein recorded, it is also necessary to note that, due to the political and social differences prevailing in the regions of the country, a powerful Nursing movement in favor of knowledge acquisition and production that increasingly narrows the relationship between Nursing and the field of mental health has been emerging. Thus, public funding must not only continue but increase, given the increasing demands for mental health services and excessively long waiting times in the services.

CONCLUSION

One of the most important considerations is that, in the last twenty years, the Psychiatric Reform has exerted a profound impact on the reduction of the perverse dehumanization of care, which has traced a long path, marked by the asylum history. Acquisition of new concepts, globally accepted in the transition process from the asylum model to the psychosocial model in Brazil, consolidated what we now call Psychiatric and Mental Health Nursing.

The current concept of Mental Health involves all the health professionals and arises from the expansion of the care spaces for people in psychological distress. For this reason, it no longer dispenses Nursing care and inhabits the context of these practices, corroborating the work perspective of the entire health team acting interprofessionally.

The theories and concepts created to support the therapeutic care provided by Psychiatric Nursing are current and relevant to psychosocial care, so much so that their application is advocated in settings where there are Psychiatric and Mental Health Nursing practices in the RAPS. The foundations that emerged with the SUS and the Psychiatric Reform were incorporated to them to arrive at what is now called Psychiatric and Mental Health Nursing, with an inclusive and ethical work logic, which is increasingly learning to consider users as protagonists of the care provided, which should be reflected in the STP. The challenges were launched by the ongoing anti-asylum movement. Many of them have been solved and others are in the overcoming phase, requiring reflections like this for greater criticality on the set of diverse knowledge and practices, which over the years have been dimensioned by Psychiatric and Mental Health Nursing and, for that very reason, managed to leave isolation to define a reforming field of action, designing the place of Nursing care in the multiprofessional team.

For these reasons, the breadth of Psychiatric and Mental Health Nursing, present in different health care devices and contexts, does not allow for institutionalizing regressions, as the advances no longer allow considering any care practice that is presented outside the community territory.

In pandemic times, mental health leapt in the eyes of the world, becoming a concern for the future and revealing itself in a social and humanitarian value, implicit in the process of individual and family development, the world of work and social relationships, reflected in the cultural diversity of global societies. In this sense, the pertinence of envisioning the constancy of advances in this area is reasserted, so that resilient and sustainable practices, both at the community level and at that of the systems and sectors responsible for strengthening support networks and coping with mental distress, are present and efficient despite the crises.

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Edited by

EDITORS

Associated Editors: Leticia de Lima Trindade, Ana Izabel Jatobá de Souza. Editor-in-chief: Roberta Costa.

Publication Dates

• Publication in this collection
  19 Sept 2022
• Date of issue
  2022

History

• Received
  12 Mar 2022
• Accepted
  09 June 2022