Nursing process in mental health : an integrative literature review

Objective: to identify evidences from the literature on the application of nursing process in care developed by the nurse in mental health. Method: integrative literature review between 1990 and 2013, in the PubMed, Scopus, CINAHL and LILCACS bases. Descriptors: nursing processes, mental health, nursing care. Results: 19 papers were identifi ed. Limited and partial usage of the nursing process in care established by a therapeutic relationship that respects the patient’s individuality. We observe care proposals systematized for patients that present pathological aspects in the limits between the physical and psychical, which might be a response to the infl uence of the practice based on evidences. Conclusion: it was found an antagonistic movement between care based on the relationship and located in the standardization of diagnoses that respond to physical malaise. A lack of evidence was verifi ed for the usage of the nursing process in mental health, and we point at the necessity for the creation of new possibilities for dialogue between relational and biological perspectives. Descriptors: Nursing Research; Mental Health; Nursing Care; Nursing Processes; Search. RESUMO Objetivo: identifi car evidências da literatura sobre a aplicação do processo de enfermagem no cuidado desenvolvido pelo enfermeiro na saúde mental. Método: revisão integrativa da literatura, entre 1990 e 2013, nas bases PubMed, Scopus, CINAHL e LILACS. Descritores: processos de enfermagem, saúde mental, cuidados de enfermagem. Resultados: identifi caram-se 19 artigos. Uso limitado e parcial do processo de enfermagem no cuidado estabelecido por meio da relação terapêutica que respeita a individualidade do paciente. Observaram-se propostas de cuidados sistematizados para pacientes que apresentam aspectos patológicos no limite entre físico e psíquico, podendo ser uma resposta à infl uência da prática baseada em evidências. Conclusão: constatou-se movimento antagônico entre cuidado pautado na relação e situado na padronização de diagnósticos que respondem ao mal-estar físico. Verifi cou-se falta de evidência para o uso do processo de enfermagem na saúde mental e aponta-se para necessidade da criação de novas possibilidades de diálogo entre perspectivas relacional e biológica. Descritores: Pesquisa em Enfermagem; Saúde Mental; Cuidados de Enfermagem; Processos de Enfermagem; Pesquisa. RESUMEN Objetivo: identifi car evidencias de la literatura sobre aplicación del proceso de enfermería en el cuidado brindado por el enfermero en salud mental. Método: revisión integrativa de la literatura, entre 1990 y 2013, bases PubMed, Scopus, CINAHL y LILACS. Descriptores: procesos de enfermería, salud mental, atención de enfermería. Resultados: se identifi caron 19 artículos. Uso limitado y parcial del proceso de enfermería en atención, establecido mediante relación terapéutica que respeta la individualidad del paciente. Se observaron propuestas de atención sistematizadas para pacientes con aspectos patológicos limítrofes entre físico y psíquico, pudiendo constituir respuesta a infl uencia de práctica basada en evidencias. Conclusión: se constató movimiento antagónico entre atención pautada en la relación y referido en estandarización de diagnósticos correspondientes al malestar físico. Se verifi có falta de evidencias para uso del proceso de enfermería en salud mental y se expresa necesidad de creación de nuevas posibilidades de diálogo entre perspectivas relacional y biológica. Descriptores: Investigación en Enfermería; Salud Mental; Atención de Enfermería; Procesos de Enfermería; Investigación. Nursing process in mental health: an integrative literature review Processo de enfermagem na saúde mental: revisão integrativa da literatura Proceso de enfermería en salud mental: revisión integrativa de la literatura REVIEW Ana Paula Rigon Francischetti Garcia E-mail: apgarcia@unicamp.br CORRESPONDING AUTHOR


INTRODUCTION
The Brazilian psychiatric reformation, a movement organized based on an heterogeneous knowledge field and practices related to clinics, politics, culture, and legal-judicial relationships, influenced the creation of the new models of mental health care adopted nowadays (1) .
Consequently, this movement sustained transformations in the health care, which resulted in the need to reorganize the working process of the professionals involved in the care provided to the mental ill (1) .In the context of these changes, nursing starts to develop actions aimed at overcoming the guardianship paradigm through the understanding of suffering in its complex relationship between the psychic, social and political determinants (2)(3) .
Currently, nursing care in mental health demands from the nurse a therapeutic agent posture (4)(5) .However, sustaining a therapeutic agent position requires a posture that prioritizes the establishment of the therapeutic relationship, understood as a technology of nursing care that allows to recognize the patients' life experiences and to stimulate their accountability in the production of their symptom, and, consequently, in the therapeutic decisions making (4)(5)(6) .
The therapeutic relationship constitutes the central action of the nurse's practice in mental health, and its consolidation is given through nursing process, which characterizes the nurses' way of thinking, whose purpose is the formulation of care (5)(6)(7) .
In order to develop the Nursing Process (NP), it is essential that the nurse has knowledge on: health needs, form of approach and information collection, method of organizing the information collected aiming at a care plan, identification and proposition of interventions and evaluation of provided care (7) .
Thus, NP becomes central to the establishment of nursing care in mental health and aids the nurse to assume an autonomous position as a therapeutic agent, which consequently qualifies the provided nursing care and can also be understood as the nurse contribution to the singular therapeutic project (3,8) .
Moreover, the NP allows a greater amplitude in the evaluation of the patient's health status, since the focus of care must be directed to the recognition of the individual meaning of the psychological suffering experience in its social, political and cultural context, not being restricted to the psychopathological symptomatology and to the psychiatric diagnosis (9) .Therefore, when nurses assume their position as therapeutic agents along with patients suffering from psychic suffering, their therapeutic contribution can be through the NP (10) .Thus, nursing care becomes consonant with the current context and Brazil's public policies that advocate their attention in a contextualized way with the social, political, economic and cultural determinants of the subjects (1,11) .
In this manner, it is possible to see the possibility of NP to structure the care for patients suffering from psychic suffering, based on the establishment of the therapeutic relationship, which extends the perspective of care to the clinical, social, political and cultural issues of the individual being treated.Therefore, the present study aims to identify the evidence found in the literature on NP application in the care developed by the nurse in mental health.

METHOD
It is an integrative review, understood as the systematic analysis and synthesis of research on a specific topic of broad or restricted scope with descriptive analysis (12) .This method is of particular importance when there is the necessity of solving a clinical problem, or to evaluate the use of a particular concept in scientific context (12) .
For the elaboration of this study, the following stages were observed: theme identification or questioning of the integrative review, sampling or literature research, categorization of the studies, interpretation of the results and integrative review presentation (13) .
The research question was elaborated with the application of the PICO strategy, an acronym in the English language that means "patient, intervention, comparison and outcomes", since they are fundamental elements of the research question and the elaboration of the question to search for evidence in the literature (14) .
Thus, P was assigned to mental health patients, to I was the application of NP in mental health care, to C was the comparison between the obtained results and to O was the presence of evidence in the literature on the application of the nursing process in the context of Mental health, which resulted in the following question: What are the evidences found in the literature on the application of NP in the nurse's care in mental health?Four databases were selected to select publications: National Library of Medicine (PubMed), SciVerse Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Latin American and Caribbean Literature in Health Sciences (LILACS), using different search strategies and three controlled descriptors.
The controlled descriptor consists of a term of a structured and organized vocabulary, so as to be used for indexing the papers in the databases because it is a subject descriptor (15) .So, the query to identify the descriptor occurred in the Health Science (DeCS/Bireme) descriptors and in the Medical Subject Headings (MeSH/PubMed), and those identified were: nursing process, mental health care and nursing care.
The inclusion criteria were papers in journals, dissertations, unpublished studies, experience reports and theses between January 1990 and July 2013, with abstract available in Portuguese or English and complete text in English, Spanish, Portuguese and French, that portray the NP in the practice of mental health nursing.The time delimitation for the search is justified when recognizing the changes in the working process of mental health professionals in the Brazilian context after the psychiatric reform movement, supported by the new legislation on health care in the country that legitimized new forms of mental health care (11,16) .
Data extraction and classification of the evidence level was performed using an instrument proposed by Stetler et al. (12) .In order to present the synthesis of the selected papers, we used a synoptic table with the description of the following aspects: name of the authors, year, aim, study design, results and conclusions (17) .And for the interpretation of the results and review presentation, it was decided to discuss the findings from the convergent themes found in the papers.
Nursing process in mental health: an integrative literature review Garcia APRF, et al.

RESULTS
We identified 365 papers using the defined search criteria: 176 in PubMed, 20 in Scopus, 37 in CINAHL and 132 in LILACS.Then, the titles and abstracts were read to make a pre-selection from the established inclusion criteria, resulting in a total of 48 studies: 20 in PubMed, 8 in Scopus, 13 in CINAHL and 7 in LILACS.
The 48 papers were entirely read and 29 studies were excluded from them, since 14 discuss the theoretical reference of nursing care in mental health without approach to the NP method; eight approach different themes with the inclusion of the process as a method of results organization; three discuss nursing care in mental health without no articulation to the NP; one develops the contraposition between the medical and the nursing diagnosis in the clinical practice of the nurse; and three studies were found in more than one database.Thus, 19 (100%) papers were included in this review and are organized based on their methodological outline.Six (31.6%) quantitative papers were found, according to Chart 1.
There are three (15.8%)case reports according to Chart 3. It is worth mentioning that, in this review, three (15.8%)theoretical studies were considered, according to Chart 4, for the reason of developing a clear indication of the application of the theoretical construction in practice, with regard to the NP.
Brazil was the country that most presented studies included in the present review, six (31.6%), followed by the United States of America, with three (15.8%); apply NP  (25) To develop an instrument to be used by the multidisciplinary team from the psychiatric reform reference.
Grounded Theory NP** was the method used to operationalize care based on the theoretical framework of psychiatric reform.This method was assumed for the collective and multiprofessional discussion, orienting the Therapeutic Projects.
Nursing care from NP** was feasible, operational and adequate to the new paradigm of mental health.NP** is a simple and technical method of assimilation, and nontechnical assimilated it to guide the Therapeutic Project.

Hummelvolt e
Severinsson/2001 (26) To explore the reflections and interpretations of the nursing team about their work in a psychiatric inpatient unit for acute patients.
Descriptiveexploratory with hermeneutical analysis.Courey/2006 (33) To focus on the importance of recognizing and addressing the mental health needs of children and adolescents using skills and practice patterns of psychiatric nursing and mental health.
Presents a proposal to apply the standards of psychiatric nursing and mental health to camps, with the use of NP* in six steps, according to the American Nursing Association (evaluation, diagnosis, expected results, planning, implementation and evolution).
NP* has become a response to the mental health needs of children and adolescents.
The nursing care in the camps must be related to other factors and requires of the nurses experience in pediatrics, medical clinic, emergency and mental and psychiatric health.
Poggenpoel/1994 (34) To formulate a model of care for psychiatric nursing using concepts derived from the nurse-patient interaction.
It assumes the Whole Person theory as part of the model of psychiatric nursing that has as its scientific basis the nursepatient interaction for the evaluation, diagnosis and prescription of nursing and proposes the use of the Psychiatric Nurse -Patient Interaction Facilitating Mental Health.
The proposition of a NP* model using the model Psychiatric Nurse -Patient Interaction Facilitating Mental Health favors the structuring of basic prognoses.
Morrison/1992 (35) To provide an integrated conceptual model for practice, using as theoretical references Peplau (1952), Bowen (1976) and NP* with the purpose of guiding the complex practice of nursing in mental health in a patient hospitalization sector.
Synchronism between the phases of the therapeutic relationship developed by Peplau (36) and the NP* phases.It affirms that the integration of these two models favors evaluation and extended action, since the therapeutic relationship has its focus of action towards the patient, and NP* has its development focused on the nurse's practice.
The use of integrated theoretical frameworks favor the establishment of care capable of responding to the complex demands of mental health patients.

Authors (year) Objective Method Results
Hirdes e Kantorski/2000 (32) To report the systematization of psychiatric nursing care provided to two patients suffering from psychic suffering.
Presentation of nursing history and assessment from psychopathology and social issues.Establishment of nursing problems, the proposal of actions and evaluation using the NP* from Irving's theoretical proposal.
The NP* was shared with the interdisciplinary mental health team and became organizer of the therapeutic project.NP*, supported by Irving's frame of reference and theoretically supported by the presuppositions of psychiatric reform, produces integral care and ethics in mental health.

Quantitative studies
We can observe that, from the six (100%) quantitative studies (Chart 1), five (83.4%) used primary data and one (16.6%)study used secondary data, characterized as a systematic review of the literature.Also, it is important to note that four (66.7%) are original and individual studies, one (16.6%)was developed in a quantitative-qualitative perspective and one (16.6%)used the integrative literature review method.
Two (33.3%) quantitative studies discuss all NP stages, specifying the clinical evaluation developed and the subsequent elaboration of the proposed diagnoses, articulating them to the interventions, expected results.In addition, they discuss how the use of NP as a method of care may guide the nurse's practice, since both are proposed for the development of care for a specific population (20)(21) .Another addresses the first phase process and emphasizes the need to systematize data collection to favor a proposal of integrated care to the interventions and results, and, for such, it presents the use of the referential based on functional health standards (19) .A study takes as its main point the teaching of NP and uses the Outcome strategy -Present State Test (OPT) that aims at making decisions and Nursing process in mental health: an integrative literature review Garcia APRF, et al.   promotes the use of NANDA International, Inc -Nursing Interventions Classification (NIC) -Nursing Outcomes Classification NOC), or NNN language, while another prioritizes the description of nursing diagnoses (7,18) .The main focus of integrative review is the articulation between the proposition of interventions and the expected results (22) .
The four studies that advance the NP development beyond the data collection phase use the NANDA-I taxonomy and the NNN language and bring in a remarkable way the shared care, integrating the patient in the evaluation and decision making (7,18,(20)(21) .

Qualitative studies
In this review, the seven (100%) qualitative papers cover a wide variety of themes that highlight the NP, as we can see illustrated in Chart 2.
Six (85.7%) addressed the importance of patient participation in assessing and sharing information for participatory care construction (24,29) .It is worth mentioning that four from those (57.1%)emphasize such participation and become a highlight for the development of the nurse-patient relationship (24,(26)(27)29) . Furtermore, one study affirms that NP favors the interaction between professional and patient and can be used as a method of assistance by other professionals who make up the mental health team (25) .
Only two (28.6%)quantitative studies use the NNN language (23,28) .The others present different theoretical references to support the use of NP, such as a study that adopts Irving's (37) framework to support nursing care in a relational perspective that systematizes the NP in the following stages: diagnosis, planning, actions and evaluation (25) .
Two studies take only the NP first stage, which is the historical, putting it at a privileged point and proposes that the comprehensive assessment of nursing in mental health can guide the other stages of the NP: planning, diagnosis, interventions and evaluation of Nursing outcomes (24,29) .
A study shows that theoretical models based on nursing theories are not sufficiently developed, which leads nurses to elaborate their practice based on tradition, so that such positioning may hinder the proposed care from the therapeutic relationship (26) .

Case Reports
In this review, three (100%) case reports were included to illustrate the nurse's practice in the use of the nursing process.they are summarized in Chart 3.
Regarding the case reports, it is worth noting that all of them point out that the establishment of the nurse-patient therapeutic relationship is a priority nursing care, which has, as its starting point, the development of the nursing history and which, therefore, makes the patient's own act of telling their life history as a factual and effective nursing action (30)(31)(32) .

Theoretical studies
The theoretical study aims to study theories, formulate frames of references and create concepts; it is worth emphasizing that these studies originate in practices, through the movement of integration, reflection and research (38) .Thus, because we identified in the theoretical studies shown in Chart 4 a clear indication for the application of NP in mental health, we chose to include them in this review (38) .
The three (100%) theoretical studies have a clear indication that the NP establishment occurs through the development of the therapeutic relationship (33)(34)(35) .Still, one of them proposes the relationship phases synchronization to the NP, stating that the nursing evaluation and diagnosis are practically equivalent to the orientation phase.Nursing planning is performed during the identification phase; the implementation of nursing actions parallels the exploration phase; and the evaluation of nursing outcomes or evolution occurs during the resolution phase of the therapeutic relationship (35) .One study shows that the activity of the psychiatric nurse is based on the nurse-patient interaction and highlights the evaluation and diagnosis as the stages in which the patterns of interaction between the patient and their internal and external environment are determined (34) .

DISCUSSION
For the results interpretation and presentation of the review we opted to discuss the findings from the convergent themes extracted from the articles.
All studies included in this review, when pointing out the way in which the nurse develops mental health care, highlight the action based on the nurse-patient therapeutic relationship (5)(6)10) . In tis perspective, it is important to discuss that the establishment of psychiatric nursing occurred in the 1950s and 1960s, when the first works appeared adapting psychotherapeutic methods to the nurse's practice, and, consequently, the structuring of the psychiatric nurse's functions (4) .
It is in this context that Peplau (36) , the forerunner of nursing theories, develops her theory based on the consideration of the different roles that nurses can take during the establishment of the therapeutic relationship, based on the psychodynamic perspective for the understanding of behaviors.She states that it is up to the nurse to develop skills to relate to the patient in order to understand the meaning of their behaviors and establish the aid relationship (4,35,38) .
Currently, we observe works which deal on nursing practice in mental health with a strong indication of the establishment of the nurse-patient therapeutic relationship as the focus of the interventions, corroborating studies which affirm that the understanding of the psychotherapeutic process is a central component That distinguished nursing in mental health (34,39) .
We also point out that the nature of health problems arising from mental health has its origin from multicausal determinants, which makes possible the coexistence of multiple paradigms (biological, cognitive, interpersonal, psychodynamic, psychoanalytical) to support the therapeutic actions of the nurse.This fact can be assumed as a positive attribute of modern mental health care, since it promotes the opportunity to work in different ways in order to achieve the best meaning for the person's existence (34,39) .
At such a mental health nursing inclination -where care is singular and with a narrow margin for generalizations, since the determining focus of care is the therapeutic relationship that cannot be transposed to other contexts beyond that established between the nurse and The patient -has an antagonistic position of the propositions of evidence-based nursing practice, which may explain the resistance of its adoption in psychiatric nursing (39)(40) .But if we consider the complexity of the object of nursing care in mental health we can defend the production of possible dialogues between the different perspectives of care (relational, biological, political, social), which would favor the multiplicity of actions with consequent favoring of the assisted patients.
Despite the multiplicity of actions arising from different perspectives on the understanding of the patient nurse relationship, a possibility of alignment for care can be created through relationship organization, respecting the nursing process stages.As an example, we can adopt the recognition of the story that the patient constructs with the nurse, when they are under the scope of the therapeutic relationship, as a way of constructing the nursing history and, as this knowledge is expanded, we simultaneously develop the Implementation of care (5,(24)(25)27,32,35) .
Respect for the patient individuality is a prerequisite for the establishment of such a relationship, and in the present paper we observe that the studies approach this issue emphatically, mainly in relation to the development of realistic parameters for the evaluation of the patient, with Identifying his or her strengths (7,24) .We also have a direct indication of the patients' participation in achieving the results and negotiation of nursing actions, with special emphasis on the purpose that such participation has to fulfill in the treatment, that is, to favor patient autonomy (30) .In this context, the planning of nursing care structured by the NP may be the contribution of this professional to the construction of the singular therapeutic project when considering its inclusion in the multiprofessional team (8) .
Such indication is not detached from the context of the nurse-patient therapeutic relationship, and, many times, the patient's participation is the way to maintain the development of this relationship, for in nursing care in mental health, the patient is the protagonist of his treatment.The psychiatric nurse uses his or her person as a therapeutic resource to facilitate the mobilization of the resources of the patient whose objective is the promotion, maintenance or recovery of mental health as an integral part of the health of the subject (34)(35) .
This position, adopted by nurses, is fundamental if we consider the context of mental health care in Brazil, which is guided by principles of Psychosocial Rehabilitation and takes the rescue of subjectivity as the ethical matrix for treatment direction (1,(3)(4)(5)25,27,30,32,34) . An important asct that emerges in this review is the inclination for the development of systematized care proposals for patients whose pathological aspect is situated between the physical and psychic limits, that is, patients diagnosed with Alzheimer's disease (23) , people with special needs (23) and anorexia nervosa (30) .
Such an inclination may be a response to the current influence of evidence-based practice, where the outcome is driven by diagnosis (39)(40) .The latter is an important point in the nursing process, and the studies that proposed to establish it in this review had, for the most part, diagnoses classified by the NANDA taxonomy (30)(31)33) . The diagnoses,in essence, describe formats in order to establish statistical correlations and standardizations (39) .Therefore, if we consider the question ofrelationship as opposed to standardization, the logical course of choice for patients for the establishment of nursing diagnoses will be one in which the symptoms are not observed in the relational light, but from a biological perspective, from which, reproduction and standardization are feasible.
Still, it is worth mentioning that the studies on evaluation highlight the nurse difficulty to evaluate psychic aspects (24,29) , since their training in reading relationships is frail (10) .

FINAL CONSIDERATIONS
This study revealed the fragility of the evidence found in the literature on the application of the nursing process in mental health.The findings also revealed that the literature found is limited, since there are no studies that present methodologies that evaluate the effectiveness of the application of the nursing process in this field.They deal with part of the nursing process, and those who aim to develop it in all its stages present conceptual models, experiences located in a particular institutional context or case studies that take pathologies that are characterized in the interface of psychic and physical symptoms.
It was found that the studies whose concern is to construct nursing diagnoses with the purpose of creating care standards tend to observe the biological model, which is antagonistic to the proposals focusing on the nurse-patient relationship.Support from the biological perspective may be influenced by the evidence-based practice model that has the characteristic of obtaining results driven from rigidly established diagnoses.
The contribution was to reveal the state of knowledge production regarding the theme and to show the importance of the nursing process construction in mental health, considering its basis in the nurse-patient relationship.It focuses on the uniqueness of care and strong tendency to observe the biomedical model as a standard for the establishment of care, at which point the present study intends to proceed.
The limitation of this study was related to the methodology adopted, since it made it difficult to discuss the main characteristic of nursing in mental health, which is the therapeutic relationship, reason that leads us to infer the possibility of resistance to the development of studies conceived by evidence-based practice.Nowadays, however, it is necessary to create new possibilities for dialogue, since mental health is a discipline that approaches the human being in its different perspectives, and the NP developed from the nurse-patient relationship can be a breakthrough in the creation of bounds for an expanded care.
Presentation of the synthesis of the qualitative studies regarding the author, objective, method, results and conclusions Note:*NIC: Nursing Interventions Classification; **NOC: Nursing Outcomes Classification; ***NP: Nursing Process.
Presentation of the synthesis of the case reports regarding the author, objective, result and conclusions Synthesis of the theoretical studies regarding author, objective, results and conclusions Note: *SNC: Systematization of Nursing Care; **Nursing Process.