Nursing Appointment in Mental Health: experience of nurses of the network

Objective: To know the experience of nurses of the Psychosocial Care Networks on the development of Nursing Appointment in Mental Health. Method: Qualitative study, with interview of 20 nurses, through the analysis of the statements in the search of the meaning core. Results: was unveiled as meaning core: lack of preparation for Mental Health Care, Non-identifi cation of the work of the nurse in Mental Health; and Performance of Nursing Appointment as bureaucratic fulfi llment. Final considerations: Nurses understand Nursing Appointment as an individualized and bureaucratic activity, to consider professional regulations, and not as a work process in the multiprofessional work, thus, the Projeto Terapêutico Singular (freely translated as Unique Therapeutic Project) is not cited as a possibility of work process. It was identifi ed necessary space for discussion of actuation and updates of the nurse in Mental Health Care in the health services studied, with emphasis on their performance in a multiprofessional team in consonance with the Mental Health Policy. Descriptors: Nursing Processes; Nursing Records; Mental Health Services; Psychiatric Nursing; Health Policy. RESUMO Objetivo: Conhecer a vivência de enfermeiros da Rede de Atenção Psicossocial sobre o desenvolvimento da Consulta de Enfermagem em Saúde Mental. Método: Estudo qualitativo, com entrevista de 20 enfermeiros, por meio da análise das falas na busca dos núcleos de signifi cado. Resultados: Desvelou-se como núcleos de signifi cado: o despreparo para a assistência em Saúde Mental, a não identifi cação do trabalho do enfermeiro em Saúde Mental; e realização da Consulta de Enfermagem como cumprimento burocrático. Considerações fi nais: Os enfermeiros compreendem a Consulta de Enfermagem como atividade individualizada e burocrática, a considerar normativas profi ssionais, e não como processo de trabalho na atuação multiprofi ssional, assim, o Projeto Terapêutico Singular não é citado como possibilidade de processo de trabalho. Identifi cou-se necessário espaço para discussão da atuação e atualizações do enfermeiro no atendimento em Saúde Mental nos serviços de saúde estudados, com ênfase à atuação destes em equipe multiprofi ssional em consonância à Política de Saúde Mental. Descritores: Processos de Enfermagem; Registros de Enfermagem; Serviços de Saúde Mental; Enfermagem Psiquiátrica; Política de Saúde. RESUMEN Objetivo: conocer la vivencia de enfermeros de la Red de Atención Psicosocial sobre el desarrollo de la Consulta de Enfermería en la Salud Mental. Método: estudio cualitativo, con entrevista de 20 enfermeros, por medio del análisis de las palabras en la búsqueda de los núcleos de signifi cado. Resultados: se desveló como núcleos de signifi cado la falta de preparación para la asistencia en la salud mental, la no identifi cación del trabajo del enfermero en salud mental y realización de la Consulta de Enfermería como cumplimiento burocrático. Consideraciones fi nales: Los enfermeros comprenden la Consulta de Enfermería como actividad individualizada y burocrática a considerar normativas profesionales, y no como proceso de trabajo en la actuación multiprofesional, así, el Proyecto Terapéutico Singular no es citado como posibilidad de un proceso de trabajo. Se identifi có necesario espacio para una discusión de la actuación y actualizaciones de los enfermeros en la atención en la Salud Mental en los servicios de salud estudiados, con énfasis en la actuación de éstos en el equipo multiprofesional en consonancia a la Política de Salud Mental. Descriptores: Procesos de Enfermería; Registros de Enfermería; Servicios de Salud Mental; Enfermería Psiquiátrica; Política de Salud. Maria Cristina Mazzaia E-mail: mazzaia@terra.com.br CORRESPONDING AUTHOR


INTRODUCTION
Mental Health Care in Brazil has its current configuration as a result of claims made in the Movimento de Reforma Sanitária (freely translated as Health Reform Movement-MRS) and after the Movimento de Reforma Psiquiátrica (freely translated as Psychiatric Reform Movement-MRP), which resulted in a new Mental Health model based on the deinstitutionalization process, with progressive reduction of beds of psychiatric hospitals and training of a specialized care network, including Mental Health Care in Primary Care, and with a program to generate income and work.The model of care advocated aims, through the care, to promote rights to users and family members.Another aspect of this new configuration of Mental Health Care is the implementation of a permanent training program for professionals, which contributes to the effectiveness of MRP proposals (1) .
Thus, in 2011 the Rede de Atenção Psicossocial (Psychosocial Care Network-RAPS) was set up in the Sistema Único de Saúde (Brazilian Unified Health System) for people in psychological distress, through decree 3088, Política de Saúde Mental (Mental Health Policy-PSM) with the aim of creating and articulating points of Mental Health Care (2) .
The RAPS has as guidelines the respect for the rights of individuals, considering their freedom and autonomy, with emphasis on the fight against prejudice and stigmas, guidelines that are achieved through Health Care in a humanized way and focused on people in distress, the which involves the diversification of care, which should be offered in the user's territory, with a focus on inclusion and the process of psychosocial rehabilitation, to instrumentalize the individual for the exercise of citizenship (2) .It is understood, therefore, that psychic suffering is multidetermined and thus requires Health Care through a regionalized network and intersectoral actions, which meets the principle of comprehensive care SUS (2) .
In order to comply with the principle of comprehensiveness, the multiprofessional approach is necessary and is materialized in the elaboration of the Unique Therapeutic Project (PTS) (3) , which translates as a collective construction of intentions, carried out with a multiprofessional team, with the participation of the user and also of his/her relatives when it so wishes.It is a continuous process, agreed upon for the achievement of needs and desires and production of autonomy, protagonism and social inclusion, in a sustainable way, that is, with changes that are maintained over time (3) .
The PTS, in addition to a health care strategy, can also be a strategy for service organization, humanization of care and effectiveness of the extended clinic, which aims to integrate several approaches to enable an effective management of the complexity of work in health, especially with regard to psychic suffering, which, as already mentioned, requires a multiprofessional approach (4) .Concepts of reference team and reference professional are contained in the extended clinic approach where the multiprofessional teams assume a certain number of users and carry out the joint construction and monitoring of their PTS.Each technician who makes up the team can become the professional of reference, depending on the quality of the bond established with the user (3) .
The PTS is established from four moments (4) : diagnosis, targets setting, division of responsibilities and reassessment.In the diagnostic phase, organic, psychological and social assessments are carried out in the search for vulnerabilities, to capture forms of how the subject is positioned against diseases, desires, interests, work, family culture and social network; in the targets setting phase these are elaborated in the short, medium and long term negotiated with the subject by the reference professional within the reference team for the user; in the division of responsibilities, the tasks of each team member are defined, especially the user and family members, when applicable, and finally, the reassessment phase in which the evolution of what is planned and done is discussed the redefinition of course and approaches if necessary (4) .
The nurse, when is a member of the referral team for a given user, participates in the elaboration of the PTS and responds to the coordination of this when presenting as the reference professional for the case.
Regarding the practice of the nurse practitioner, there are professional norms (5) that need to be observed as a method of work, and that do not corroborate with what is recommended for Mental Health care according to the current PSM, since it establishes that the nurse must perform their data collection, develop their diagnoses, their planning of results and interventions necessary to reach these results; and finally, to carry out its assessment, to document, all this process, independently of the work that develops in a multiprofessional team.
According to Resolution 358/2009 (5) of the Federal Nursing Council, the Systematization of Nursing Care (SAE) organizes professional work regarding method, personnel and tools, making possible the operationalization of the Nursing Process (NP) (5) , therefore, to constitute a scientific tool for the identification of health and disease situations, contributing to the promotion, prevention, recovery and rehabilitation of the subject, family and community (6) .
The same resolution (5) , in its article 1, paragraph 2, decides that NP in outpatient health services correspond to Nursing Appointment (NA), and it is divided into five stages: nursing history, diagnosis, implementation and assessment of nursing, these stages occur simultaneously, that is, at the moment when the nurse implements interventions, being able to carry out assessments of these and collect new data that may suggest new diagnoses, and so on.
It should be noted that in this study, the use of the terms NP and NA in the references consulted was observed, and the term NP is the most used; thus, in the presentation of arguments or discussion of results, the terminological choice of the authors cited will be respected.
According to the COFEN resolution (5) , the NA should be used as a way of organizing and documenting nurses' practice, but, in addition to the requirement, it should be noted that the development of NA (7) is a subsidy for the provision of care, through which the needs of the individual are identified with the collection of information and constitutes a tool for the rapprochement between professional and user, to enable the therapeutic relationship, through the establishment of bond, listening, dialogue and the observation of non-verbal communication (7) .
When considering the professional norms, it is identified that the phases of the PTS end up contemplating the stages of NP or NA in the community health services.The nurse is part of the team and needs to reconcile and meet the demands of professional norms and PSM bodies.
Nursing Appointment in Mental Health: experience of nurses of the network Almeida PA, Mazzaia MC.
The NA, therefore, is an important resource when considering respect for the principle of comprehensive health care in the psychosocial approach, in which the nurse contributes to the multiprofessional team, which is advocated in the current PSM, as a consequence of the MRP (1) .
However, not always the NA care process or its documentation are used as an tool in health care, nurses from both the hospital and community network refer to knowledge deficits for use, lack of own forms, lack of professional nurses enough to perform of work in accordance with professional norms, resulting in reduced contact time with the users, which leads nurses to collect data and prescriptions, and not perform the diagnoses and their evolution, so there is no process that considers inputs and results, the nurses end up not being able to relate if what was planned and prescribed, by the nurse to the user, had the expected effect (6) .
A review study carried out with the objective of identifying evidence on the application of NP to nursing care in Mental Health, it was observed that of the 19 studies selected, six were conducted in Brazil, three in the United States, two in Australia and two in Spain , the rest of the articles was published one in each country, to show that the theme presents a greater interest in Brazilian nursing; with only one study classified with the level of evidence III the remaining between levels IV, V and VI (8) .The study discusses the importance of developing the Therapeutic Relationship (TR) to be established between nurse and user for the development of NP, and refers that both act in a collaborative way, that is, TR facilitates the development of NP, as it facilitates the establishment and maintenance of TR.It should be emphasized that NP is the nurses' work method and should be based on theoretical foundations that will outline the practice of care to be developed (8) .
National and international studies deal with parts or stages of NP and when concerned with the construction of diagnoses for the elaboration of standard of care, tend to the biological model antagonistic to the recommendations not only of PSM but also of international collegians on multifactorial approaches to care in Mental Health (8)(9) .
In the studies that deal with NP, NA and SAE, nurses' work is not highlighted as a member of the multiprofessional team except when referring to NP as a therapeutic project organizer for users assisted by a multiprofessional team (6)(7)(8) .When the nurse's share of care is mentioned, it refers to the participation of users in the elaboration of NP and not sharing by the nurse with the multidisciplinary team and family (8) .
It is observed that in Brazil, in spite of proposals of the PSM and the professional representation organs in a prescriptive way, still it is perceived distancing between the training, normatization and performance of the professional nurse.The NP is not understood, therefore, as a way of systematizing the care or as the work process for the nurse, incidentally, as presented in a recent study, it is not used nor as a nomenclature for the nurses' work process being privileged the concept NA as already mentioned (7) .
Regarding the practices of nursing professionals in meeting the needs of the population with a focus on Mental Health, in a discussion with a group of nurses from one of the Health Coordenadorias de Saúde da Secretaria Municipal de Saúde de São Paulo (freely translated as Coordination of the Municipal Health Department of São Paulo State-SMSSP), the open-ended question arose about which would be the practices of nurses working in the RAPS, regarding the development of the Nursing Appointment in Mental Health.

OBJECTIVE
To know the experience of RAPS nurses on the development of Nursing Appointment in Mental Health.

METHOD Ethical aspects
The project was approved by the Research Ethics Committees of the Universidade Federal de São Paulo and the SMSSP, in compliance with the guidelines and standards of Resolution 466/2012 of the National Health Council (Conselho Nacional de Saúde).Data collection only occurred after the Health Coordination, health services and those in the sample who agreed to sign the Informed Consent Form.

Theoretical and methodological frameworks
The research was based on the multiprofessional approach advocated in the Mental Health Policy (2) , with emphasis on psychosocial rehabilitation and also on professional nursing legislation (5) .

Type of study
It is an exploratory study, with a qualitative approach that sought to advance the statement of the subjects interviewed to the meaning of this and to provide an approximation to their subjectivities, the latter being the collaboration of the individual to the context in which he lives and who is influenced (10) , thus, the type of study chosen approximates the author of the experience of the nurses professionals regarding the attendance of prescriptive professional aspects, as well as the meaning of the experiences for the interviewees with respect to NA.

Methodological procedures
The study site was 16 CAPS and two Basic Health Units (BHU).The study sample consisted of 20 nurses, one professional from each CAPS and one professional from each FHS (Family Health Strategy) team, who agreed to participate in the research, and who worked in Mental Health Care for at least six months, and in full exercise of professional activities on the day of the researcher's visit.
For data collection, which occurred from November 2015 to March 2016, semi-structured interviews were conducted through a script prepared by the authors themselves, with questions about the sociodemographic profile such as age, gender, workplace, training, professional experience, form of administration of the health service, and an open question where nurses were asked about their practice in carrying out the Consulta de Enfermagem em Saúde Mental (Mental Health Nursing Appointment-CESM) at their place of work.One of the authors of the study was the interviewer, being able to do so by being a specialist in the area of Mental Health.
The interviews were transcribed in their entirety, and the successive listening and floating readings of the collected material Nursing Appointment in Mental Health: experience of nurses of the network Almeida PA, Mazzaia MC.
were developed by the two authors of the study, individually, and afterwards, in order to allow the organization of the material and the identification of the indicators based on the frequency of the emergence of themes, highlighting them through the paralanguage and emotional load contained in the interviewees' statements, and the indicators were obtained: training and qualification, identification and recognition of the work by the team and professional bureaucracy (11) .Afterwards, a process of articulation of indicators occurred, the organization of the meaning cores and their nominations, since we sought to move from the statement to its meaning, from the external to the subjective and singular statement of the interviewees (10) .The authors worked as Mental Health Nurse and University Professor in Mental Health Nursing at the time of the study.As examples of the results obtained, it was chosen to present sections of the nurses' statements in a literal way.The participating nurses were identified by the letter E followed by a numeral corresponding to the sequence of interviews performed, for example (E1), in order to guarantee confidentiality.

RESULTS
Of the 20 nurses interviewed, 19 were women.The age ranged from 27 to 60 years, with a period of performance in Mental Health from two to 23 years, and performance in the health services visited between six months and 20 years.The training period ranged from five to 39 years, with eight nurses (40%) having specialization in the area of Mental Health, and six (30%) worked in services administered by Social Health Organization (OSS) and two (10%) in SMSSP direct administration services.
Participating services were seven Child and Youth CAPS, six CAPS Alcohol and Drugs, three CAPS II Adult and two BHU, seven of which were directly administered by SMSSP and 13 by Social Health Organization (OSS).
When questioned about the achievement of the NA, seven nurses stated that they did not perform in their daily work, of which, two had specialization in Mental Health.Of the 13 nurses who claimed to perform NA, six had specialization in Mental Health.
It was observed that nurses were difficult to express their experience in the development of the CESM, being highlighted by the aspects that hindered the development of the NA in their understanding, so the meaning core revealed by the statements were: lack of preparation for Mental Health Care; Non-identification of the work of the nurse in Mental Health; and Performance of Nursing Appointment as bureaucratic fulfillment, and the meaning core are presented below exemplified by the statements of the interviewees.
It should be emphasized that the multiprofessional approach advocated by PSM with the construction of PTS, in a team and in a shared manner, was not mentioned by the nurses interviewed at any time as a work process for the nurse, thus, it is understood that NA/NP are considered as part of the multiprofessional teamwork process, in the community services of Mental Health Care.

Non-identification of the work of the nurse in Mental Health
It is this concern of usual, to have the identity of the nurse appearing in the care, is, and that has to be in that format, sometimes of a formal space like the appointment, that is what bothers me a little, I don't see myself being able to record and being faithful to the situation within a space of this formality, sometimes the patient here is attended within an informality.Perhaps it is this, how to create a tool in which we can record this, if necessary, to make the identity of this nurse, of this space formal, without being so strict.(E1) So, it's difficult even for the team to see the importance, since it also has a clinical doctor here and the person comes and goes through several professionals, we don't want to redound the service, asking the same thing, it's a thing that wears the patient.(E9)

What I find most difficult, first is this obligation that I think is different, I don't know how this is for other services, but because is in CAPS, I think there is a difficulty of our legislation, COREN, of our orientation in understanding that it is a different dynamic of the services and that to understand that we perform all the time processes of systematization and not only when we go to a room and do all the examination. (E8)
To do something that is really instrumental, good for service and not just a response to the law, because what we were trying to do there in the beginning was a COREN response to stop talking to us.(E20) Nursing Appointment in Mental Health: experience of nurses of the network Almeida PA, Mazzaia MC.

DISCUSSION
Considering that NA is characterized as a method that contributes to the organization of work, even though most of the interviewed nurses do it, one can notice in the content of statements presented that in some of the health services visited it is not a practice common.
The identification of difficulties for the implementation of NA and its use as nurses' work process can be related to the lack of scientific knowledge of the professional, the devaluation in the daily work and the distance between theory and practice (11)(12)(13) .It is observed in the statements presented the confusion with the terms SAE and NA/NP (5) .
In this study, the professionals who presented the most difficulties in the development of NA were those without specialization in Mental Health, which contributed to a deeper and better understood knowledge of the practice.In the statements, it can be observed that activities developed with the multiprofessional team are not understood as part of the actions of the nurse in what concerns the collection of data and information, nor any diagnostic, planning and intervention actions, thus, despite performing corresponding actions to the NA, do not recognize them as such, perhaps then, because they take place in the development of team activities, as quoted by E8 "...all the time processes of systematization and not only when we go to a room...".Moreover, for this very reason, the performance of NA as an isolated activity, and in this case, the documentation of the NA is understood as something and useless.The nurses, then, understand that they do not perform the NA because they do not document in the manner prescribed by the professional inspection body.This can be a form of interpretation for both the professional nurse and the professional supervisory body.
By means of the statements, it is implicit that, in order for NA to occur, different conditions are required for what is presented in the health services and the dynamics of Mental Health care experienced by the sample.
Improving the use of this care methodology proposes to qualify the care provided to the individual in psychological distress, and enrich the nursing practice and also the health team, improving professional performance in this process (8) .
Due to the emergence of community services in Mental Health according to PSM, it was necessary to reorganize the work processes, and it is up to the nurse to appropriate new practices in his daily life, characterizing between the transition from the technical and biomedical model to a vision constructive and reflexive approach to therapeutic practices and knowledge, from the point of view of psychosocial rehabilitation (1) .According to nurses interviewed, there are still distances from these practices during university education as found in the literature (11) .
The difficulties in the practice of care in Mental Health can begin in the lag of undergraduate nursing courses that should be attentive to training based on the transformation and effectiveness of the Reforma Psiquiátrica Brasileira (Brazilian Psychiatric Reform-RPB) process, and not be based only on the clinical model, often without the use of mental health practice fields, which makes it difficult to approach practice, so that there is no articulation between the specific knowledge and the reality of the knowledge network included in the health system (11)(12) .
In this sense, there is an intense need for the search for knowledge and skills for the work of the Mental Health nurse, achieved through specialization courses, for example, in which topics such as psychosocial rehabilitation, interpersonal relationships and therapeutic relationship, reception, recognition of subjectivity of the individual and comprehensive care should be the foundation of the training process.
The practice of psychosocial rehabilitation is constantly being elaborated; there is no path or model to follow, even though RPB consolidation is still ongoing in Brazil.Thus, what exists is the construction of educational actions aimed at approaching the individuality of each individual through dialogue, communication, listening and bonding, tools that should be used by nurses in their practice, to deconstruct preconceived ideas in the form of to deal with and understand the psychological suffering, to enable this professional to gain space in the team, so that the questioning in their daily lives become instruments in their work process (2,(11)(12) .
In the meaning core concerning the identification of the work of the nurse in the Mental Health services, we observe in the statements of the interviewed nurses difficulties in perceiving themselves in the process of individual and group work in the practice in Mental Health.Another issue observed is the difficulty for the collective construction of care by multiprofessional practice.The specificity of nurses' work is defined by the way they document their work and not by their performance, which refers to the predominantly clinical approach, as observed in E9.
The factors that promote tension and frustration, observed in the statements about the professional identity, can be correlated to the conflict of their actions as a Mental Health nurse, who are characterized by going beyond the attributions of care and professionals focused only on the biological dimension or aspect curative aspects of the health problem, and are constituted through the therapeutic relationship, primarily in the development of bonding, listening and reception processes, which, in fact, is performed by all professional categories in a Mental Health service (8 -9) .In the statements, it is observed that the nurse is not understood as a therapeutic instrument, which demonstrates supremacy of doing to the being.
The literature points out that the conflict presented and quoted by nurses in outpatient mental health services can also be attributed to the recent creation of the care model in this area, organized from the CAPS (8)(9)13) , where it is added that the new proposal to assist in Mental Health requires the development of skills to act as a therapeutic instrument (14) .
The multiprofessional teamwork was mentioned by the interviewees, in which professionals often perceive their homogenized actions, since care must be built collectively and with the inclusion of the individual in the care process.The search for greater integration of knowledge and decision-making is shared among all of the team and not in isolation (3,(13)(14) .Teamwork is fundamental in Health Care and nurses do not lose their identity when developing strategies in conjunction with other professionals, as well as organizing the practice of the service, favors the comprehensiveness of the care provided (14) .This practice is evidenced through the development of the user's PTS, since there is a dialogue between all the professionals of the service and the person to be cared for, and from the proposals of each Nursing Appointment in Mental Health: experience of nurses of the network Almeida PA, Mazzaia MC.
one, it is possible to determine a plan of actions (13)(14) , which can and should be correlated to the nursing interventions defined during NA or to be constituted as such.
According to the resolution of COFEN 358/2009, NP/NA must be carried out, deliberately and systematically, in all public or private environments in which professional nursing care takes place (5) .However it is notorious in the statements that even with the obligation, its implementation and performance in the Mental Health services are not considered effective by some professionals, and often being fulfilled only by the legal prescription, as observed in the meaning core of Nursing Appointment performance for bureaucratic compliance.
One of the statements assumes that there is no use for NA activity, perhaps because it consists of a collection and documentation of data that is already contemplated in the user's chart and may have been performed in a team when the PTS was being prepared.Another issue that is revealed in relation to the NA is the simple documentation of information to serve as a response to normative requirements and not as a therapeutic proposal of the professional.
In the literature it is observed that the main difficulties presented by the nurses for the NP/NA implementation are related to the lack of knowledge about them, the lack of nurses in the services, the overload with other activities, the non-involvement of these professionals with the process, the personal limitations and the devaluation of the team/administration with respect to the development of this activity (15)(16) .
As one of the interviewees reveals, it is realized that it performs NP/NA, or is developing one of its stages, during all the time it is in activity, but suggests that what is accomplished is not observed as such, and that only the documentation of these actions in the normatively recommended format would be translated as nursing work by professional inspection bodies.To promote care based on a new way of thinking the NA/NP, as the proposal of the construction of the PTS in a multiprofessional team, promotes advances in the quality of nursing assistance with benefits for the user of the service to promote the valuation of the nurse as a professional Mental Health team and make the work process and its documentation, no longer just a frustrated and normative alternative (16) .
Unfortunately, at no time has the PTS theme been cited by the sample as a possibility of a process for the nurse's work, since this must be done in a team and, in a team, also the form of documentation of the performed assessments and proposed interventions should be discussed; is the recommended form of strategy for the organization of care (3,9,14) .The documentation in the PTS medical record adopted by the team is the responsibility of the professional of reference, which is named for the quality of its link with the user, as already mentioned.The reference professional can be the nurse, or not.Thus, this form of care organization often discards the individual documentation of the professional categories that make up the team (3)(4) , as the nurses' professional norms advocate (5) .
It is intriguing to imagine that, perhaps not mentioning the PTS as a possibility for the NA/NP, is due to the fact that the nurse does not participate in this activity, which is based on the discussion of limitations and possibilities of each case, and thus, the nurse would be aware of the caring process advocated in the PSM.

Study limitations
The study was based on the experience of nurses from only one health coordinator in the city of São Paulo and it is suggested that studies with a sample be performed to represent nurses in the municipal network of the city of São Paulo, that is, to include the other coordination of health of the municipality.It is understood that new studies must be carried out in order to know the actuation and documentation of care activities performed by the nurse practitioner in Mental Health services when the latter builds his care and works in a multiprofessional team.

Contributions to the sector of nursing, health or public policy
The study shows that nurses do not understand that they comply with the NA stages when they attend in order to respect the psychosocial rehabilitation approach, that is, in a multiprofessional team to develop PTS.The fact that nurses are asked to document the assistance provided in an individualized way, that is, in their own documents and not in a team, does not meet the recommendations of the PSM, which may be the reason for not understanding the multiprofessional work as a work process for the nurse in Mental Health.The study made possible initiatives of discussion with the supervisory body and discipline of the nursing exercise on the work process of nurses in Mental Health services and the respect to the development of the same in consonance with the PSM which means the acceptance of the PTS built collectively as the nurses' work process and also as the NA documentation.The study also provides subsidies for new studies investigating the participation of professional nurses in work in multiprofessional teams.

FINAL CONSIDERATIONS
The nurses interviewed do not understand their way of working in a multiprofessional team, such as following the steps of what the NA would be.When questioned about this practice, they refer to the difficulties they encounter in complying with it as unprepared for Mental Health care, identification of the work of the nurse in Mental Health and the accomplishment of the Nursing Appointment for bureaucratic compliance.
It is urgent that the nursing professional who assists in Mental Health understands that, regardless of the place of performance, he/she performs, or must carry out the NA/NP, since it is not possible to meet the demands and needs without gathering and evaluating data, identifying human responses that would be the diagnosis of the situation, a diagnosis that demands a proposal of intervention that ends up being assessed through the results obtained.Thus, for the sample studied, the conflict is found in the documentation of what it performs in its work, since the documentation of data collected and analyzed in a multiprofessional manner and, therefore, with the participation of the nurse, must be considered and presented, as a result and work process of the nurse, since, to this end, nurses use their knowledge framework.
The study shows that updating or training activities that involve discussions with nursing professionals about RAPS, SAE, NA, NP, PTS, are necessary, and should also contemplate the relationship between the demands of professional legal prerogatives and established care policies for Mental Health.
So I arrived as a nurse, without knowing anything specifically about Mental Health, what I knew was from a public health context, knowledge of PSF, and then I empowered myself with a little bit of work and knowledge.(E3) I don't feel I understand about Mental Health, I have practically no training, I have been reading and learning from practice.(E4)