Nursing process implantation in mental health: a convergent-care research

Objective: to understand the perception of nurses and their needs regarding Nursing Pro- cess implantation in a long-term psychiatric hospitalization unit. Method: a convergent care research, carried out in a psychiatric institute in Rio de Janeiro, with 13 nurses. Data were pro- duced between May/2016 and August/2017, with observation in a field diary, semi-structured interviews and groups. Data were analyzed regarding content, theme and by the software NVivo. Results: three thematic categories were developed: Knowledge and practices of participants on Systematization of Nursing Care, Nursing Process and classification system; Con- vergence points: Nursing Process in practice and research; Challenges of Nursing Process implantation in mental health. Final considerations: implantation was perceived by nurses as a way to be constructed: in the stages of Nursing Process, in handling classifications, but mainly in articulation with the Brazilian National Mental Health Policy. Descriptors: Mental Health; Psychiatric Nursing; Nursing Process; Nursing Diagnosis; Elderly Health. RESUMO


INTRODUCTION
Nursing Process (NP) implantation in psychiatric institutions with elderly people in a context of institutionalization is still a challenge. These are people who are hospitalized for a long time and devoid of long-standing social interaction. Thus, they require complex care, require specialized knowledge of geriatrics and mental health, from a holistic and humanistic perspective.
Thus, they need to redeem their human rights and citizenship, as recommended by Federal Law 8080/90, which guarantees the principles of Universality, Equity and Comprehensiveness of health care of the Brazilian population (1) . As well as psychosocial care and social reintegration, according to Law 10,216 of 2001, which provides for the protection and rights to people with mental disorders, by redirecting the mental health care model for psychosocial approach and deinstitutionalization (2) .
In a complementary way, another political resolution associated with this study is based on Systematization of Nursing Care (SNC) implantation, which represents the organization of the work of nurses regarding the method, personnel and instruments, in order to operationalize the NP, a methodological instrument guiding profession care (3) . Therefore, within the scope of SNC, it is important to guide: the dimensioning of personnel; standard operational protocols; the care model adopted; the NP's implanting instruments; and the consolidation of a nursing manual of the institution. As a consequence, NP implantation is an indispensable step in the development of SNC, especially in settings with greater operationalization difficulties.
Another aspect is the indispensability of professional attitude in decision-making, support to scientific method and adoption of interrelated actions (4)(5) . However, in practice, in psychiatric hospitalization services, organization of care focused on tasks prevails, which often institutes an automatic and bureaucratic clinical practice, without the development of clinical reasoning to plan scientific care that meets the needs of the individual. Among the difficulties, there is: little or lack of training on NP stages; fragility in the domain of physical and psychic examination; lack of adequate records; existence of conflicts of functional roles; difficulty in accepting change; focus on the investigation of body systems; lack of credibility of nursing actions; and staff shortage (6) , which justifies the development of this study. Given the complexity of care that long-term clients need, this would be the greatest challenge in the area. Thus, considering the responsibility of nursing for comprehensive care, the NP constitutes an essential instrument, as proposed in this study. Therefore, NP implantation is supported by theoretical and practical domains, existing in nursing, by the use of taxonomies that underlie the diagnoses, results and interventions, as well as accuracy for the performance of clinical trial (7) . Therefore, promoting quality comprehensive care based on NP (8) helps to attend to the rights of citizens' health proposed by the Psychiatric Reform and ethical responsibility of nursing (9) .
Also, based on the proposal of NP implantation in psychiatric institutions, this study seeks to present perspectives of nursing care with a focus on a comprehensive health, in the look at the elderly and their well-being. This positioning favors the nurse-patient interaction, promoting the construction of the therapeutic relationship (10) .

OBJECTIVE
To understand the perception of nurses and their needs regarding NP implantation in a long-term psychiatric hospitalization unit.

Ethical aspects
Confidential identities and privacy-related information have been secured confidentially. The Research Ethics Committee of the proposing and co-participant institutions approved the research, with authorization from the institution where the study was developed to disseminate the study site.

Type of study
This is a convergent care research (CCR), considered an instrument that, in its development, sustains the close relationship with the social situation and aims to find solutions to problems, make changes and introduce innovations in the social situation (11) . Thus, the path for NP implantation was led by the incessant search for the active participation of nurses. Having said that, the NP was developed in a comprehensive and deliberate manner, with all five of its stages articulated to this study: I -Nursing data collection -a deliberate, systematic and continuous process, carried out with the help of methods and techniques (3) . This study focused on the assessment of mental and psychic examination, the ability to perform Activities of Daily Living and socialization. It was based on Gordon's theory, following the functional patterns of health, and Peplau's theory, application of the principles of interpersonal relationships, understanding the nursing care person. These aforementioned were chosen by the group participating in the study; II -Nursing diagnosis -process of interpretation and grouping of data collected in the first stage, which culminates in decisionmaking on nursing diagnostic concepts that represent, more accurately, the responses of the person (3) . At this stage, we used the group discussion of the main diagnoses applied to the elderly and mental health found at NANDA International (NANDA-I); III -Nursing planning -determination of the results expected to be accomplished and nursing actions or interventions that will be performed in view of the answers of the person (3) . In this stage, we discussed in a group diagnostic prioritization, formation of an instrument that contemplated in a linear and visual way the diagnoses, the expected results, from the Nursing Outcomes Classification (NOC) -Initial; interventions, from the classification of Nursing Interventions Classification (NIC); and the results achieved or NOC-Final.
IV -Implantation -implantation of actions or interventions determined in the nursing planning stage (3) . At this stage, we considered how the intervention is carried out in isolation without the necessary decision-making and planning, based on Hildegard Peplau's theory; V -Nursing assessment -a deliberate, systematic and continuous process of verifying changes in the responses of the person, family or human collectivity at a given moment in the health-disease process, to determine whether nursing actions or interventions accomplished the expected result; and verification of the need for changes or adaptations in the steps of NP (3) . At this stage, considered a major challenge in the area, the area was considered on 8 of Nursing process implantation in mental health: a convergent-care research Silva TG, Santana RF, Dutra VFD, Souza PA.
the demonstration and effective recording of the results, as well as the emerging need for NP implantation.

Study setting
The research was carried out at Instituto Municipal de Assistência à Saúde Juliano Moreira (IMASJM, freely translated as Juliano Moreira Municipal Health Care Institute), where patients with psychiatric disorders have been hospitalized for more than 40 years. IMASJM was created in 1924, had as idealizers the psychiatrists Franco da Rocha and Teixeira Brandão, who represented the European and hygienist thought of Doctor Juliano Moreira (12) . The institution currently houses about 300 patients, with a mean age of 66 years, and an average length of stay of 40 years. The main axis of the work developed is the deinstitutionalization program, which promotes progressive transfer of patients outside hospital facilities. Those with greater autonomy are discharged and start living in therapeutic homes and receive social assistance benefits.

Participants
Nurses who were active in the Institute's Care Centers (ICC) participated in the study. The ICC has a staff of 33 nurses who alternate on shifts with 12 hours of work for 60 hours of rest. Among these, 13 nurses who agreed to participate voluntarily in the study, both in the interview and in the convergent-care groups, constituted the study group. The inclusion criteria were being a nurse and performing their activities in the IMASJM care centers. The exclusion criteria were being nurses who performed administrative activities, who were on vacations and on leave. Care nurses were considered as those who provide direct care to inmates.

Data collection and organization
Data collection occurred from May 2016 to August 2017, with the techniques of data production: participant observation, medical records research, semi-structured interviews, and convergent-care groups. Initially, immersion was performed in the field, observing the work process and collecting data in the medical records about nursing records and documentation. Field diary was used to describe observations, with notes from the researcher throughout the data collection period. Collection was carried out by three researchers and authors of this manuscript. The first author and employee of the research institution coordinated all stages of data collection with the help of the other authors. It is noteworthy that the theories guided from the construction of the interviews to the development of convergent-care groups.
The interviews were previously scheduled at the work environment, conducted by the first author. They happened inside the IMASJM, guided by a semi-structured script, recorded and later transcribed. Reflective questions were asked on the central theme: talk about NP implantation in mental health? And as deepening questions: what is your education training on NP? Your professional experience with NP? How is the recording of your professional practice being performed at the core in which you work? How do you see the application of the NP here at the institution? For you, what nursing classifications should be used here? For you, what is the difference between SNC and NP? What NP phases do you apply in practice? How do you observe nursing diagnoses in practice? What would you like to know about NP? At the end, the interviewees were invited and agreed to participate in the convergent-care groups suggesting the return of the material and the discussion of the NP in the institution.
Convergent-care groups occurred in an auditorium of the institution separated from the care area, in five meetings, coordinated by two researchers, with an average duration of 90 minutes entitled as Lifeline (a reflection of oneself, professional life experiences and learning); Almanac (cut and paste your own sequence of mental health work events); Clinical Session (three meetings to discuss previous data, clinical cases and NP in mental health).
The main objective of the groups was to implant NP in care practice. The choice of dynamics was the possibility of inciting reflection and the joint construction of the concepts that contributed to these changes. Thus, the examination phase that included production, collection and recording of data was methodologically completed, and convergedly favoring the improvement of mental health nursing care (11) . The material produced in the group was returned and discussed at the beginning of the next group, such as first group presented results of the interviews, second group was returned the result of the first group and so on.

Data analysis
We opted for content analysis (13) , with data processing and speeches of all moments of the study, supported by the software NVIVO ® , in the following stages: reading of the transcribed interviews; definition of the units of record; definition of the themes in units of meaning; grouping of units of meaning; and categorization, according to Table 1. of Nursing process implantation in mental health: a convergent-care research Silva TG, Santana RF, Dutra VFD, Souza PA.

RESULTS
Most of the participants were women (9), single (6), aged between 30 and 39 years (6), working during the day (10), worked under CLT (Brazilian Consolidation of Labour Laws) system (10) and approved by the City Hall's public tender (3).

Category I: Participants' knowledge and practices about Systematization of Nursing Care, Nursing Process, and classification system
It was demonstrated a diversity and an insufficiency in the formation of the group with SNC, NP and classification systems and methodology of nursing care. Nurses point out difficulties regarding the registration and demonstrate that the NP in their education basically dealt with the learning of the nursing evolution record: The statements report that each nurse determines their care according to the "changes in shifts", without planning nursing actions in an individualized way. There were discourses of performance of the care plan differently by each nurse, mostly without a pre-established path, of assessing users according to the "tasks of the shift". Theory use in nursing reflects a movement of the profession in search of autonomy and delimitation of its actions. The difficulty of recognizing the body of self-knowledge fosters the desire to know its true nature and build its identity. Thus, nurses recognize that SNC and NP use directs care focused on the singular needs, as well as documenting their actions in an organized way to the care promoted, according to the statement: Using some theory to substantiate us is very interesting, it is valid.
SNC is a proposal for change and the Process is a change in practice. (Nurse 10 -Interview) One of the main results of this study lies in the complexity of the application of the NP in mental health, different from that learned in professional training, which emphasizes the application of the NP in another setting, the hospital environment: I believe that we need to improve a lot, because our work is different from hospital routines. (Nurse 1-Interview) It is different that you evolve a patient who is in a medical clinic, in a post-surgery or who has been hospitalized for some pathology that needs to be antibiotic. A follow-up of a psychiatric and elderly patient hospitalized in this institution for years. (Nurse 2 -Lifeline Workshop) The reports show the experience of participants with the NP, which comes exclusively from the hospital environment. In mental health, the small number of care nurses responsible for direct care to users is also faced, since many become oncall and appointed as nursing supervisors. Thus, administrative activities are prioritized and work overloaded, which lead to the non-performance of the NP: The experience I have in college is hospital, here is also a hospital, but it is of a totally different characteristic, the profile of patients is different. In the participants' discourse, there are reports that the NP in mental health cannot depend on measurable and rapid results, as seen in the hospital model. The mental health model is long-term and biopsychosocial care: I confess that here I have difficulty making this plan, because we always aim at improving the patient through the plan, but that the pathology makes it difficult to solve the problem, it causes a discouragement, makes us evolve almost always the same characteristics. And so sometimes we do not evolve in medical records because it probably does not have to evolve. Due to their pathology, there are characteristics of these pathologies that they do not change, quite the contrary, their tendency is even aggravated. (Nurse 1 -Interview) The report demonstrates the need for discussions regarding the role of nurses in the Psychiatric Reform and the logic of deinstitutionalization. Nursing care aims to maximize the positive interactions of the person with the environment, promote well-being and improve the perception of oneself, valuing the person's context, with a view to their social inclusion, and not only the cure of the disease. For this, the adoption of a theoretical-conceptual and methodological framework can help in the work process orientation.
of Nursing process implantation in mental health: a convergent-care research Silva TG, Santana RF, Dutra VFD, Souza PA.

Category II: Convergence points: Nursing Process in practice and research
During the moments proposed by the CCR, discussions about the work of nurses in mental health were extended. Thus, the CCR allowed possibilities to research and implant the EP with a focus on psychosocial rehabilitation: We recorded everything in medical records, and usually the technicians make the daily evolutions and we, nurses, report the complications during the shift. The statements point to the challenges in the nurses' registry centered on data collection and intervention. Therefore, disconnected between the fundamental phases for accomplishment and evidence of nursing outcomes. In addition, they demonstrate the technical-social division of nursing work: The diagnosis is we who make, but who implants and puts into practice is not only the nurse, it is the multidisciplinary team and, in the end, I think that everyone is champions, both the team and the patient who is receiving this improvement in treatment.

All this work requires a team willing. (Nurse 9 -Interview)
If everyone is together, we will be able to put this work in our area and together with the other professionals, we will be able to achieve the positive result for patient. (Nurse 9 -Interview) Thus, the inadequacy and insufficiency of records make it impossible for information to be spread safely, besides keeping the nursing practice invisible, before the Law and other professionals.
Another point of convergence pointed out by nurses was the fear of working with a ready, formatted and prescriptive instrument. Professionals yearn for the NP to help, too, in working with therapeutic workshops and psychosocial rehabilitation: We only need to be careful not to cast care. (Nurse 1 -Interview) We could adapt to our mental health terms. I want to learn the five phases and see how to apply in our area. (Nurse 2 -Interview)

Knowing how to apply in mental health, so that every team understands and is included in the PTS of the patient. (Nurse 5 -Interview)
A playful thing that is to work with them. We cannot have with them something ready, a process done inside the office, it has to be all another way in order to achieve the goal. (Nurse 2 -Almanac Workshop) The statements show the concern regarding the implantation of the NP and its articulation with the Singular Therapeutic Project (PTS -Projeto Terapêutico Singular). A point of convergence of the results of care practice with the research was the group's desire to qualify, the importance of conducting workshops and work based on a theoretical support.

Category III: Challenges of implanting Nursing Process in mental health
Of the nurses interviewed, most emphasize that one of the difficulties to apply the NP in mental health is the lack of academic and practical experience of the professional with the classifications/taxonomies, as well as the lack of curricular investment of this nurse articulating the NP with the Brazilian National Mental Health Policy: Most nurses do not feel prepared to work in psychiatric nursing or mental health, being not adequately informed about the political changes that have been taking place in the area. Most of these professionals who work in mental health services are surprised by the lack of specific knowledge, their practical experiences come from general hospitals: When I arrived here, I realized that I did not have enough knowledge to work in psychiatry, I came from emergency. (Nurse 11 -Almanac workshop) In addition to the difficulties in training and practice, with the NP and its connection with mental health, there is a resistance of nurses to welcome the scientific method as a method of work. Caring for a person with psychiatric disorders in psychosocial rehabilitation involves family, friends, neighbors, resources of their territory and other structures according to affinities and life history, soon requires interpersonal relationships, involvement, short, medium, and long-term planning. orientation groups and welcoming users in psychosocial rehabilitation. The NP rescues and consolidates the representativeness of nurses with autonomy, often dilapidated in solving immediate problems and bureaucratic tasks.
In the field of mental health, the purpose of care deals with the needs of the person, differing from merely clinical results, which in psychiatry can be simply to buy, choose their own hygiene or food products. This is in the units with guidance of the work proposal for psychosocial rehabilitation. Thus, the NP can be an important instrument for documenting actions: Therefore, the study focused on thinking of an instrument that would present nurses as protagonists, creating possibilities and alternatives for taking care of themselves, detaching themselves from the care model and the drug focus, in compliance with the Psychiatric Reform principles and NP implantation, supporting in a nursing theorist, in this case, Hildegard Peplau, as shown in Figure 1.
Finally, Table 2 presents the data observed in 30 medical records randomly from the three care centers under study. The daily evolutions are made by day and night nursing technicians, the records made are specific to the routines regarding the performance\monitoring of the bath, monitoring\acceptance of diets, performing intimate hygiene, administration of medications and reconciliation of sleep. Table 2 shows that the results corroborate the effective implantation of the EP in the institution. Thus, it is initially observed a predominance in the records in medical records performed by nursing technicians. However, there was a significant increase in nurse registrations when compared year by year, according to the Wilcoxon test (nonparametric) (p-0.046).

DISCUSSION
The context in which nurses work in the traditional molds was distanced from other professionals, subordinated to work and medical know-how, valuing drug treatment, technical assistance activities, such as checking vital signs, hygiene and comfort measures. In addition, it also occurs by observing the changes in the individual that may occur during the day, a characteristic situation in nursing homes. However, currently, the nurse, as a member of the multidisciplinary team, is a professional capable of going further, by investing in the therapeutic relationship and gathering information related to the user's subjectivity, the therapeutic and organizational environment (9.14) .
These questions envisage the need for theoretical and practical support from nursing teams to implant NP. The SNC, as an organizational process, implies the definition of the nature and type of work to be performed, from the theoretical-philosophical basis, type of professional required, techniques, procedures, methods, to the objectives and material resources for the production of care (15) . Thus, the NP enables the development of the SNC, when used as a work methodology applied for the continuity of individualized assistance and the work in a multidisciplinary team.
In this sense, the domain of information is essential for the therapeutic process organized in the nursing records. This information comes from the relationship with the user, family, health team and community network. Thus, the discussion and the joint construction of the therapeutic proposal by the multidisciplinary team make interdisciplinarity feasible, recommended by the Health Policy (16) .
Scholars have shown the lack of clarity of the nurse's role in places of mental health care, which often occurs only when completing the first stage, data collection, as observed in the initial stage of this study. This fact sometimes hinders the therapeutic interpersonal relationship and, consequently, NP implantation (17) .
As a consequence, this deficiency in the training of nurses is reflected in practice and vice versa. If the practice does not encourage the training of a qualified professional, both contribute to the impasse of NP implantation in mental health services. The Mental Health Policy recommends specialist nurses. However,  there is still the existence of generalist nurses working, which takes time and availability, institutional and personal will for adequate training, whether in inpatient or territorial-based services (1,9,18) . For its proper implantation in mental health, the NP must be built and implanted in a continuous line, without skipping steps, or one step to the detriment of another, as observed in the statements of the participants regarding the diagnosis and intervention. Therefore, it is important to appropriate the team on the management of care and the phases of the NP, respecting the person being cared for, their individual needs and prioritizing diagnoses, results and interventions aimed at psychosocial rehabilitation (6,19) .
Participants reported that NP can provide greater autonomy for nurses, in addition to promoting rapprochement with the user and the multidisciplinary team (20) . In this sense, the experiences with the implantation of the NP provided the group with hope in changing the culture of nursing practice in mental health and in the recognition of their work.
The use of nursing theories reflects a movement of the profession in search of autonomy and the delimitation of its actions. With the advancement of technologies, nurses find themselves reflecting on social recognition and their professional practice unrelated to the biomedical model. Thus, the SNC and the NP are presented as management/care instruments to promote change in mental health nursing practice (9) .
The nurses participating in the study recognize that the NP must allow care aimed at preserving the user's autonomy. When proposing diagnoses that direct the subject to circulate in social spaces, a care plan is also proposed that allows the rescue of the "lost" citizen over the decades of continuous institutionalization. This includes a PTS that provides for your hospitalization and psychosocial rehabilitation. Autonomy, in this perspective, is represented as a care that enables the user to be the protagonist of their life, recognizing their limits and possibilities (20) .
With all this theoretical and technical apparatus, the nurse is thus able to participate effectively in the health team, proposing comprehensive and specialized care, to achieve the well-being and deinstitutionalization of users. Each user has a PTS, defined as a set of articulated therapeutic approaches, the result of the collective discussion of the interdisciplinary team. The PTS is elaborated with the user, based on their choices, their way of understanding life, subjectivities, singularities, and based on the technologies of relationships, such as welcoming, listening and bonding, proposing new ways of mental health care (21) . As a consequence, the nurse who uses the NP to intervene in the goals established in the PTS thus meets the responsibility of nursing in the multidisciplinary team in a scientific, systematized and humanized way.

Study limitations
The limitations are related to the fact that the study occurred in only one institution. However, due to the complexity of the proposal, it is understood the need to broaden studies on the theme still incipient in the area.

Contributions to nursing
The accomplishment of this research contributed to fill an existing gap in mental health nursing care, which could serve the specific setting, as it can also be used by other nurses, for NP consultation and implantation in their institutions. The CCR use made it possible to reflect on the practice of nursing and to initiate the development of SNC in a long-term psychiatric service. That is, the CCR enabled investment in in-service training aimed at care practice.

FINAL CONSIDERATIONS
The analysis of the nursing team regarding NP implantation in a long-term psychiatric hospitalization unit demonstrated the need for training in the NP stages and in handling the classifications. There are several difficulties in implanting NP in a psychiatric institution typically asylum. Among these, there is the historical context, with the execution of tasks in a mechanized way and based on medical knowledge that oppose the search for comprehensive care and the PTS and propose the minimization of isolation, dependence and institutionalization.
For NP implantation, participants point out the importance of in-service training; the need for reflection on the role of nurses in the institution; the number of professional nursing assistants; and the relevance of NP records. For an effective implantation process, it needs to be articulated with the Brazilian National Mental Health Policy, in a dynamic, autonomous process based on the theoretical bases of nursing and mental health. Therefore, the development of the SNC and the implantation of the NP were perceived by nurses as a path to be built continuously.