STRENGTHENING THE ARTICULATION OF THE MUNICIPAL PSYCHOSOCIAL NETWORK FROM AN INTERDISCIPLINARY PERSPECTIVE

ABSTRACT

Objective:

to elaborate strategies of strengthening for articulating the municipal services that make up the psychosocial care network.

Method:

participant research with qualitative approach, carried out in the months of March and April 2019 in a municipality of the South of Brazil. Data collection involved a documental analysis, questionnaire and focus group. Sample composed by thirteen professionals of Basic Health Care, Expanded Nucleus of Family Health, Municipal Polyclinic, Psychosocial Care Center and General Hospital. Data analysis according to Minayo and elaboration of strategies through data triangulation.

Results:

potentialities and weaknesses found in daily professional work, organization and articulation of the network, and strategies to strengthen it. Among the strategies elaborated, the need for matrix support in health services, training and empowerment of professionals stand out.

Conclusion:

Literature is scarce on strategies for network articulation, and new studies are recommended. The current research shows the importance and unavoidability of articulation, contributing for the improvement of practice.

DESCRIPTORS:
Mental Health; Mental Health Services; Mental Disorders; Unified Health System; Nursing

RESUMO

Objetivo:

elaborar estratégias de fortalecimento para articulação dos serviços municipais que compõem a rede de atenção psicossocial.

Método:

pesquisa participante, de abordagem qualitativa, realizada em março e abril de 2019 em um município do sul do Brasil. A coleta de dados envolveu análise documental, questionário e grupo focal. Amostra composta por treze profissionais da Atenção Básica, Núcleo Ampliado Saúde da Família, Policlínica Municipal, Centro de Atenção Psicossocial e Hospital Geral. Análise dos dados de acordo com Minayo, elaboradas as estratégias através da triangulação dos dados.

Resultados:

potencialidades e fragilidades encontradas no cotidiano profissional, organização e articulação da rede, e estratégias para fortalecê-la. Dentre as estratégias elaboradas, destacamse a necessidade do matriciamento nos serviços de saúde, capacitação, empoderamento dos profissionais.

Conclusão:

A literatura é escassa sobre as estratégias para articulação da rede, recomendando-se novos estudos. A atual pesquisa mostra a importância e inevitalidade da articulação, contribuindo na melhora da prática.

DESCRITORES:
Saúde Mental; Serviços de Saúde Mental; Transtornos Mentais; Sistema Único de Saúde; Enfermagem

RESUMEN:

Objetivo:

elaborar estrategias de fortalecimiento para la articulación de los servicios municipales que componen la red de atención psicosocial.

Método:

pesquisa participante con aproximación cualitativa, realizada en marzo y abril de 2019 en un municipio en el sur de Brasil. La recolección de datos implico el análisis documental, cuestionario y grupo focal. Muestra compuesta por trece profesionales de Atención Básica, Núcleo Ampliado de Salud Familiar, Policlínica Municipal, Centro de Atención Psicosocial y Hospital General. El análisis de los datos según Minayo y elaboración de estrategias mediante la triangulación de los datos.

Resultados:

potencialidades y fragilidades encontradas en la vida profesional cotidiana, organización y articulación de la red, y estrategias para fortalecerla. Entre las estrategias elaboradas se destacan la necesidad de apoyo matricial en los servicios de salud, la capacitación y el empoderamiento de los profesionales.

Conclusión:

Hay escasez de literatura sobre estrategias para la articulación de la red y se recomiendan nuevos estudios. La actual investigación indica la importancia e inevitabilidad de la articulación, lo que contribuye a mejorar la práctica.

DESCRIPTORES:
Salud Mental; Servicios Comunitarios de Salud Mental; Trastornos Mentales; Sistema Único de Salud; Enfermería

INTRODUCTION

In 2011, the Psychosocial Attention Network (RAPS) for people in psychic distress was instituted in the Unified Health System (SUS), supported by ordinance 3.088, with the purpose of creating and articulating points of attention to Mental Health ⁽¹⁾. RAPS is based on the respect for the rights of people in mental suffering, with emphasis on fighting prejudice and stigma, achieved through health care in a humanized and people-centered manner, which implies several forms of care that should be offered in the territory, focusing on social inclusion and reinsertion, psychosocial rehabilitation, as well as helping the person to exercise citizenship⁽¹⁾.

There are weaknesses in the articulation between health services, identified by different authors, reinforcing that these occur due to the fragmentation of the network due to bureaucratic issues and lack of communication between services, among others(²,³,⁴).

The problem of the study is the lack of articulation of the services that make up the RAPS in the municipality. Therefore, it is necessary to elaborate strategies for the articulation of health services acting in the study scenario: Psychosocial Care Center (CAPS), Basic Health Units (UBS), Expanded Nucleus of Family Health (NASF), Municipal Polyclinic and General Hospital (HG), strategies that, for their effectiveness, should include service professionals. It assumes that effective mental health care is linked to the integration of health services that, when articulated, present greater chances of success, promoting a humanized, welcoming and integral assistance.

It is expected that this study will contribute with articulation strategies in the municipal RAPS, to strengthen the care provided to the person with mental disorder, increase access and improve the quality of assistance in health services. Furthermore, it may cooperate as a source of consultation for other researchers interested in the topic, thus strengthening the research in this field. Thus, the goal is to develop strategies to strengthen the articulation of municipal services that make up the RAPS.

METHOD

This is a participant research, with a qualitative approach. It had as scenario the health services that compose the Network of Psychosocial Attention in a city in the south of Brazil, in the period from March to April 2019.

For the development of the research, the data were collected through triangulation, involving document analysis, questionnaire and focus group. As for the documental analysis, those responsible for each health service were asked to provide the existing documents related to the study object. In all, five documents available in the services were analyzed.

In the stage of the questionnaire, 13 professionals participated and in the focal group, 11 professionals, among them: nurses, social worker, psychologist, pharmacist, coordination of NASF, representative of the Nursing Manager of HG. It was defined as inclusion criterion to be a higher level professional and to have at least six months of performance in the city and exclusion to be on vacation or leave in the period of data collection. Of the 13 participating professionals, all were female, with time of operation in the institutions between 1 and 22 years, with age range of 26 to 52 years.

The questionnaire was applied in the month of March and contained open questions regarding the reception of the person with mental disorder, mental health actions, difficulties and facilities to interact with the other health services and suggestions for improvements to strengthen the articulation.

The focus group took place in four meetings in the month of April. In the first group session, a dynamic of integration was carried out; after the presentations, the discussion on RAPS and Matrix support began, relating theory with practice. In the second group session, the professionals discussed the role of each health service in the municipality and reflected on the realities faced in the daily services, identifying the limits/potentialities experienced. In the third group session, strategies for service integration were raised. The six hats technique, created by Edward de Bono, aimed at stimulating people to use various reasoning in a systematic and disciplined manner ⁽⁶⁾. In the last group session, strategies for strengthening the articulation of the municipal RAPS were discussed.

The collected data were transcribed in their entirety, utilizing NVIVO® qualitative analysis software, through which it was possible to evaluate, interpret and explain social phenomena ⁽⁷⁾. From the analysis, the data were grouped by similarity, giving rise to three main categories and five subcategories.

The data were analyzed in the light of Minayo’s thematic analysis, whose method consists in the execution of three phases: pre-analysis; exploration of the material and treatment of results and interpretation⁽⁸⁾. The analysis of institutional documents, questionnaires and focus group are in the pre-analysis phase, and the information found in the documents is described; questionnaires and group sessions have been transcribed, and a thorough reading and organization of the material by similarity is carried out. Each material has a distinct purpose and, therefore, leads to differentiated interpretations, perceptions and reflections, since the richness of the result extracted also depends on the exhaustive contact of the researcher with the field material and on his reflexive freedom, in order to respond to the questions that emerge during the process⁽⁹⁾.

The study obtained ethical approval under the opinion 3,198,381. The study participants signed the Informed Consent Form and were identified in this study by the letter P (Professional), followed by a number. The focus groups were identified in the excerpts as the focus group, followed by a number.

RESULTS

Participated in the study professionals from NASF coordination, HG Nursing management, nurses, social worker, psychologist and pharmacist. At this stage, three categories and five subcategories emerged, which are presented in Chart 1.

Chart 1
Categories and Subcategories. Braço do Norte, SC, Brazil, 2019 (continues)

Main Category	Subcategories
1. Organization and assignment of the psychosocial care network	1.1 Composition and structuring of the services that make up the psychosocial care network
	1.2 Mental health actions
2. The articulation between the services that make up the municipal psychosocial attention network	2.1 Strengths of the Municipal Psychosocial Care Network Articulation
	2.2 Weaknesses of the municipal psychosocial care network
	2.3 Professional discomfort
3. Strategies for strengthening the psychosocial care network

• Source: Authors, 2019.

1.

Organization and assignment of the psychosocial care network

This category points out how the network is organized, its attributions about services and professionals, and counts on the subcategories Composition and structuring of the services that make up the network of psychosocial attention and Mental health actions.

The documental analysis and the narrative of the professionals indicate the organization of the network that involves the services available in the municipality, with some of them present in the institutional documents.

CAPS-I aims at assisting the population with severe, persistent mental disorders and needs arising from the use of alcohol and other drugs and their families, promoting social reintegration in line with the understanding of the Psychosocial Care Network (10:4)

1.1

Composition and structuring of the services that make up the psychosocial care network

Regarding the composition of the network, some professionals, when questioned, identified some services as being part of RAPS. The structure of the services is based on the documents available in health institutions.

[...]psychologist, psychiatrist, CAPS, NASF, social assistance office, Social Assistance Reference Center (CRAS), Specialized Social Assistance Reference Center (CREAS), Guardianship Council, Hospital, SAMU. (P2)

[...] I see that all services work, all services work and very well, it is a very well-structured municipality, it has CRAS, it has CREAS, NASF, it has a trained team. (Focus Group 1)

1.1

Mental health actions

In the organization of the network, it is also important to highlight the actions that are carried out. In all health units, the reception, rounds of talks on topics related to mental health on the days when recipes are delivered at the reception, as well as monthly campaigns are highlighted, according to the program of the Ministério da Saúde.

In this health service, the care to the person with suffering or mental disorder is performed weekly, on this day the patients are attended in free demand for renewal of prescriptions and are approached issues inherent to the subject in the waiting room. (P2)

The reception takes place in a suitable environment, with the objective of investigating the signs and symptoms and their conditioning aspects that justify the care and the necessary procedures. (P7)

The practice of listening is perceived in the sense of referring the person to the necessary professional and the prescription of medicines, many times without the sensitive listening, a tool so primordial to the daily professional and effective.

2.

The articulation between the services that make up the municipal psychosocial attention network

To identify strategies to strengthen the municipal RAPS, professionals were asked about this articulation. In the data analysis, it was possible to identify the strengths and weaknesses of the network, as well as the discomforts faced by professionals in their daily work, composing the subcategories.

2.1

Strengths of the Municipal Psychosocial Care Network Articulation

In the perception of the professionals, the meetings between the Family Health Strategy (FHS) and CAPS, as well as the psychologists’ attendance at NASF, stand out as strengths of the municipal RAPS articulation:

In addition to individual care at the unit performed by NASF psychologists, there are anxiety and depression groups based on psychoeducation. (P3)

Network meetings with CAPS facilitate case knowledge and exchange of information on emergencies; exchange of information over the phone to clarify the case. (P4)

Matrix support even among FHS nurses with the CAPS nurse, and between FHS and NASF, and CAPS and HG, are important actions in this context.

2.2

Weaknesses of the municipal psychosocial care network

The weaknesses of the articulation between the services are found in the great demand for mental health, difficulty in scheduling appointments with the professional psychiatrist, as well as in the communication deficiency with the social assistance network.

We find it very difficult to get appointments with the network psychiatrist, since the queue of patients is immense. In addition, the support network between the health and social services units is out of step, since there is no teamwork between these services. (P2)

Often the patient “runs” too far to find his place of care. (P3)

2.3

Professionals` discomforts

The opening of discussion spaces allowed some discomforts to emerge in the daily life of work environments, sometimes being discouraging for the profession.

[...] they come to you and say: I will kill myself as if we were responsible for it. And we stay, because somehow, we are responsible. (Focus Group 3)

The problem is that we are there at the end only putting out fire [...] we don’t have patience anymore... [...] I have already answered 40 and if I arrive more I will answer too, so we don’t have more time, just put out fire, the patient arrives and he wants it on time [...] (Focus group 3)

The discomforts cited by professionals are related to the excessive demand in basic care and the population’s demand, without adequate time to perform qualified care, hindering listening and reception, tools so important to be practiced in health services.

3.

Strategies for strengthening the municipal psychosocial care network

There are several strategies identified by the professionals both in the questionnaire and in the focus group, contributing to the survey in a positive way. Among them are the need for training network professionals, permanent health education, therapeutic groups in family health strategies, better integration between health professionals and services, meetings between the services that make up the RAPS, including the social assistance network.

Training of health professionals on what it is, how to refer, to whom and in what situation; expanding cooperation among the network (CRAS- CREAS- CAPS- hospital), showing that mental health is an “issue” for everyone, not for each individual universe. (P9)

Green hat: [...] so I think it would be interesting to have a period for us to have at least a diagnosis of the patients [...]. People are going to consult; they are renewing their prescriptions for a long time and they don’t even have a diagnosis. (Focus Group 3)

Red hat: [...] we need to have more of these meetings [...] call other professionals from other areas, CRAS, CREAS so that we are always discussing, to do and really put something into action. (Focus Group 3)

Black hat: reassess all mental health patients, give a diagnosis and treat correctly. [...] there are many indiscriminate prescriptions. (Focus Group 3)

Yellow hat: [...] I really hope that we can continue these meetings, so that we can help each other, because this way only one goes somewhere to complain, or just us complaining won’t solve much, we have to meet [...] (Focus group 3)

Blue hat: [...] we need time to make team meeting in basic attention, because we are not doing, we need time for us to vent. (Focus Group 3)

DISCUSSION

According to the Ministério da Saúde (MS), seven components make up the RAPS and comprise a set of actions and services whose purpose is to meet the different needs of users and their families in the most diverse territories. These services are called points of attention: Basic health care; Psychosocial care; Emergency and emergency care; Residential transitional attention; Hospital care; Deinstitutionalization strategies; and Psychosocial rehabilitation strategies ⁽¹¹⁾. In relation to the existing services in the studied municipality, basic health care, psychosocial care, emergency and emergency care, and a municipal service of medical specialties are part of RAPS.

In the data collection it was found the articulation of CAPS with FHS. However, it is known that a good integration between only two services is not enough; for the network to be effectively integrated and articulated, all health services that make up RAPS need to improve this integration. Matrix support becomes essential to strengthen the care network, elaborating new perspectives in psychosocial care, establishing bonds, relationships of trust, availability and affectivity ⁽¹²⁾.

The MS states that complaints related to mental health are the second largest cause of demand for basic care ⁽¹³⁾. There are many discussions raised by primary care professionals regarding the difficulty in meeting the demand for mental health, as well as the excessive amount of controlled prescription renewal. This excess only solves issues that arise on a daily basis, making it impossible for professionals to stop, discuss and schedule what can be done to change this context in their areas of work.

The practice of reception, therapeutic listening, matrix support among the teams, accompaniment and strengthening of the autonomy of people with mental disorders have the power to modify the conduct of living and interfere in the social, economic and environmental fields ⁽¹⁴⁾. The participating professionals also point out mental health actions in the services, either in the reception or in the monthly reception and campaigns related to mental health, actions that strengthen the bond between the person with mental disorder and the professionals.

Since the user must be the protagonist of his care process, the nurse must understand him as an active agent responsible for his treatment and rehabilitation. According to the above, it is feasible to affirm that co-responsibility and self-management of care are primordial tools for the realization of reception, since the person feels valued as a human being and responsible for himself ⁽¹⁵⁾.

In the municipal services that make up the RAPS, according to the professionals, the practice of reception occurs in all health services, however, this tool in some situations is confused with screening. Reception differs from screening because it is not only about hearing the complaint and referring it to a specific professional: it is about making a qualified listening, creating a bond with the person, understanding the need of the one who is being exposed, putting oneself in the place of the other, and giving resolution to the problem presented⁽¹⁶⁾.

According to a study ⁽¹⁷⁾, psychosocial attention has its proposal oriented by integrality. In these circumstances, the team’s work must occur in an integrated and collective manner and demand commitment on the part of those involved, whether professional, service users, family members and the community.

An important strategy is the training of all professionals working in mental health services, because through training and continuing education, professionals are able to combine theory and practice, discuss their experiences and what can be improved ⁽¹⁸⁾. For this reason, services must be structured, prepared to meet challenging situations, always in articulation not only with health services, but also with other social, educational and community institutions, that is., environments that are part of the coexistence of people with mental disorders.

The articulation at RAPS breaks the concept of centrality of care, that is, it allows flexibility to the services involved in the care, aiming at an improvement in the results offered in psychosocial care⁽¹⁹⁾. It can be seen from the excerpts described that the practice is different from what the literature suggests. Currently, professionals and services do not operate in a network, although professionals have the knowledge of the importance of integrated work, and this articulation is possible to occur in the scenario studied, making it necessary to put into action strategies that will improve the daily routine of professionals.

The personnel turnover, the lack of knowledge about the role of each service, the lack of communication and unnecessary referrals are some of the dilemmas in the scenario studied.

In 2017, the MS approved some changes in the National Mental Health Policy. Despite establishing guidelines to strengthen this network, the path to follow is to review actions and interventions and broaden horizons in search of new approaches, new paths and proposals that are emerging, leaving aside the differences between the medical model and the reform model, to open spaces and continue improving mental health programs, as proposed by the World Health Organization (WHO)⁽²⁰⁾.

Combining the WHO proposal with practice, developing strategies for a RAPS is a difficult and complex intervention that requires the engagement of all involved. Through the data, it was possible to identify some strategies to strengthen this psychosocial care network by professionals, corroborating what the literature also indicates, especially regarding training of professionals and articulation of services, avoiding their fragmentation, thus ensuring integral assistance, as well as intersectionality(²¹,²²).

Among the strategies indicated, the following stand out: a) Train all professionals working in RAPS; b) Empower professionals working in RAPS; c) Hire another psychiatrist professional; d) Implement the Multi-professional Team Specialized in Mental Health II; e) Prepare a bimonthly meeting schedule with all services that make up the municipal RAPS; f) Allow for a weekly team meeting in all basic health units; g) Carry out the project “Caring for the Caretaker” in all services that compose the psychosocial attention network; h) Create alternative therapeutic groups in basic health units; i) Diagnose people with mental disorders who carry out their treatment in family health strategies; j) Perform professionals through public contest; k) Carry out a flowchart of care to people with mental disorders; l) Prepare an orientation booklet of the Psychosocial Attention Network.

Discussing this topic allowed us to understand the municipal RAPS in a broader way, identifying that there are several knots that need to be built and tied in order to unite health with other departments. We can compare these knots with those of a fishing net that, in order to be elaborated, it is necessary to interweave the several knots it contains until it is ready for use, and when put into practice, sometimes some of these knots loosen, others burst, being necessary to redo them so that the net can be used again. So, is the RAPS: each service that makes up the network is a node, and for the services to be articulated, these nodes must always be tied and strong, because when a node falls apart or loosens, the assistance to the person with mental disorder becomes fragmented, making the integration process even more difficult.

The study presented as a limitation the number of participants and municipality, being understood, therefore that future research, involving a larger sample and other municipalities, be undertaken, for a broad discussion on the subject.

FINAL CONSIDERATIONS

From the meetings carried out in the study scenario, the professionals were able to list strategies to strengthen the psychosocial care network in the municipality, which at first may seem simple, but if put into practice, it is believed that they will strengthen the network, enabling changes in the current context.

The weaknesses presented by the professionals become evident, highlighting the lack of communication, referrals without returns, difficulties in assisting people with mild mental disorder, moderate and severe, difficulty in relation to referrals in a correct manner to the services that make up the RAPS in the municipality, indicating that there is a need for a more articulated action and a rethinking of the implementation of RAPS.

This study adds specific knowledge to the production of knowledge in nursing, for identifying strategies to improve mental health care, since studies have approached the difficulties and facilities, without pointing out what can be improved. It is believed that this study, which had the participation of professionals, contributes to the enlargement of the discussion, in an articulated way, as well as to the municipal psychosocial network itself, pointing out that the strategies used to foment the reflexive process were the driving force of the meetings carried out. The implementation of the proposed strategies, the commitment of managers and professionals to modify this current situation may allow the municipality to be a reference in the region through the integrated care of the person with mental disorder.

• *
  Article extracted from a Master´s Degree dissertation “Strategies for Strengthening the Municipal Articulation of the Psychosocial Attention Network”. Universidade Federal de Santa Catarina, 2019.

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Edited by

Associate editor: Susanne Elero Betiolli

Publication Dates

• Publication in this collection
  29 Oct 2021
• Date of issue
  2021

History

• Received
  21 Jan 2020
• Accepted
  23 July 2020