Labyrinths of nursing training and the Brazilian National Mental Health Policy

Laberintos de la formación en enfermería y la Política Nacional de Salud Mental Brasileña

ABSTRACT

Objective:

to analyze the training of nurses from public and private educational institutions of the city of São Paulo from the perspective of the Brazilian Psychiatric Reform.

Methods:

a qualitative, descriptive-exploratory research, using as methodological framework documentary analysis of the pedagogical projects of the participating institutions and content analysis of the interviews carried out with mental health professors.

Results:

it was identified that most mental health courses had insufficient workload for adequate training; theory emphasized the study of mental disorders and drug treatment; practice, in some schools, was carried out in psychiatric hospitals. There were problems that interfered with the quality of the education offered.

Final considerations:

educational institutions still did not offer training in undergraduate nursing from the perspective of the Brazilian Psychiatric Reform.

Descriptors:
Nursing; Mental Health; Psychiatric Nursing; Health Care Reform; Politics

RESUMEN

Objetivo:

analizar la formación de enfermeras de instituciones educativas públicas y privadas en la ciudad de São Paulo, en la perspectiva de la Reforma Psiquiátrica brasileña. Métodos: investigación cualitativa, descriptiva-exploratoria, utilizando el marco metodológico del análisis documental de los proyectos pedagógicos de las instituciones participantes y el análisis de contenido de las entrevistas realizadas con docentes de la disciplina de salud mental.

Resultados:

se identificó que las disciplinas de salud mental, en su mayoría, tenían una carga de trabajo insuficiente para una capacitación adecuada; el campo teórico enfatizó el estudio de los trastornos mentales y el tratamiento farmacológico; el campo práctico, en algunas escuelas, todavía se realizaba en hospitales psiquiátricos. Hubo problemas que interfirieron con la calidad de la educación ofrecida.

Consideraciones finales:

las instituciones educativas aún no ofrecían capacitación en enfermería de pregrado, en la perspectiva de la Reforma Psiquiátrica brasileña.

Descriptores:
Enfermería; Salud Mental; Enfermería Psiquiátrica; Reforma de la Atención de Salud; Política

RESUMO

Objetivo:

analisar a formação dos enfermeiros oriundos de instituições de ensino públicas e privadas, da cidade de São Paulo, na perspectiva da Reforma Psiquiátrica brasileira.

Métodos:

pesquisa qualitativa, descritiva-exploratória, com uso do referencial metodológico da análise documental dos projetos pedagógicos das instituições participantes e da análise de conteúdo das entrevistas realizadas com os docentes da disciplina de saúde mental.

Resultados:

foi identificado que as disciplinas de saúde mental, em sua maioria, tinham a carga horária insuficiente para a formação adequada; o bloco teórico tinha como ênfase o estudo dos transtornos mentais e tratamento medicamentoso; o bloco prático, em algumas escolas, ainda, era realizado em hospitais psiquiátricos. Havia problemas que interferiam na qualidade do ensino ofertado.

Considerações finais:

as instituições de ensino ainda não ofertavam formação na graduação em enfermagem, na perspectiva da Reforma Psiquiátrica brasileira.

Descritores:
Enfermagem; Saúde Mental; Enfermagem Psiquiátrica; Reforma dos Serviços de Saúde; Política

INTRODUCTION

The Brazilian Psychiatric Reform (PR) is a highly complex political and social process. In this sense, its development involved different actors and institutions, forces from different sources and territories, including the three spheres of government, health services market, professional councils, associations, social movements, and universities¹.

The Brazilian reformist process proposing a change in the mental health care offered in the country goes through an important issue, discussed by this movement, which is human resource training. Human resources are indispensable for overcoming the asylum model and for sustaining the transformative practice of care. In this perspective, it is expected that universities seek strategies to consolidate their political-pedagogical projects in order to meet the advances, so that they train technically and politically capable professionals to meet the challenges of modernity².

Concerning the training of nurses to work in mental health, nursing schools are places that condition the construction of students’ perceptions about the reality of health and practices of these future professionals. For this reason, over time, these institutions began to be charged with promoting transformations in teaching in mental health and psychiatry in order to meet the demands of new care models³.

However, it is observed that nursing courses have not yet been adapted to the assumptions of PR. Teaching mental health has been proposed by courses with reduced workload, with theoretical contents that emphasize approach of psychopathologies, drug treatment and care for individuals to the detriment of the study of mental health policies in force⁴. Moreover, it is identified that psychiatric hospitals remain places of choice for educational institutions to develop internship practices⁵. This condition can be justified by the inheritance of the biomedical learning model, traditionally instituted for health education. This model emphasizes the curriculum structure in the specialties, divided by courses and having the hospital as a learning field⁶.

In relation to curriculum organization by subjects in a fragmented way, it is noticed that this organization creates in students a simplistic, compartmentalized and static view of the reality of health. Also, it interferes in learning about health-disease processes of individuals from the perspective of integrality⁷. Therefore, compartmentalized and non-articulated content can be considered limiting factors in teaching and learning psychiatric nursing and mental health⁸. In this context, in order to obtain quality mental health training, it is necessary to impose changes in the bureaucratic, departmentalized and coursed structures of higher education institutions (HEIs)⁵.

The Brazilian National Curriculum Guidelines (Diretrizes Curriculares Nacionais) for undergraduate health courses establish guidelines on curriculum construction. These guidelines must be followed by all HEIs in order to ensure the quality of the training offered, deconstructing the old molds of the curriculum, ensuring solid training. Thus, future professionals will be prepared to face the challenges of changes in society, labor market and professional practice⁹.

It is possible to see that failure to adapt undergraduate nursing courses to the PR proposals conditions graduation of professionals, with inadequate training to support the proposal. The aforementioned impairs provision of quality mental health care. Thus, if there is impairment in care, there is a compromise in actions and care for individuals with mental disorders. The problem raised about training and, consequently, performance of nurses is added to the gap in the research. Such gaps refer to studies on nursing in PR and the Brazilian National Mental Health Policy (Política Nacional de Saúde Mental, abbreviated PNSM).

OBJECTIVES

To analyze the training of nurses from public and private educational institutions of São Paulo from the perspective of PR through content signed by political-pedagogical projects and theoretical-methodological framework. Such framework supports mental health courses offered by undergraduate nursing courses in terms of theoretical content and internship practices. The transformations proposed by PNMS are considered.

METHODS

Ethical aspects

The study respected the ethical aspects recommended by Resolution 466 of December 12, 2012 of the Brazilian National Health Council (Conselho Nacional de Saúde)¹⁰ and other legislation. To carry out the research, educational institutions were asked for authorization to analyze their pedagogical projects and for the participation of professors in charge of mental health-related courses. Of the twenty-five educational institutions that could participate in the research, only nine actually did so.

The research proposal was submitted to the Research Ethics Committee of Universidade Federal de São Paulo.

All interviewees expressed their acceptance to participate in the study by signing the Informed Consent Form (ICF). To preserve the identity of participants, letter “I” was used as identification followed by the number referring to the order in which interviews were conducted. Names of institutions, health services, cities, neighborhoods were replaced by names of flowers.

Theoretical-methodological framework

The methodological framework used for the study was documentary analysis of pedagogical political projects (PPP) and thematic content analysis (11) of the interviews conducted.

Type of study

This is a qualitative, descriptive-exploratory study.

Methodological procedures

Professors in charge of mental health-related courses of the HEIs who agreed to participate in the research were interviewed. Also, analysis of the PPP that guided the nursing courses of these institutions was carried out.

Interviewees, coordinators or professors in charge of the course or curriculum unit and having been teaching classes on mental health topics at this institution for at least one year have been included. Coordinators or professors in charge of mental health-related course or curriculum unit from different campi of the same educational institution, in order to avoid duplication of participation, have been excluded. In this case, the coordinators/professors were interviewed only once by a single unit from the same institution.

Study setting

The research was carried out in public and private HEIs of São Paulo, which offered undergraduate nursing courses.

Data collection and organization

The interviewees were contacted about their interest in participating in the study, the research’s objective was explained, and the ICF was signed. Data collection took place in the first half of 2018. The interviews were recorded on audio, conducted in a private location, with a date and time previously agreed with the participants. Subsequently they were transcribed in full and then factual elements of oral communication and expressions typical of colloquial language were removed, followed by categorization and analysis. A script made by the authors was used as an instrument to direct the interviews, consisting of data of participant identification and five guiding questions.

Data analysis

Analysis was divided into two moments. In the first, PPP of the courses were analyzed according to PNSM’s legal framework and PR assumptions. In the second, examination of interviews was carried out, following pre-analysis, exploration of the material and treatment of the results proposed by Bardin¹¹. The data obtained were categorized and represented in thematic units. Three categories emerged from this process, which made up the original study, but for this article the category “mental health course and training for mental health policy” was chosen.

RESULTS

Of the nine schools that participated in the research, two were public and seven were private. The interviewees were mostly female, aged between 34 and 59 years, nurses, graduated 12 to 35 years ago and working in this field between 9 and 30 years. Most were trained in mental health, with lato sensu and stricto sensu graduate courses, master’s and doctoral degrees, but only two professors held a doctorate degree in mental health.

Mental health course and training for mental health policy

The category in question deals with the functioning and structure of the mental health course in the HEIs studied, describing workload, theory and practice teaching, problems identified as conditioning factors that interfered in the quality of the education offered. There was a shortage of professionals to teach that course, insufficient workload for teaching PR and mental health policies and no integration between the courses that made up the curriculum matrix.

From the interviewees’ reports, it was possible to know the workload available to develop the mental health course, mentioning the quantitative distribution of hours/classes. In public institutions, there were an average of 145 hours in the specific subject, and in private institutions, most had 80 hours.

We managed to bring this course back, because a few years ago it was absorbed in the pedagogical project... we did it for a life cycle. Psychiatry was part of the specialties and was taught together with others. We had a life cycle of specialties that it was in the middle of. There came a time that took up the practice of psychiatry and I think that for a few years now, for about 3 years or so, we have been talking, arguing that it was important to return to mental health and psychiatry. All hours of specialties are still the same. You have 80 hours for theory and practice... 40 for each. (I1)

This course has 165 hours and is taught today by four professors and in former times it had seven professors. There are four of us... this course takes place in the third term; the student is experiencing mental health and psychiatry and women’s health and children’s health. We work on the theoretical part in two weeks. A part of the theoretical part takes place in two weeks and then we go on to an adult CAPS internship and an alcohol and drug CAPS. There is still a theoretical part in the course, because as the course is full-time, the theoretical part happens in the two weeks in the morning and in the afternoon, then it enters the internship in the morning and has some content in the afternoon. (I4)

With regard to theory, the general content taught by professors were listed, such as the history of psychiatry, therapeutic communication, PR. However, the themes referring to psychopathologies and drug treatment stand out as the most addressed in the specific courses studied in mental health.

... in mental health, we specify the pathologies related to mental health. (I3)

... we work much more depending on the result of drug treatment in the patients’ behavior than focusing on a psychopharmacology course, because they had this notion, at the beginning, of how these drugs are classified... I work more in sense of how it will impact care. (I7)

... in psychiatry, I get into the most serious pathologies, but I keep talking... we are going to have a class on panic, before we didn’t see panic medications and now, we’ll see all the panic treatment as it is. It used to be talked about the elderly, that they could have a panic syndrome and what is panic syndrome, but now it will go deeper into panic syndrome and other diseases as well. (I8)

With regard to practice, the interviewees described how it happened and the HEIs in which it was offered. Of the schools studied, six offered internships, two offered only technical visits and one did not offer the practical part. The fields of practice were composed of units proposed in PR such as Psychosocial Care Centers (Centros de Atenção Psicossocial, abbreviated CAPS) and units excluded in the mental health policy such as psychiatric hospitals.

... until then, they were going to the psychiatric emergency room and psychiatric hospital. I couldn’t find CAPS because of a matter from the city, I mean, last semester I got an adult CAPS, but I couldn’t get a specialized professor... I was very afraid, it wasn’t so good because they have a theory with me that is very solid and when he goes to practice, get an inexperienced professor... this next semester I already requested, I asked the school to request adult CAPS. Not specifically the Adult, so that students can understand this. What I also have is that in the curricular internship I go to a psychiatric hospital that has a day hospital... there was no field. The only one that the city released was adult CAPS. I think the school was also learning to ask the city for these fields that we didn’t know how to do because we were without psychiatry for a while. (I1)

... in the lab, they have the physical restraint part that I also do with them at those hours... I already talk about a lot without this visit to CAPS that would not take these 22 hours just for that. I would spend a lot of time with that. (I2)

... mental health has two moments: in this course, students make a technical visit at CAPS, then they spend another semester on the internship... this technical visit I’m talking about, we take 90 hours, 3 days, actually. There are 3 days, 15 hours for this technical visit with the groups. (I6)

In relation to the identified problems that interfered with the quality of the education offered, the interviewees exposed the difficulties associated with lack of professors to develop the specific course.

I did not share the course because I have not yet found any professor prepared to share. I have two more years that I can be alone, then I think I will need another one, but I am preparing some people. In mental health, not in teaching... one of them was even an intern and resident there at Lírio [health service], but not at CAPS... what most catches me in the practical part is teaching... I have no physical conditioning to go to the field with all of them. I have to delegate to the professors who are going to be in the different fields. There is an emergency room, an internment camp, a CAPS camp. I depend on these professors who are in practice. They have to have training in the field and they have to have professor training. (I1)

... we have a limitation that is a limitation of personnel. We are just two mental health professors to meet all the needs of the school and the institution with regard to mental health... we don’t have physical conditioning for that, sometimes you have to be prioritizing where you are going to deposit your energies. (I5)

Another condition, which was observed in the interviewees’ reports that put mental health teaching adequacy in doubt, was related to incipient workload to teach contents on PR and its policies.

I take a day out of those three days of master class that I am with everyone. Someday, you can be sure that this class will talk about reform. All the time and then when I am with them in smaller groups, I will discuss on CAPS. Do not discuss CAPS because I already discussed it, but the assistance because I bring the pathologies and how you have to see it. (I1)

There was an absence of dialogue between mental health-related courses and the specific course. This condition was demonstrated by adaptation by mental health professors to contemplate the contents that were not taught in other subjects of the curriculum matrix.

... we have a huge limitation in the amount of hours I have to work on the specificity of mental health and in fact it ends up being care for sick people already well committed... we are proposing changes that are yet to be voted on and we believe that will only achieve this for 2019, for the beginning of 2019 class... we talked about issues that we need to review and we tried to bridge that gap. Working a little bit of interdisciplinarity between what they saw in psychology and what we are going to use in mental health. As there are flaws, we try to introduce into the mental health course what we perceive is missing... before starting the course, I already sent e-mail to the classrooms reinforcing the content that was developed in fundamentals... nowadays there is content that I develop in the second semester of the first term, then there is content that we develop in the first semester of the second term and our course comes in the second semester of the second term. It’s too far. When we start the course, I send the emails to the classrooms asking them to return to the contents that were given until assessment of the mental state, psychic evaluation, the communication contents, mainly therapeutic communication. (I5)

DISCUSSION

Data show that most professors had considerable time in mental health and in nursing training. Moreover, specialization and a master’s degree in mental health predominated as specific training for these professionals. Teaching in nursing requires knowledge and requirements for the development of teaching activities. Those that stand out are: the professor’s expertise in understanding and transitioning between specialty and pedagogy; valuing the knowledge acquired in professional experience; deepening of knowledge in relation to pedagogical practices¹².

From this perspective, longer working in mental health and nursing training can be considered a positive point. Professors possibly have more professional baggage and more experiences as collaborators for the exercise of teaching. However, due to the fact that most of them have a master’s degree and specialization in specific training, it is necessary not only more qualification, but also an attitude of permanent study both for teaching and for engagement in carrying out scientific research in the field.

With regard to mental health in its structure and functioning, it was observed that the workload available for teaching this course was insufficient to train generalist professional nurses. The designated hours/classes were not able to supply mental health teaching in different life cycles and levels of care. It is noteworthy that the setting presented here is consistent with the curriculum structure reality of Brazilian undergraduate nursing courses, showing that the total average workload of the mental health and psychiatry courses corresponded to 104.6 hours. Furthermore, when comparing public and private institution workload, the difference between the averages corresponded to 142.12 hours and 81.20 hours, respectively¹³.

Concerning mental health teaching workload reality in other undergraduate courses, a study identified that although the medical course has a higher total workload than nursing, psychology, occupational therapy and social work, it presented a lower workload related to mental health, corresponding to only 1.2% of the total value of the course. However, psychology presented 5.8%, showing a higher workload of the mental health courses among all analyzed courses. Disproportion here provides evidence of the importance that the theme occupies in the training for each course⁶.

In this context, it is clear that mental health training of health professionals does not receive due attention from universities. There is little emphasis on the approach of this theme, so that lower-quality courses with unsatisfactory curriculum workload for teaching are worked on when compared to the other subjects of the curriculum^14-15.

It was also possible to verify in mental health structure and functioning that theory had teaching geared towards the biomedical model, with an emphasis on the study of psychopathologies and exclusively drug treatment. History of psychiatry, PR and public mental health policy-related contents were taught in part of the institutions at specific times, indicating a possible deficiency in teaching. These subjects are extensive and complex, and it is not possible to teach them in a few hours/classes.

This condition is associated with the legacy of the Flexnerian paradigm, which has long permeated health care models and training in the field of nursing. Thus, the biological and organic issue is seen as defining the health-disease process^13,16. For this reality to be modified, it is necessary for professors to direct the curriculum for training that goes beyond traditional psychiatry, assuming the psychosocial model more concretely¹⁷.

Accordingly, in research that reveals the history of nursing education in mental health of the city of Volta Redonda, RJ, it was noticed that the contents covered were consistent with mental health policies at national and local level. This condition is due to the political involvement of the professor in charge of the course with the PR movement and his or her professional performance in managing a health district in that city¹⁸.

Research results on the theoretical-practical mental health teaching showed that theoretical teaching emphasized the study based on the biological and curative model. Mental disorders were mainly addressed, in addition the concepts referring to psychosocial care were not taught. Furthermore, the authors highlighted mismatch between theory and practice. the practice scenarios showed care from the perspective of prevention and health promotion from a psychosocial perspective, and the theory provided a basis for mental disorder treatment¹⁹.

Following the logic of theoretical-practical activities, it is worth noting that in mental health, practices were being developed in CAPS by five of the institutions. However, some of the schools still performed these activities in institutions of a hospital nature. The aforementioned issue shows that such schools were not meeting the precepts of PR, since psychiatric hospitals still remained as fields of practice. Therefore, the importance of internship in community services proposed by PR is emphasized, since students are brought closer to care from the perspective of psychosocial rehabilitation²⁰.

Student participation in practice settings is an essential link in the teaching and learning process, so that contact with professionals and users of health services constitutes a sphere that produces knowledge and care²¹. Moreover, this participation allows consolidation of theoretical knowledge, favoring individual construction about understanding mental health care, as well as the alternatives to operationalize it¹⁷. In this way, substitution of practical activities for technical visits or classes in laboratories, as happened in the teaching offered in part of the institutions participating in our study, indicates that training is not appropriate. This occurs mainly because it does not allow the student the possibility of interacting with individuals with mental disorders and allowing experiences about care developed in services.

It should be noted that theoretical-practical activities in internship fields constitute initial contact of nursing students with the reality of health work at different levels of care, of which there are hospitals, Basic Health Units, CAPS, among others. This contact is considered essential for professional and personal training due to the important role it plays in developing technical and attitudinal skills inherent in the performance of this profession²².

In relation to the problems identified in mental health teaching, which interfered with the quality of training provided by the schools, it was noted that scarcity of professionals to teach this course is possibly associated with devaluation that still permeates this field of work, compromising teaching in mental health. Historically, psychiatric nursing has been surrounded by prejudice in relation to developed manual work. There were practically no scientific therapeutic interventions being reduced to the submission of disciplinary orders that regulated operation of psychiatric hospitals²³. Nowadays, this devaluation refers to inadequate working conditions, work overload and lack of training for professionals²⁴.

From the perspective of devaluation of nursing in mental and psychiatric health in teaching, Souza⁸ makes explicit in his study, through the reports of professors, that there is no recognition and appreciation of nursing practice by institutions and by others coworkers. It was also evidenced that with reduced number of mental health and psychiatry professors, it is difficult to meet the institutional demands that go beyond the pedagogical aspects of teaching work.

Moreover, another problem is insufficient workload for teaching PR and mental health policies. This shows that nursing education in the institutions precariously contemplated or did not contemplate approach of these contents, reiterating mastery of the biomedical model. It is observed that although HEIs have an important role in the PR process, the academic culture, despite being critical, has not yet been able to fully confront the hospital-centered tendency. The aforementioned training focuses on the clinic of mental disorders to the detriment of critical thinking based on training linked to mental health policy²⁵.

The limitations in mental health care in the various health services are associated with the teaching that, as mentioned above, maintains the clinical and traditional view as a foundation, requiring political investment in professional training. Thus, it is necessary that the psychosocial model be discussed in undergraduate courses to provide a broad view of the current mental health setting as well as the development of skills to provide quality assistance to individuals and their families²⁶.

It also includes the conjuncture of teaching problems raised by professors and the lack of integration between the courses of the curriculum matrix. There was a lack of interdisciplinary work between the mental health course and the other courses, mainly those that make up the basic cycle. The result of a study on the training of nurses in different health regions in Brazil corroborates the findings of this research. Most nursing courses were organized into two basic and professional cycles. The cycles in question were constituted by isolated courses, so that with this configuration, implementation of content integration and interdisciplinarity become a challenge²⁷.

A research on a nursing course at a federal institution of São Paulo showed that curriculum was presented by a list of courses organized in a hierarchical manner with isolated content. Such an organization is associated with the professors’ lack of preparation regarding pedagogical knowledge to guide the elaboration of PPP with their own identity, thus breaking with the traditional teaching paradigm²⁸.

Although curriculum guidelines direct teaching based on the integrated curriculum, it is a current challenge to put this issue into practice in a way that allows students to learn to care for patients from the perspective of singularity and integrality. With regard to mental health, this condition is revealed by the historical context of the course, which, since its creation, has been structured in the model of the disciplinary curriculum, being isolated from the others¹⁷.

Although it is challenging to integrate knowledge in a disciplinary curriculum, this is a condition to be faced. In this perspective, there are some strategies that enable the beginning of overcoming this condition, such as involvement of professors in collective discussions and joint development of research, teaching and extension projects. However, it is emphasized that these strategies need to be systematized according to interdisciplinarity²⁹.

Study limitations

The limitations are associated with the reality portrayed about mental health teaching only in schools of São Paulo, SP, so that it does not allow generalization of the setting presented.

Contributions to nursing, mental health, and public policies

The research revealed that the reality of teaching undergraduate nursing courses, with regard to the training of nurses to work in the mental health field, is not in accordance with of PR and PNSM assumptions. The elements of the education offered that need modification are brought in collaboration so that nursing schools have the possibility of adapting teaching and offering training based on reformist precepts and health policies in force.

FINAL CONSIDERATIONS

The results of this study allow to mention that the educational institutions did not offer training in undergraduate nursing from the perspective of PR. By analyzing PPP, mental health theme was not worked on in an interdisciplinary way as proposed in PNSM. This issue is associated with the structuring of courses in the curriculum matrix that were presented in isolation without the existence of integration between them. With regard to mental health, due to the theoretical contents covered and practices of internships carried out, it was found that most schools have not yet followed the changes proposed by PNSM. It is demonstrated that this condition by the subject in question addresses primarily mental disorder and drug treatment teaching. The number of hours devoted to teaching mental health was also very small in terms of number of professors. In relation to practice, in some schools, the psychiatric hospital was still maintained as a field for the development of activities, in addition to replacing internships with technical visits or classes in rooms and laboratories.

ACKNOWLEDGMENT

To the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) for the Master’s scholarship granted during the research.

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Edited by

EDITOR IN CHIEF: Antonio José De Almeida Filho

ASSOCIATE EDITOR: Fátima Helena Espírito Santo

Publication Dates

• Publication in this collection
  17 July 2020
• Date of issue
  2020

History

• Received
  26 Nov 2019
• Accepted
  13 Mar 2020