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Approaches to workload in psychiatric and mental health nursing

Enfoques para la carga de trabajo en enfermería psiquiátrica y salud mental

ABSTRACT

Objective:

to investigate approaches to workload in psychiatric and mental health nursing in Brazilian and international production of knowledge

Methods:

integrative literature review using six databases, covering January 2005 to March 2019. Articles in full in English, Spanish and Portuguese were included.

Results:

the sample consisted of 23 original articles classified as quantitative or emotional. The quantitative dimension was addressed in 12 articles and included: assessing patient care needs, identifying activities performed by the team, measuring time spent and developing and validating a measurement instrument. The emotional dimension included 11 articles the focus of which was on identifying stressors in the workplace, psychosocial risks and coping strategies.

Conclusion:

strategies were found for measuring workload and assessing the impact of stressors on nursing teams.

Descriptors:
Workload; Nursing Staff; Psychiatric Nursing; Mental Health; Workplace

RESUMEN

Objetivo:

investigar los enfoques existentes de carga de trabajo en la producción de conocimiento nacional e internacional en enfermería psiquiátrica y salud mental.

Métodos:

revisión bibliográfica integradora, en seis bases de datos, con un marco temporal desde enero de 2005 hasta marzo de 2019. Los artículos en inglés, español y portugués estaban disponibles y disponibles en su totalidad.

Resultados:

La muestra constaba de 23 artículos originales clasificados en dos dimensiones. La dimensión cuantitativa fue abordada por 12 artículos e incluyó: evaluación de las necesidades de atención al paciente, identificación de actividades realizadas por el equipo, medición del tiempo empleado y desarrollo y validación de un instrumento de medición. La otra dimensión emocional incluyó 11 artículos cuyo foco estaba en identificar estresores en el lugar de trabajo, riesgos psicosociales y estrategias de afrontamiento.

Conclusión:

se evidenciaron estrategias para medir la carga de trabajo y evaluar el impacto de los estresores en los equipos de enfermería.

Descriptores:
Carga de Trabajo; Recursos Humanos de Enfermería; Enfermería Psiquiátrica; Salud Mental; Condiciones de Trabajo

RESUMO

Objetivo:

investigar as abordagens de carga de trabalho existentes na produção do conhecimento nacional e internacional em enfermagem psiquiátrica e saúde mental.

Métodos:

revisão integrativa de literatura, em seis bases de dados, com recorte temporal de janeiro de 2005 a março de 2019. Foram incluídos artigos em inglês, espanhol e português disponíveis na íntegra.

Resultados:

a amostra constituiu-se de 23 artigos originais classificados em duas dimensões. A dimensão quantitativa foi abordada por 12 artigos e abrangeu: avaliação de necessidades de cuidados de pacientes, identificação de atividades realizadas pela equipe, mensuração do tempo despendido e desenvolvimento e validação de instrumento de mensuração. A outra dimensão emocional incluiu 11 artigos cujos enfoques recaíram sobre identificação de estressores no ambiente de trabalho, riscos psicossociais e estratégias de enfrentamento.

Conclusão:

evidenciaram-se estratégias para mensuração da carga de trabalho e avaliações do impacto dos estressores nas equipes de enfermagem.

Descritores:
Carga de Trabalho; Recursos Humanos de Enfermagem; Enfermagem Psiquiátrica; Saúde Mental; Condições de Trabalho

INTRODUCTION

Since the Psychiatric Reform movements11 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Coordenação Geral de Saúde Mental. Reforma psiquiátrica e política de saúde mental no Brasil. Documento apresentado à Conferência Regional de Reforma dos Serviços de Saúde Mental: 15 anos depois de Caracas [Internet]. OPAS. Brasília, novembro. 2005[cited 17 Jul 2019]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/Relatorio15_anos_Caracas.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
, nursing professionals working in psychiatry and mental health have been reorganizing their practice continuously. Based on changes in the work process, questions arise regarding quantifying time required for care22 Sousa C, Seabra P. Assessment of nursing workload in adult psychiatric inpatient units: A scoping review. J Psychiatr Ment Health Nurs. 2018;25:432-40. doi: 10.1111/jpm.12468
https://doi.org/10.1111/jpm.12468...
and investigating how work can impact the health of these workers33 Alves SR, Santos RP, Oliveira RG, Yamaguchi MU. Mental health services: perception of nursing in relation to overload and working conditions. Rev Pesqui: Cuid Fundam. 2018;10(1):25-29. doi: 10.9789/2175-5361.2018.v10i1.25-29
https://doi.org/10.9789/2175-5361.2018.v...
-44 Sousa KHJF, Gonçalves TS, Silva MB, Soares ECF, Nogueira MLF, Zeitoune RCG. Risks of illness in the work of the nursing team in a psychiatric hospital. Rev Latino-Am Enfermagem. 2018;26:e3032. doi: 10.1590/1518-8345.2458.3032
https://doi.org/10.1590/1518-8345.2458.3...
.

Workload (WL) in nursing is the amount of time and physical and cognitive effort required to provide care (direct and indirect) to the patient and to perform non-assistance care activities, including professional development. By measuring this, personnel involved in providing services to different types of patients under different conditions can be assessed qualitatively and quantitatively55 Alghamdi MG. Nursing workload: a concept analysis. J Nurs Manag. 2016;24(4):449-57 doi: 10.1111/jonm.12354
https://doi.org/10.1111/jonm.12354...
-66 Swiger PA, Vance DE, Patrician PA. Nursing workload in the acutecare setting: a concept analysis of nursing workload. Nurs Outlook. 2016;64(3):244-54. doi: 10.1016/j.outlook.2016.01.003
https://doi.org/10.1016/j.outlook.2016.0...
.

When aiming to characterize its scope, it has usually been categorized in two distinct ways. In the first77 Felli VEA, Costa TF, Baptista PCP, Guimarães ALO, Anginoni BM. Exposure of nursing workers to workloads and their consequences. Rev Esc Enferm USP. 2015;49(spe2):98-105. doi: 10.1590/S0080-623420150000800014
https://doi.org/10.1590/S0080-6234201500...
, it is divided into physical (noise, temperature), chemical (medication), biological (body fluids), mechanical (accidents with sharp materials), physiological (inadequate posture) and psychological (working conditions). In the other approach88 Carayon P, Alvarado CJ. Workload and Patient Safety Among Critical Care Nurses. Crit Care Nurs Clin N Am. 2007;19(1):121-9. doi:10.1016/j.ccell.2007.02.001
https://doi.org/10.1016/j.ccell.2007.02....
, it is classified into seven dimensions. Identifying and measuring the time consumed by nurses in carrying out their care activities (direct and indirect) covers the quantitative dimension, and the working conditions include the qualitative dimension. The cognitive dimension includes mental effort and information overload, with physical effort, including handling the patient, corresponding to the physical dimension. The impact on the worker’s mental health corresponds to the emotional dimension. Time pressure is related to short deadlines and the need to work fast, and the variability of the WL, as the name itself implies, is constantly changing and increasing and/or decreasing.

Transformations in the psychiatry and mental health care model encourage the reorganization of nursing processes, requiring tools to support decision making22 Sousa C, Seabra P. Assessment of nursing workload in adult psychiatric inpatient units: A scoping review. J Psychiatr Ment Health Nurs. 2018;25:432-40. doi: 10.1111/jpm.12468
https://doi.org/10.1111/jpm.12468...

3 Alves SR, Santos RP, Oliveira RG, Yamaguchi MU. Mental health services: perception of nursing in relation to overload and working conditions. Rev Pesqui: Cuid Fundam. 2018;10(1):25-29. doi: 10.9789/2175-5361.2018.v10i1.25-29
https://doi.org/10.9789/2175-5361.2018.v...
-44 Sousa KHJF, Gonçalves TS, Silva MB, Soares ECF, Nogueira MLF, Zeitoune RCG. Risks of illness in the work of the nursing team in a psychiatric hospital. Rev Latino-Am Enfermagem. 2018;26:e3032. doi: 10.1590/1518-8345.2458.3032
https://doi.org/10.1590/1518-8345.2458.3...
and, consequently, require greater involvement on the part of nursing team to meet these new demands, which can negatively impact the WL and quality of life of professionals33 Alves SR, Santos RP, Oliveira RG, Yamaguchi MU. Mental health services: perception of nursing in relation to overload and working conditions. Rev Pesqui: Cuid Fundam. 2018;10(1):25-29. doi: 10.9789/2175-5361.2018.v10i1.25-29
https://doi.org/10.9789/2175-5361.2018.v...
. Thus, studies focused on this topic can benefit management of nurses working in mental health, reflected in the work environment, in the care process and in the team’s well-being.

OBJETIVE

Investigate approaches to workload in psychiatric and mental health nursing in Brazilian and international production of knowledge.

METHODS

This is an integrative literature review. This method comprehensively analyzes scientific knowledge in order to understand a particular phenomenon. It has the potential to construct science by contributing to developing theories that can be applied in practice and constitute new public policies (99 Hopia H, Latvala E, Liimatainen L. Reviewing the methodology of an integrative review. Scand J Caring Sci. 2016;30(4):662-69. doi: 10.1111/scs.12327
https://doi.org/10.1111/scs.12327...
-1010 Akerjordet K, Furunes T, Haver A. Health-promoting leadership: An integrative review and future research agenda. J Adv Nurs. 2018;74:1505-16. doi: 10.1111/jan.13567
https://doi.org/10.1111/jan.13567...
.

The integrative review in this study was based on the steps recommended in the literature1111 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-53. doi: 10.1111/j.1365-2648.2005.03621.x
https://doi.org/10.1111/j.1365-2648.2005...
. Although this methodology was proposed in 2005, it is still widely used in research 99 Hopia H, Latvala E, Liimatainen L. Reviewing the methodology of an integrative review. Scand J Caring Sci. 2016;30(4):662-69. doi: 10.1111/scs.12327
https://doi.org/10.1111/scs.12327...
-1010 Akerjordet K, Furunes T, Haver A. Health-promoting leadership: An integrative review and future research agenda. J Adv Nurs. 2018;74:1505-16. doi: 10.1111/jan.13567
https://doi.org/10.1111/jan.13567...
.

I) Identify the problem

The research question was: which approaches to the psychiatric and mental health nursing team WL are found in the scientific literature?

II) Search of the literature

In March 2019, a search was conducted by one of the integrative review authors in the following databases PubMed/MEDLINE of the National Library of Medicine, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), EMBASE, SCOPUS and Web of Science.

So as to cover the topic entirely, keywords and descriptors researched in the Medical Subject Headings (MESH) and Health Sciences Descriptors (DECS) were included in Portuguese, English and Spanish. The following controlled descriptors, keywords, synonyms and Boolean operators were used, considering the particularities of each database:

PubMed, EMBASE, CINAHL, SCOPUS, WEB OF SCIENCE: (“workloadORclassification”) AND (“Psychiatric NursingORMental Health Nursing”) AND (“nursesORnursing staffORstaff nursingORnursing staffsORnurse staffingORStaff NursesORnursing personnelORNursing, TeamORNursing TeamORTeam Nursing”).

LILACS: (“workload” OR “carga de trabajoOR “carga de trabalho” ORclassificationOR “classificação”) AND (“psychiatric nursingORenfermería psiquiátricaOR “enfermagem psiquiátrica”) AND (“Nursing StaffORPersonal de EnfermeríaOR “Recursos Humanos de Enfermagem”).

The eligibility criteria included articles with abstracts available in Portuguese, English and Spanish addressing the WL of psychiatry and mental health nursing teams. The comprehensive time frame, from January 2005 to March 2019 was chosen to try to understand how scientific production has been impacted by the reorganization of nursing work in the mental health area. Gray literature and new studies, after the end of the search period, were not included in the research.

III) Data evaluation

A total of 721 studies were found. The search results were imported to the review support platform, Rayyan, where duplications were resolved and 267 studies were excluded at this stage.

The articles were pre-selected based on reading titles and abstracts, and the final sample was reached based on reading the articles in full, which was done by two researchers, independently. Of the remaining 454 studies, 39 were selected. After reading the selected articles in full, 23 articles were included in the review. The search strategies used in the respective databases and the reasons for exclusion are shown in Figure 1.

Figure 1
Flowchart used to select the studies - PRISMA(12)

IV) Data analysis

The studies were analyzed individually, and data were extracted using an instrument that covered year, country, type of study, situation, approach, results and conclusion, and subsequently categorized according to the dimension of the WL addressed. The five dimensions considered in this study were adapted from the seven previously described88 Carayon P, Alvarado CJ. Workload and Patient Safety Among Critical Care Nurses. Crit Care Nurs Clin N Am. 2007;19(1):121-9. doi:10.1016/j.ccell.2007.02.001
https://doi.org/10.1016/j.ccell.2007.02....
so that variability of WL was incorporated into the quantitative dimension and time pressure into the cognitive dimension.

RESULTS

Twenty-three original articles which met the inclusion criteria were selected. The synthesis of the scientific production evaluated is organized in charts (Chart 1, Chart 2 and Chart 3) in ascending order of the year of publication.

Chart 1
Distribution of articles selected for integrative review between 2005 and 2009 (n=7)
Chart 2
Distribution of articles selected for integrative review between 2009 and 2013 (n=9)
Chart 3
Distribution of articles selected for integrative review between 2014 and 2018 (n=7)

In the period from 2005 to 2010, ten studies were found, and in the period from 2011 to 2018, 13, with higher frequencies in the years 2008, 2009 and 2012 (three studies/year). The studies were carried out in several countries, such as Brazil (n = 5), United Kingdom (n = 4), Australia (n = 3), Japan (n = 2) and China (n = 2). Belgium, Spain, Jordan, Ireland, Greece, Sweden and the United States each contributed only one study. The studies were published in Brazilian and international nursing journals addressing generic subjects (n = 9), in psychiatric nursing and mental health journals (n = 10), in multiprofessional journals specialized in mental health (n = 2) and in multiprofessional journals with general themes (n = 2).

The articles were also evaluated regarding the situations in which the research was carried out, the most frequent being psychiatric hospitals (n = 11), followed by psychiatric units in general hospitals (n = 8), community mental health services (n = 4) and private psychiatric clinic (n = 1). The use of more than one situation in the same study stands out.

The quantitative dimension of WL was addressed in 12 articles and included: assessing patient care needs1313 Ridley C. Relating nursing workload to quality of care in child and adolescent mental health inpatient services. Int J Health Care Qual Assur. 2007;20(5):429-40. doi: 10.1108/09526860710763343
https://doi.org/10.1108/0952686071076334...

14 Oliveira RS, Laus AM. Characterization of patients in psychiatric hospitalization units according to the degree of dependence on nursing care. Rev Esc Enferm USP. 2011;45(5):1164-70. doi: 10.1590/S0080-62342011000500019
https://doi.org/10.1590/S0080-6234201100...
-1515 Mukai HA, Jericó MC, Perroca MG. Care needs and workload required by institutionalised psychiatric patients. Rev Latino-Am Enfermagem. 2013;21(1):340-7. doi: 10.1590/S0104-11692013000100008
https://doi.org/10.1590/S0104-1169201300...
; identification of activities performed by the team 1616 Bee PE, Richards DA, Loftus SJ, Baker JA, Bailey L, Lovell K, et al. Mapping nursing activity in acute inpatient mental healthcare settings. J Ment Health. 2006;15(2):217-26. doi: 10.1080/09638230600608941
https://doi.org/10.1080/0963823060060894...

17 Gerolamo AM. An exploratory analysis of the relationship between psychiatric nurses' perceptions of workload and unit activity. Arch Psychiatr Nurs. 2009;23(3): 243-250. doi: 10.1016/j.apnu.2008.06.005
https://doi.org/10.1016/j.apnu.2008.06.0...
-1818 Heslop B, Wynaden D, Tohotoa J, Heslop K. Mental health nurses' contributions to Community mental health care: an Australian study. Int J Ment Health Nurs. 2016;25:426-33. doi: 10.1111/inm.12225
https://doi.org/10.1111/inm.12225...
, measuring time spent1616 Bee PE, Richards DA, Loftus SJ, Baker JA, Bailey L, Lovell K, et al. Mapping nursing activity in acute inpatient mental healthcare settings. J Ment Health. 2006;15(2):217-26. doi: 10.1080/09638230600608941
https://doi.org/10.1080/0963823060060894...
,1818 Heslop B, Wynaden D, Tohotoa J, Heslop K. Mental health nurses' contributions to Community mental health care: an Australian study. Int J Ment Health Nurs. 2016;25:426-33. doi: 10.1111/inm.12225
https://doi.org/10.1111/inm.12225...
-1919 Furaker C. Nurses' everyday activities in hospital care. J Nurs Manag. 2009;17:269-277. doi: 10.1111/j.1365-2934.2007.00832.x.
https://doi.org/10.1111/j.1365-2934.2007...
, measuring care hours and WL1515 Mukai HA, Jericó MC, Perroca MG. Care needs and workload required by institutionalised psychiatric patients. Rev Latino-Am Enfermagem. 2013;21(1):340-7. doi: 10.1590/S0104-11692013000100008
https://doi.org/10.1590/S0104-1169201300...
; development2020 Willis E, Henderson J, Toffoli L, Walter B. Calculating nurse staffing in community mental health and community health settings in South Australia. Nurs Forum. 2012;47(1):52-64. doi: 10.1111/j.1744-6198.2011.00251.x
https://doi.org/10.1111/j.1744-6198.2011...
test, application2121 Iglesias C, Villa MJA, 2005. A system of patient classification in long-term sychiatric inpatients: Resource Utilization Groups T-18 (RUG T-18). J Psychiatr Ment Health Nurs. 2005;12:33-7. doi: 10.1111/j.1365-2850.2004.00789.x
https://doi.org/10.1111/j.1365-2850.2004...
-2222 Fanneran T, Brimblecombe N, Bradley E, Gregory S. Using workload measurement tools in diverse care contexts: the experience of staff in mental health and learning disability inpatient settings J Psychiatr Men Health Nurs. 2015;22:764-72. doi: 10.1111/jpm.12263
https://doi.org/10.1111/jpm.12263...
and validation of instrument for measuring WL2323 Martins PASF, Arantes EC, Forcella HT. [Patient classification system in psychiatric nursing: clinical validation]. Rev Esc Enferm USP. 2008;42(2):233-41. doi: 10.1590/S0080-62342008000200004. Portuguese
https://doi.org/10.1590/S0080-6234200800...
; and identification of factors contributing to WL2424 Henderson J, Willis E, Walter B, Toffoli L. Community mental health nursing: Keeping pace with care delivery? Int J Ment Health Nurs. 2008;17:162-70. doi: 10.1111/j.1447-0349.2008.00528.x
https://doi.org/10.1111/j.1447-0349.2008...
.

Another dimension found, the emotional, included 11 articles the focus of which was on: identifying stressors in the workplace and coping strategies2525 Carvalho MB, Felli VEA. [Psychiatric nursing work and workers' health problems]. Rev Latino-Am Enfermagem. 2006;14(1):61-69. doi: 10.1590/S0104-11692006000100009. Portuguese
https://doi.org/10.1590/S0104-1169200600...

26 Cai ZX, Li K, Zhang XC. Workplace stressors and coping strategies among Chinese psychiatric nurses. Perspect Psychiatr Care. 2008;44(4):223-31. doi: 10.1111/j.1744-6163.2008.00181.x
https://doi.org/10.1111/j.1744-6163.2008...

27 Currid T. Experiences of stress among nurses in acute mental health settings. Nurs Stand. 2009;23(44):40-6. doi: 10.7748/ns2009.07.23.44.40.c7108
https://doi.org/10.7748/ns2009.07.23.44....

28 Yada H, Abe H, Lu X, Wakizaki Y, Omori H, Matsuo H, et al. Job-related stress in psychiatric nurses in Japan caring for elderly patients with dementia. Environ Health Prev Med. 2014;19:436-43. doi: 10.1007/s12199-014-0414-6
https://doi.org/10.1007/s12199-014-0414-...
-2929 McTiernan K, McDonald N. Occupational stressors, burnout and coping strategies between hospital and community psychiatric nurses in a Dublin region. J Psychiatr Ment Health Nurs. 2015;22:208-18. doi: 10.1111/jpm.12170
https://doi.org/10.1111/jpm.12170...
; work environment and psychosocial risks: exhaustion3030 Leka S, Hassard J, Yanagida A. Investigating the impact of psychosocial risks and occupational stress on psychiatric hospital nurses'mental well-being in Japan. J Psychiatr Ment Health Nurs. 2012;19:123-13. doi: 10.1111/j.1365-2850.2011.01764.x
https://doi.org/10.1111/j.1365-2850.2011...
; social support and quality of life3131 Hamaideh SH. Occupational stress, social support, and quality of life among Jordanian Mental Health Nurses. Issues Ment Health Nurs. 2012;33:15-23. doi: 10.3109/01612840.2011.605211
https://doi.org/10.3109/01612840.2011.60...
; WL and quality of care3232 Van Bogaert P, Clarke S, Willems R, Mondelaers M. Nurse practice environment, workload, burnout, job outcomes, and quality of care in psychiatric hospitals: a structural equation model approach. J Adv Nurs. 2013;69(7):1515-24. doi: 10.1111/jan.12010
https://doi.org/10.1111/jan.12010...
; work overload3333 Alves SR, Santos RP, Gimenes RMT, Yamaguchi MU. Nursing workload in mental health. Rev Rene. 2016;17(5):684-90. doi: 10.15253/2175-6783.2016000500014
https://doi.org/10.15253/2175-6783.20160...
; conflict and satisfaction3434 Konstantinoua AK, Bonotisa K, Sokratousb M, Siokasb V, Dardiotis E. Burnout evaluation and potential predictors in a greek cohort of mental health nurses. Arch Psychiatr Nurs. 2018;32(3):449-56. doi: 10.1016/j.apnu.2018.01.002
https://doi.org/10.1016/j.apnu.2018.01.0...
; and violence at work3535 Yang BX, Stone TE, Petrini MA, Morris DL. Incidence, type, related factors, and effect of workplace violence on mental health nurses: a cross-sectional survey. Arch Psychiatr Nurs. 2018;32(1)31-8. doi: 10.1016/j.apnu.2017.09.013
https://doi.org/10.1016/j.apnu.2017.09.0...
.

DISCUSSION

Brazilian and international scientific production on WL in psychiatry and mental health nursing was distributed across four continents, most from Europe, with emphasis on the United Kingdom. Brazil led with the largest number of studies, being the only country in South America, to contribute to the topic in the period under investigation.

It was observed that community mental health services are not yet the main situations for such research, possibly due to the history of the hospital environment as a consolidated model of health care 3636 Santos TBS, Pinto ICM. National Policy for Hospital Care: con(di)vergences among the Federal Executive's rules, Conferences and strategies. Saúde Debate. 2017;41(spe3):99-113. doi: 10.1590/0103-11042017s308
https://doi.org/10.1590/0103-11042017s30...
. Therefore, it is natural that research on management, organization and conditions of nursing work is more frequent with inpatients. It is believed, however, that studies should follow the trend in funding for mental health, prioritizing the community area, and focusing on strategies for improving management and quality of care for these services3737 Trapé TL, Campos RO. The mental health care model in Brazil: analyses of the funding, governance processes, and mechanisms of assessment. Rev Saúde Pública. 2017;51:19. doi: 10.1590/s1518-8787.2017051006059
https://doi.org/10.1590/s1518-8787.20170...
.

Most of the studies identified were focused on psychiatric care for adult patients, with little progress being seen when it comes to WL and child and adolescent psychiatry, which requires differentiated care planning from the nursing team, always aiming to expand and articulate the care network3838 Maia MPM, Valença CN, Sobreira MVS. Conceptions concerning mental health held by professional working within the Family Health Strategy. Rede Cuid Saúde. 2017;11(1):1-22. doi: 10.1590/S1983-14472013000100010
https://doi.org/10.1590/S1983-1447201300...
-3939 Pachêco MVGM, Campos CNA, Barbosa LNF, Alves JS, Fernandes JR. [Characterization and epidemiological profile of a child psychiatry service in Recife]. Rev SBPH [Internet]. 2017[cited 2019 Jul 17];20(2):136-52. Available from: http://pepsic.bvsalud.org/pdf/rsbph/v20n2/v20n2a09.pdf Portuguese
http://pepsic.bvsalud.org/pdf/rsbph/v20n...
. To this end, child psychiatric care in Brazil has been advancing since 2002, with the creation of mental health services known as Child and Youth Psychosocial Care Centers (CAPSi)4040 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde Mental: Cadernos de Atenção Básica, 34 [Internet]. Brasília: Ministério da Saúde; 2013[cited 2019 Jul 17]. 176p. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/cadernos_atencao_basica_34_saude_mental.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
. However, at the national level, studies on WL with this clientele were not identified either.

Regarding the approaches, they were evenly balanced between the quantitative (identification and measurement of WL) and emotional (impact of work on the worker’s mental health) dimensions, with fluctuations over the years.

The time frame was divided into three phases, of five years each, enabling us to see how the researchers’ view shifted from a predominantly quantitative approach (phase 1 - construction and development of measurement instruments), to the beginning of an approach with the emotional dimension (phase 2 - occupational stressors), culminating in greater emphasis on the latter (phase 3 - satisfaction and coping strategies).

In the quantitative dimension, the results showed concern with finding strategies to improve the adaptation of personnel in psychiatric and mental health nursing. Investigations addressing the identification of activities carried out and the measurement of time spent by the team, as well as the development, testing, application and validation of an instrument for measuring WL, were concentrated in the United Kingdom, Brazil and Australia.

Although the development of such instruments, especially those for classifying patients (PCI), began in the 1960s in the United States, it was only after the 1990s that they were developed in Brazil4141 Abreu SP, Pompeo DA, Perroca MG. Use of patients' classification instruments: analysis of the Brazilian production of knowledge. Rev Esc Enferm USP. 2014;48(6):1111-8. doi: 10.1590/S0080-623420140000700020
https://doi.org/10.1590/S0080-6234201400...
. Nevertheless, they were intended for clinical areas other than psychiatric nursing, and, thus, they placed more emphasis on somatic characteristics, with little sensitivity to changes in patients’ psychopathological conditions2121 Iglesias C, Villa MJA, 2005. A system of patient classification in long-term sychiatric inpatients: Resource Utilization Groups T-18 (RUG T-18). J Psychiatr Ment Health Nurs. 2005;12:33-7. doi: 10.1111/j.1365-2850.2004.00789.x
https://doi.org/10.1111/j.1365-2850.2004...
,2323 Martins PASF, Arantes EC, Forcella HT. [Patient classification system in psychiatric nursing: clinical validation]. Rev Esc Enferm USP. 2008;42(2):233-41. doi: 10.1590/S0080-62342008000200004. Portuguese
https://doi.org/10.1590/S0080-6234200800...
. As psychiatry and mental health has been consolidating itself and changes in public policies are recent, instruments for measuring WL in this area were developed later, in the 1980s, in the United States 4242 Schroder PJ, Washington WP. Administrative decision making: staff-patient ratios (a patient classification system for a psychiatric setting). Perspect Psychiatr Care. 1982;20(3):111-23. doi: 10.1111/j.1744-6163.1982.tb00160.x
https://doi.org/10.1111/j.1744-6163.1982...
, and in 2006, in Brazil2323 Martins PASF, Arantes EC, Forcella HT. [Patient classification system in psychiatric nursing: clinical validation]. Rev Esc Enferm USP. 2008;42(2):233-41. doi: 10.1590/S0080-62342008000200004. Portuguese
https://doi.org/10.1590/S0080-6234200800...
. These studies were a major advance for psychiatric nursing, which until then was based on instruments from other clinical areas.

However, knowledge gaps remain regarding possible obstacles to the use of measurement instruments, since few productions have been identified regarding their use. More than ten years after publication of the Instrument for Classification of the Level of Dependence for Psychiatric Nursing developed in Brazil 2323 Martins PASF, Arantes EC, Forcella HT. [Patient classification system in psychiatric nursing: clinical validation]. Rev Esc Enferm USP. 2008;42(2):233-41. doi: 10.1590/S0080-62342008000200004. Portuguese
https://doi.org/10.1590/S0080-6234200800...
, only two investigations reported its application in the practice setting. The first1414 Oliveira RS, Laus AM. Characterization of patients in psychiatric hospitalization units according to the degree of dependence on nursing care. Rev Esc Enferm USP. 2011;45(5):1164-70. doi: 10.1590/S0080-62342011000500019
https://doi.org/10.1590/S0080-6234201100...
, to identify the patients’ demand for nursing care and their care profile and the other 1515 Mukai HA, Jericó MC, Perroca MG. Care needs and workload required by institutionalised psychiatric patients. Rev Latino-Am Enfermagem. 2013;21(1):340-7. doi: 10.1590/S0104-11692013000100008
https://doi.org/10.1590/S0104-1169201300...
, focusing on care planning, measuring the hours of care and calculating the WL.

Article 4 of Brazilian Nursing Council (COFEN) Guidelines 543/20174343 Conselho Federal de Enfermagem. Resolução nº543 de 18 de abril de 2017. Atualiza e estabelece parâmetros para o dimensionamento do quadro de profissionais de enfermagem nos serviços/locais em que são realizadas atividades de enfermagem[Internet]. Brasília, 2017[cited 2019 Jul 17]. Available from: http://www.cofen.gov.br/resolucao-cofen-5432017_51440.html
http://www.cofen.gov.br/resolucao-cofen-...
, which updates and establishes parameters for nursing staff size, sets out considerations to assist psychiatric and mental health patients, contributing greatly to the specialty. It recommends using the Dependency Level Classification Instrument for Psychiatric Nursing2323 Martins PASF, Arantes EC, Forcella HT. [Patient classification system in psychiatric nursing: clinical validation]. Rev Esc Enferm USP. 2008;42(2):233-41. doi: 10.1590/S0080-62342008000200004. Portuguese
https://doi.org/10.1590/S0080-6234200800...
for mental health services operating 24 hours a day, including Psychiatric Intensive Care Units, psychiatric emergency services, psychiatric wards and Psychosocial Care Centers III ( CAPS III). Thus, nurses and managers in this area are supported in the practice situation. Understanding the benefits of using this instrument frequently will enable progress to be made in investigations into nursing care demands from psychiatric patients and measuring WL, with a view to adjusting the number of staff in the units and services.

In the dimension of emotional WL, it was found that the researchers’ sought to identify and assess occupational stressors in nursing teams, such as pressure from managers in the work environment, lack of resources, dealing with death, aggressive patient behavior and high WLs in particular.

The nurse-patient relationship is the main focus in psychiatric and mental health nursing, and skills, such as empathy, active listening, non-judgment and emotional support, require engagement and demand physical and emotional availability from the professional4444 Delaney KR, Johnson ME. Metasynthesis of research on the role of psychiatric inpatient nurses: what is important to staff? J Am Psychiatr Nurses Assoc. 2014;20(2):125-37. doi: 10.1177/1078390314527551
https://doi.org/10.1177/1078390314527551...
-4545 Junqueira M, Andrade LF. Cuidados de enfermagem em pacientes com transtornos mentais inseridos nos Centros de Atendimentos Psicossociais (CAPS). RBCV [Internet]. 2017 [cited 2019 Aug 03];(supl l), 5(2) 1-24. Available from: http://jornal.faculdadecienciasdavida.com.br/index.php/RBCV/article/view/539
http://jornal.faculdadecienciasdavida.co...
. The findings included difficulty in handling the patient among the team’s occupational stressors2929 McTiernan K, McDonald N. Occupational stressors, burnout and coping strategies between hospital and community psychiatric nurses in a Dublin region. J Psychiatr Ment Health Nurs. 2015;22:208-18. doi: 10.1111/jpm.12170
https://doi.org/10.1111/jpm.12170...
,3131 Hamaideh SH. Occupational stress, social support, and quality of life among Jordanian Mental Health Nurses. Issues Ment Health Nurs. 2012;33:15-23. doi: 10.3109/01612840.2011.605211
https://doi.org/10.3109/01612840.2011.60...
. Therefore, due to therapeutic relationship demands, training for these professionals should be prioritized, even when dealing with more subjective practices compared to procedures in other specialties.

As the main coping strategies, professionals used avoidance and seeking support from co-workers. The former can compromise the treatment of the patient, as the professional will not always be able to interact in the appropriate, therapeutic way required by the job 4444 Delaney KR, Johnson ME. Metasynthesis of research on the role of psychiatric inpatient nurses: what is important to staff? J Am Psychiatr Nurses Assoc. 2014;20(2):125-37. doi: 10.1177/1078390314527551
https://doi.org/10.1177/1078390314527551...
. The latter contrasts with another result found, namely that many nursing professionals did not feel supported at work, which may infer that some seek help, but do not necessarily feel supported in this environment. Some alarming data, also among the coping strategies, was the use of mechanical restraint3535 Yang BX, Stone TE, Petrini MA, Morris DL. Incidence, type, related factors, and effect of workplace violence on mental health nurses: a cross-sectional survey. Arch Psychiatr Nurs. 2018;32(1)31-8. doi: 10.1016/j.apnu.2017.09.013
https://doi.org/10.1016/j.apnu.2017.09.0...
. This is a coercive technique, used in specific situations, after other therapeutic approaches fail. The decision to use it is taken jointly by the multiprofessional team, it is not used indiscriminately4646 Del-Ben C, Sponholz-Jr A, Mantovani C, Faleiros MC, Oliveira G, Guapo V, Marques JM. [Psychiatric emergencies: psychomotor agitation management and suicide risk assessment]. Medicina [Internet]. 2017 [cited 17 Jul 2019];50(supl1):98-12. Available from: http://www.revistas.usp.br/rmrp/article/view/127543. Portuguese
http://www.revistas.usp.br/rmrp/article/...
. Therefore, it is an inappropriate coping strategy that goes against the ethical conduct of this health professional. It can be inferred from the findings of the review that training is needed and forms of support must be established.

The nursing team’s mental health, including psychiatry, was studied because it is directly associated with the quality of care4747 Fernandes MA, Soares LMD, Silva JS. Work-related mental disorders among nursing professionals: a Brazilian integrative review. Rev Bras Med Trab. 2018;16(2):218-24. doi:10.5327/Z1679443520180228
https://doi.org/10.5327/Z167944352018022...
, which was detected in the review, showing that the occupational stressors identified were associated with high emotional exhaustion and feeling of psychological overload2525 Carvalho MB, Felli VEA. [Psychiatric nursing work and workers' health problems]. Rev Latino-Am Enfermagem. 2006;14(1):61-69. doi: 10.1590/S0104-11692006000100009. Portuguese
https://doi.org/10.1590/S0104-1169200600...
,2929 McTiernan K, McDonald N. Occupational stressors, burnout and coping strategies between hospital and community psychiatric nurses in a Dublin region. J Psychiatr Ment Health Nurs. 2015;22:208-18. doi: 10.1111/jpm.12170
https://doi.org/10.1111/jpm.12170...
-3030 Leka S, Hassard J, Yanagida A. Investigating the impact of psychosocial risks and occupational stress on psychiatric hospital nurses'mental well-being in Japan. J Psychiatr Ment Health Nurs. 2012;19:123-13. doi: 10.1111/j.1365-2850.2011.01764.x
https://doi.org/10.1111/j.1365-2850.2011...
, directly influencing the quality of care provided by the professional3232 Van Bogaert P, Clarke S, Willems R, Mondelaers M. Nurse practice environment, workload, burnout, job outcomes, and quality of care in psychiatric hospitals: a structural equation model approach. J Adv Nurs. 2013;69(7):1515-24. doi: 10.1111/jan.12010
https://doi.org/10.1111/jan.12010...
.

The other dimensions considered were not identified by the review. Studies were found addressing topics such as therapeutic relationship (cognitive), mechanical restraints (physical) and working conditions (qualitative), however they were not investigated from the perspective of WL, which generate information about the professional in this specialty. Investing in studies to expand this overview could contribute to the area of psychiatric nursing and mental health, taking into account the activities of this team already found in the literature as beneficial for patient treatment4545 Junqueira M, Andrade LF. Cuidados de enfermagem em pacientes com transtornos mentais inseridos nos Centros de Atendimentos Psicossociais (CAPS). RBCV [Internet]. 2017 [cited 2019 Aug 03];(supl l), 5(2) 1-24. Available from: http://jornal.faculdadecienciasdavida.com.br/index.php/RBCV/article/view/539
http://jornal.faculdadecienciasdavida.co...
.

Despite the distinction of the WL dimensions, they are permeated, that is to say, the characteristics of the patient are identified as factors contributing to the quantitative WL, and difficulties in dealing with patients are identified as occupational stressors. Also, for high WL (quantitative), there is a higher level of exhaustion in the professional (emotional). It is noted, therefore, that one dimension can influence the other. Thus, investing in improvements to one factor may entail benefits for other dimensions.

Limitations of the Study

The limitations involve not including indexing databases for university (dissertation and thesis) production or material not published in digital databases or in other languages.

Contributions to the Field of nursing, health or public policy

This is an international and Brazilian overview of approaches to WL in the context of psychiatric nursing and mental health. As it was the first study in this specialty, it enabled a greater understanding of the topic.

The synthesis of the scientific production identified areas of investigation that are as yet incipient. Among them, the low frequency of research on instruments for measuring WL in healthcare practice in the last 10 years stands out, and it is not possible to draw comprehensive conclusions regarding its applicability.

Moreover, the studies were predominantly in the hospital context. This must move to community mental health services, which represent the basis of the current psychiatric treatment model. Regarding the focus of care, the research focused on adult patients, not including children and adolescents. The cognitive (therapeutic relationship), physical (mechanical restraint) and qualitative (working conditions) dimensions were insufficiently addressed.

Labor factors and unhealthy coping strategies were highlighted, indicating the importance of directing health service policies toward establishing improvements for the team, positively influencing the quality of care by these professionals.

Thus, this review guides more in-depth investigations in order to reorganize work in the area of psychiatric and mental health nursing WL in a more substantiated way, reflected in improvements for the service, professionals and patients served.

CONCLUSION

Quantitative and emotional dimension approaches to the WL of psychiatric and mental health nursing teams were found in the scientific literature, with emphasis on Brazil in productions in both dimensions. The researchers’ concern was evidently in establishing strategies for measuring WL and assessing the impact of stressors, ways of coping and the psychosocial risks of the team in the work environment. However, scientific production was shown to be insufficient to meet professional needs.

Thus, we suggest greater articulation between researchers and nurses working in the care process and in care management to encourage more widespread use of existing instruments and advancement in increasingly reliable measurement strategies and, also, the emergence of other matters relevant to the situation of working in this specialty.

  • FUNDING
    This study was carried out with the support of the Coordination for the Improvement of Higher Education Personnel (CAPES), Financing Code 001.

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    Fernandes MA, Soares LMD, Silva JS. Work-related mental disorders among nursing professionals: a Brazilian integrative review. Rev Bras Med Trab. 2018;16(2):218-24. doi:10.5327/Z1679443520180228
    » https://doi.org/10.5327/Z1679443520180228

Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho
ASSOCIATE EDITOR: Hugo Fernandes

Publication Dates

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

History

  • Received
    13 Nov 2019
  • Accepted
    23 Apr 2020
Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br