The history of Psychiatric Nursing education at the Universidade Federal de Alagoas (1976-1981)

La historia de la enseñanza de enfermería psiquiátrica en la Universidad Federal de Alagoas (1976-1981)

ABSTRACT

Objective:

To historically analyze psychiatric nursing teaching at the Universidade Federal de Alagoas from 1976 to 1981.

Methods:

Qualitative study; social-historical approach employing Thematic Oral History based on the documentary sources and testimonials from nurses, students, professors, and professionals at the psychiatric hospital where these practices occurred. The study researched World, Brazil, and Alagoas history and the Curricular Guidelines for Nursing for the history comprehension and used Erving Goffman’s concepts as a theoretical reference.

Results:

They revealed the structural conditions of the university in 1976, the American contribution to the teaching staff, the students’ psychological preparation in theoretical and practical classes, the precarious scenario of psychiatric care in Alagoas, and the care that minimizes stigmas through empathy and sensitive listening.

Conclusion:

With the emergence of that discipline, students and professors expanded their views on mental illness and emphasized their need for academic training based on reforming care principles.

Descriptors:
Nursing Education; Psychiatric Nursing; History; Undergraduate Nursing Programs; Psychiatric Hospitals

RESUMEN

Objetivo:

Analizar históricamente la enseñanza de enfermería psiquiátrica en la Universidad Federal de Alagoas de 1976-1981.

Métodos:

Estudio cualitativo; abordaje histórico-social con auxilio de Historia Oral Temática basada en fuentes documentales y deposición de enfermeros, discentes, docentes y profesionales del hospital psiquiátrico en que prácticas ocurrían. Para comprensión de la historia, utilizaron investigaciones sobre historia mundial, de Brasil, de Alagoas y Directrices Curriculares de Enfermería, además de conceptos de Erving Goffman como referencial teórico.

Resultados:

Revelaron condiciones estructurales de la universidad en 1976, contribución estadunidense al cuerpo docente de la disciplina, preparación psicológica de estudiantes en clases teórico-prácticas, escenario precario de la asistencia psiquiátrica en Alagoas y el cuidado reductor de estigmas mediante la empatía y escucha sensible.

Conclusión:

Con el surgimiento de la disciplina, estudiantes y profesores ampliaron miradas acerca de enfermedad mental y evidenciaron la necesidad de mantener una formación académica pautada en principios reformadores de la asistencia.

Descriptores:
Enseñanza de Enfermería; Enfermería Psiquiátrica; Historia; Programas de Grado en Enfermería; Hospitales Psiquiátricos

RESUMO

Objetivo:

Analisar historicamente o ensino de enfermagem psiquiátrica da Universidade Federal de Alagoas de 1976-1981.

Métodos:

Estudo qualitativo; abordagem histórico-social com o auxílio da História Oral Temática com base em fontes documentais e depoimento de enfermeiros, discentes, docentes e profissionais do hospital psiquiátrico em que práticas ocorriam. Para a compreensão da história, utilizaram-se pesquisas sobre história mundial, do Brasil, de Alagoas e Diretrizes Curriculares da Enfermagem, além dos conceitos de Erving Goffman como referencial teórico.

Resultados:

Revelaram-se as condições estruturais da universidade em 1976, a contribuição estadunidense no corpo docente da disciplina, a preparação psicológica das estudantes nas aulas teórico-práticas, o cenário precário da assistência psiquiátrica em Alagoas e o cuidado minimizador de estigmas mediante a empatia e escuta sensível.

Conclusão:

Com o surgimento da disciplina, estudantes e professores ampliaram olhares sobre o adoecimento mental e evidenciaram a necessidade de manter uma formação acadêmica pautada em princípios reformadores da assistência.

Descritores:
Ensino de Enfermagem; Enfermagem Psiquiátrica; História; Programas de Graduação em Enfermagem; Hospitais Psiquiátricos

INTRODUCTION

The in-depth understanding of reality is possible through political, historical, and social analysis of the phenomena. Studying the history of nursing and its intersection with the field of mental health contributes to the construction of health education focused on humanized care practices based on principles and guidelines conquered by the Brazilian Psychiatric Reform.

From this perspective, a subject such as the history of Psychiatric Nursing teaching at the Universidade Federal de Alagoas (UFAL), from 1976 to 1981, is fundamental for the preservation of the memory of mental health care, which, in the feature of this study, was characterized by loss of patients’ identity, mistreatment and negligence in asylums services of moral treatment, surveillance and social reclusion^(1-6).

In 1973, after the stay of the American school-hospital ship HOPE in Maceió, UFAL created the first undergraduate course in Nursing, which began in 1974, whose scenario at the time was of moral, political, and economic repression, with alarming social indicators and little investment in health, education, and housing^(7-11). To start this course’s activities, UFAL composed the first faculty by public examination, hiring nurses Lenir Nunes da Silva Oliveira and Vera Lúcia Ferreira da Rocha. In 1975, it expande the staff with five more nurses: Zandra Maria Cardoso Candiotti, Maria Cristina Soares Figueiredo Trezza, Regina Maria dos Santos, Francisca Lígia Sobral Leite and Maria Violeta Dantas⁽¹¹⁾.

The 1970s were marked by social movements driven by health workers, user associations, professional councils, and universities, in favor of reform in Brazilian psychiatric care, in defense of a political and social process in the theoretical-conceptual, technical-assistance, legal-political, and sociocultural dimensions. Thirty years later, this movement resulted in Law 10.216/2001, referring to mental health care rights and directions by establishing significant political and social milestones in the national conjuncture^(2-4,12-14).

In this sense, the social phenomenon under study happened amid contradictions revealed in the complaints of ill-treatment and precariousness of psychiatric care. Therefore, understanding how this occurred in universities, which, in the 1970s, followed an anti-mental institution discourse but with internship practices in mental institutions, brings to light many ideological, political, and welfare conflicts that deserve to be historically investigated and understood.

This contradiction permeated nursing teaching in Brazilian universities, and it was no different in Alagoas. With the military coup of 1964, the policy of privatization of assistance in the system of beds maintaining an agreement with Social Security provided the expansion of these beds, including psychiatric beds in private hospitals, to facilitate patient admission. The aim was to profit from the sickness and not necessarily the well-being of people.

In Maceió, capital of Alagoas, properties that once belonged to wealthy families were transformed into private psychiatric clinics such as Casa de Saúde Miguel Couto, founded in 1947/48; Hospital Psiquiátrico José Lopes de Mendonça, in 1961; and Hospital e Casa de Repouso Ulisses Guimarães, in 1968. There was only the Hospital Colônia Portugal Ramalho in the public sector, created in 1956. All of them had overcrowded wards and insufficient professionals⁽¹⁵⁾. Two of them, the public and one private, were scenarios of the internship practices of the discipline of Psychiatric Nursing of UFAL.

This discipline was implemented three years after the beginning of the undergraduate nursing course, still conceived in the hospital-centered psychiatric model. In the beginning, it had three actual professors: Violeta Dantas, from Paraiba, graduated from the Nossa Senhora das Graças Nursing School in Recife; Vera Rocha, from Alagoas, graduated from the Nursing course at the Federal University of Pernambuco; and June Sessil Barreras, from the United States, Vera Rocha’s counterpart in Project HOPE, who stayed on land for five years after the HOPE ship departed^(9-11).

Given the above, one can imagine the size of the challenges faced by faculty and students in undergraduate nursing education, especially in mental health care. Thus, it is relevant to analyze this context to keep alive in nursing education the challenges faced in the teaching-learning process that occurred in the 1970s so that the mental health care settings are ratifying spaces of the Brazilian Psychiatric Reform process.

OBJECTIVE

To analyze the teaching of psychiatric nursing historically at UFAL, from 1976 to 1981.

METHOD

Ethical aspects

The research’s ethical aspects were considered in compliance with the Resolutions CNS 466/2012 and 510/2016 and appreciated and approved by the Comitê de Ética em Pesquisa (CEP) (Research Ethics Committee) of UFAL. All participants signed the Termo de Consentimento Livre e Esclarecido (TCLE) (Free and Informed Consent Form) and the granting of the interview to the database of the Grupo de Estudo D. Isabel Macintyre (GEDIM) of EENF/UFAL, of which the study is part. Personal names were kept in the statements, as authorized, and required by the interviewee to preserve the principle of the subject’s autonomy who built his/her history and experienced the facts under analysis, taking his/her place in social history.

Theoretical framework

The theoretical framework that helped analyze and interpret the data was the theory of Erving Goffman through his concepts of “stigma,” “mortification of the self,” “social identity,” and “personal identity.” Also consulted studies on the World, Brazilian, and Alagoas history in the field of psychiatry; and CFE Opinion 163/1972, which established the minimum curriculum for undergraduate nursing and guided the demand of the discipline of Psychiatric Nursing.

Type of study and scenario

This study is qualitative⁽¹⁶⁾ with a historical-social approach. The temporal cut starts in 1976, when the discipline of Psychiatric Nursing was offered for the first time in the undergraduate course in Nursing at UFAL, and ends in 1981 when changes in the faculty, activities, and scenarios of practical classes were evident. The documental corpus was composed of the first curricular structures of the Nursing course, and the documents originated from the transcription of the interviews guided by a semi-structured script.

Methodological procedures

As inclusion criteria for the interviews, the study participants were professors and students of Psychiatric Nursing at UFAL between 1976 and 1981, as well as professionals who worked at the Hospital Colônia Portugal Ramalho at the time, one of the practice scenarios. The study did not include students who did not complete the discipline offered at that time or substitute professors.

Collection and organization of data

The study used the method of Oral History to collect the testimonies. The participants’ selection was based on the list of undergraduates of the first nursing class at UFAL and their professors. Researchers contacted people by telephone to explain the research and schedule a possible interview at a place chosen by the participants. Each interviewee indicated other potential contributors to the study. So, they conducted seven interviews of approximately one hour and 30 minutes, four of which were with students, two with nursing professionals (nursing attendants and assistants) of the Hospital Escola Portugal Ramalho (HEPR), previously known as Hospital Colônia Portugal Ramalho, and one with a professor.

After interviews, researchers carried out transcriptions and textualizations of the statements, as well as the choices of main oral excerpts responding to this study’s objectives. They were read thoroughly to organize the narratives in chronological time and themes, making it possible to describe the complete process with as much detail as possible. Transcriptions were organized by color, according to each theme referring to each excerpt of the report. The speeches were subsequently triangulated with the historical context, social structures, and the symbolic universe of the discourse, following a logically and didactically order of importance of the facts.

RESULTS

The discipline of Psychiatric Nursing was offered for the first time in 1976. Graça (student of the first class) and Violeta (professor since 1975 at UFAL) give some data on the university’s structural conditions for the classes of the newly created course:

The course took place in 1976; the theoretical classes were held in the shed owned by Petrobrás because we had no place at the Federal University of Alagoas [UFAL]. It was too hot. We stayed under the mango trees. (Graça)

I entered UFAL in 1975. We didn’t even have a laboratory. We used the nursing auxiliary school laboratory, which was very neat and tidy. (Violeta)

The first class, composed of nine students, was taught by professors of the discipline of Psychiatric Nursing, June Barreras and Vera Rocha, as Graça tells us:

We were nine students, and the professors, June Barreras and Vera Rocha. (Graça)

Later, Violeta, who started teaching the subject Introduction to Nursing, was invited by June to take on the subject of Psychiatric Nursing, as she describes:

We started the course without knowing how to teach; without a curriculum, it was complicated. I began with Introduction to Nursing - that was the subject’s name. In 1977, I suffered many losses, family issues. I went on leave, and when I came back, nurse June Barreras, from HOPE, thought I should go to psychiatry, and I was so fragile due to the losses in my life that I agreed... June thought I had the capacity, and so I went. (Violeta)

June Barreras, an American nurse, came to Brazil as Vera Rocha’s counterpart in Project HOPE on land. June had some difficulties with the Portuguese language, which made Vera more active in the dynamics of the discipline:

Both professors were present in the classroom, but Vera was the Brazilian one and was in charge of the discipline. From time to time, June Barreras would complement the classes the way she could. Vera understood her best. We, students, had a hard time with June due to this language issue inside the classroom. (Graça)

June didn’t speak Portuguese and we didn’t speak English. (Violeta)

Despite the communication difficulties, June was of great importance in establishing humanized principles for the discipline and her professional colleagues. Violeta graduated from a traditional nursing school, and in the practical teaching of psychiatric care was taught the biomedical model of “moral” and inhuman treatment, as she reports:

For a long time, [June] worked there [in the USA] with psychiatry. It was fundamental for us not to reproduce that nasty treatment. June contributed to every modification. I studied in Recife, in that traditional school; it was all inhumane. We were almost educated to be afraid, to treat [patients] with distance. (Violeta)

June’s teachings considered the integrality of the discipline, according to Violeta:

June taught us not to look too much at the patient’s chart, not get stuck on the diagnosis, but to work on the behaviors. Is the patient aggressive? It doesn’t matter if he is schizophrenic, bipolar. What matters is that he is aggressive, so let’s work on his aggressiveness. The patient is depressed. It doesn’t matter what the diagnosis is either because it can be wrong. I loved learning this from June. Another great lesson from June is treating the patient as someone normal and treating him without fear as much as possible. As I also learned from June, we have to respect the patient’s privacy who is so disturbed. All day long, we come in, turn on the light without asking permission. The patient can be masturbating, and nobody gives us the right to disturb them. He is in a hospital, deprived of sex, and has the right to masturbate. Another lesson: nurses used to blame the physician. When the patient asks when he will leave, if he is going to be discharged, the nurse replies that the physician is the one who knows. The correct answer would be, “You will leave when you get better.” It would not blame the physician and hold the patient accountable for their improvement. About delirium, another beautiful teaching: once the patient grabbed me, saying that the hospital was falling down and we would die. I learned from June...I let her calm down; I stood there with her and said: “Look, I know you’re seeing the hospital falling down, you’re hearing the noise, but I’m not, so that’s why I’m not going to do anything, but I’m going to stay with you until you calm down.” So, you respect the patient’s delirium, but you’re not going to play along. [...] We didn’t use white [in the practical classes] because they [patients] were afraid, they thought we were souls or authorities, so June prohibited white. At most, we wore lab coats. (Violeta)

The first curricular structure of the nursing course at UFAL was based on the one already existing at the Federal University of Pernambuco. There, one can observe a smaller workload for the discipline of Psychiatric Nursing compared to other disciplines, but it is not clear whether this workload is related to the existence of a shorter course or if this choice is related to the social stigma that the person with mental disorder “does not need” intensive care. In Chart 1, the image confirms this information.

Chart 1
First Curricular Structure adopted in the Nursing Course in 1974, Maceió, 2020

Period	Code	Denomination	Course load	Credits
74.1	EI - 0011107	1st Curricular Unit	270	18
	EI - 0020305	2nd Curricular Unit	120	08
	MAT - 003-5	Mathematics and Statistics	75	05
	ELF - 00110002	Physical Education - Gymnastics	30	02
74.2	EI - 0030814	3rd Curricular Unit	330	22
75.1	EI - 0070611	4th Curricular Unit	255	17
	ENF - 0010405	Introduction to Nursing	135	09
	ENF - 0110004	Supervised Internship I	60	04
75.2	ENF - 0020402	Medical-Surgical Nursing	90	06
	ENF - 0140004	Supervised Internship II	60	04
	ESO - 0010100	Study of Brazilian Problems I	15	01
	ESO - 0020100	Study of Brazilian Problems II	15	01
	ESO - 0010100	Sociology	45	03
	ESO - 0010100	Introduction to Psychology	60	04
	MSO - 0150200	Nutrition	30	02
	MSO - 0160200	Epidemiology	30	02
	MSO - 0170300	Sanitation and Community Health	45	03
76.1	ENF - 0060202	Psychiatric Nursing	60	04
	ENF - 0070202	Nursing in Communicable Diseases	60	04
	ENF - 0130304	Nursing in the Surgical Center	105	07
	ENF - 0160004	Supervised Internship IV	60	04
	ENF - 0170004	Supervised Internship V	60	04
	ENF - 0210004	Supervised Internship I	60	04
76.2	ENF - 0040402	Maternal and Child Nursing	90	06
	ENF - 0080400	Nursing Practice	60	04
	ENF - 0120302	Emergency Nursing	75	05
	ENF - 0150004	Supervised Internship III	60	04
	ENF - 0190004	Supervised Internship VIII	60	04
	ESO - 0990200	Psychology of Personality	30	02
77.1	ENF - 0030004	Supervised Internship	60	04
	ENF - 0050202	Pediatric Nursing	60	04
	ENF - 0090400	Applied Didactics	60	04
	ENF- 0100306	Administration Applied to Nursing	135	09
	ENF - 0200206	Nursing in Intensive Care Recovery Unit	120	08
Total			2880	192

SOURCE: Costa, 2012.

This first curricular structure was not implemented. A second structure more adequate to the Opinion Nº 163/1972 of the Conselho Federal de Educação (Federal Board of Education), which established the minimum curriculum for undergraduate Nursing courses, was in effect until the early 1980s. Then, the course was divided into two cycles (Chart 2): the first was taught, primarily by physicians in joint classes to Medicine, Nursing and Dentistry students, considered the basic cycle; and the second cycle was taught by the faculty of nurses existing in the course, who conducted the teaching-learning process of the specific disciplines of Nursing.

Chart 2
Second Curricular Structure adopted in the Universidade Federal de Alagoas Nursing Course in 1974, Maceió, 2020

1ST CYCLE (Basic)
MANDATORY DISCIPLINES		OPTIONAL DISCIPLINES
1st Curricular Unit Elements of Mathematics and Statistics 2nd Curricular Unit 3rd Curricular Unit Introduction to Psychology Sociology	4th Nursing Curricular Unit Study of Brazilian Problems I Study of Brazilian Problems II Sociology Introduction to Psychology Nutrition Epidemiology Sanitation and Community Health	Psychology of Personality General Chemistry Ecology
2ND CYCLE (Specific)
MANDATORY DISCIPLINES		OPTIONAL DISCIPLINES
Introduction to Nursing Medical-Surgical Nursing Maternal and Child Nursing Psychiatric Nursing Nursing in Communicable Diseases	Nursing Practice Didactics Applied to Nursing Administration Applied to Nursing Pediatric Nursing Supervised Internship I, II, II, IV, V,VI.	Intensive Care Nursing Emergency Nursing Surgical Center Nursing Supervised Internship VII, VIII, IX.

Source: Adapted from Costa, 2012.

In the Second Curricular Structure, discipline of the Psychiatric Nursing was offered in two large blocks, one theoretical and the other practical. The theoretical block happened in two moments:

The theoretical classes were [held] two afternoons before we went to practice. (Graça)

The theoretical classes were aimed at the students’ psychological preparation to help them face what they would experience during the practical classes, as well as for sensitization and humanization, preventing the reproduction of social stigmas. In this way, Vera worked on the students’ individual issues, in groups or privately, depending on their needs:

Vera worked on each student’s personal issue, so the whole class had a powerful bond with her. She knew about our lives. There were individual and collective moments. We went through a lot of sensitization before we got there [at the internship]. [Vera] tried to alleviate our fears, and we went along with all the support. The humanistic issue was decisive with her, full of love for the profession. (Graça)

During the practices, the student had direct contact with the intern. Subjects about the emotional conditions were discussed, and they talked, participated in recreation, but did not get involved in routine hospital activities, such as feeding and administering medications; there were meetings between professors and students to share the experiences of each day, intending to relieve anguish and afflictions and discuss the theory-practice relation:

We talked with them about their problems, feelings, experiences in the hospital...We had moments of leisure and recreation. We didn’t deal with hygiene, medication, or food. After the practice, we had a meeting to discuss the users’ behavior, our feelings, and we left feeling lighter. (Graça)

Each student would choose a patient to interact with therapeutically; however, this choice could occur the other way around:

Vera made us feel comfortable. She said we could choose the patient, but we could also be chosen: if a patient approached us wanting to talk and empathized, we could stay with him/her. (Graça)

In 1981, a few years after the first class’s experience, the teaching staff of the discipline was reconfigured, with the departure of Professors Vera and June and the permanence of Professor Violeta, along with the collaboration of substitute professor Suely. Professor Vera left the course to do her master’s degree in another state and, when she returned, she was invited to take on a position in the pro-rectory, requiring a reduction in her teaching load in the undergraduate course. As for Professor June, she returns to her homeland, the United States, after concluding Alagoas’s HOPE project. All this was reported by Graça and Zélia, also students who experienced the subject in 1981:

She [Vera] went to take positions in the pro-rectory and got a reduced workload [of the discipline]... Violeta came in. She traveled for her master’s degree, and when she came back, she was already invited for other positions. Then other professors came in. It was a pity that she left psychiatry; she went to a minor discipline: Integration to Nursing. (Graça)

If I’m not mistaken, it was in the 7th period [time of the discipline]. I’m sure it was in the 7th period, around the fourth year. At that time, our professors were Violeta and Suely: they shared the discipline. The most active was Violeta; Suely was also very important, but she only gave support. (Zélia)

In that same year, there were changes in the scenario of practices, which took place in Hospital Miguel Couto (private hospital) and moved on to Hospital Colônia Portugal Ramalho (public hospital), where interviews, recreation, therapeutic conversations, and other interventions took place, adding care not incorporated before.

Violeta gave us this idea of getting in touch with the patients, listening to their stories, and getting to know their family’s stories. What we did in the hospital, we discussed in class. We would connect what we heard from the patient with the story told during the home visit: that was the beauty of it. (Zélia)

In the internship, we provided hygienic care, bath time, haircuts... and a lot of recreation, dancing, and talking. We did a lot of case studies. They were so rejected that they didn’t even want to leave the hospital. The “hospitalism syndrome”. We showed them that life was outside the gate. (Violeta)

The reports show that there was already concern about social isolation, and, according to Lysete, a student in 1981, the forms of treatment given to the patients witnessed by the students caused discomfort and reflection:

We were prepared to go to the internship. Still, we couldn’t prepare ourselves enough because it [the reality of the hospital] was very shocking. No matter how well prepared we were, with the professors’ goodwill, all the theories clashed with the practical reality [...]. They [professors] came from HOPE teaching, and our reality was totally different from the American ones. (Lysete)

The guiding concepts of psychiatric nursing at UFAL were based on preventive psychiatry principles, an American reality not consistent with Alagoas’s reality. Thus, even though the professors’ effort to prepare the students emotionally for what they would experience in the practical classes, this attempt to alleviate the astonishment and fear did not have the desired effect. The reality presented in the Hospital Colônia Portugal Ramalho’s routine, today named Hospital Escola Portugal Ramalho (HEPR), was so undeveloped that it hindered the implementation of a humanized teaching practice by the students.

At the time, in HEPR, as reported by Mendes (janitor) and Manoel (nursing attendant), there was a minimal number of professionals and a shortage of materials for provision of care. Also, nursing was basically composed of attendants, who lacked technical and scientific knowledge for quality care, as reported by:

When I passed by the door [of the facility], I said, “Good morning, what is this injection for, and where do you apply it?” And the girl answered, “It’s glucose, and I apply it to the muscle.” I said, “Not in the muscle.” They didn’t know anything. They had no auxiliary nurse in there. They couldn’t read or write, but they gave injections. Nursing training started only in 1997. (Mendes)

At that time, there were no qualified personnel to work in psychiatry: most were nursing attendants or had the auxiliary course. (Manoel)

The result of this health care offered in a precarious and unqualified way caused fear and anguish in the students who worked there as interns:

Little by little, we were breaking the prejudice. Even though the course already had this characteristic of getting in touch with patients, fear still remained. Some nurses didn’t even want to finish the internship; if possible, they would pass without paying for the course. (Zélia)

To reduce feelings that prevented them from progressing in the practices, the professors extended therapeutic help to the students and held meetings at the end of the practice to work on their fears - a teaching method positively differentiated from the standard at that time. They invested in group processes for self-knowledge to break the negative stigma of the discipline:

Violeta already had a differential at that time. As students, we were already doing group work, group work, experiences, and each person shared their life story. It was not only about the illness. She already broke that paradigm of “caring for the crazy people.” It was a criticized method because it was not the experience we had. I remember that we made a group for students to open up: there was crying, and many people didn’t understand. (Zélia)

Also, the students had to understand the interns and their “obstacles.” To do so, they would need to learn to deal with these issues and respect their decisions. Some presented resistance to the students’ approach, as Violeta tells:

Some patients didn’t accept the students and warned that they didn’t want anyone. (Violeta)

With a different way of viewing people with mental illness and their desire for changes in the psychiatric field, Violeta sought to minimize social stigmas. They created a bond. A relationship of trust, in which the practice became positive and pleasant for the interns, students, and professors. Despite being assistance provided without a defined standard, they acted in the way that, consciously and intuitively, seemed to be best:

Our assistance, however intuitive, was therapeutic. We didn’t have anyone to follow. (Graça)

We already had a bond with them [patients]. They liked our presence... It was very touching. We were touched by their suffering. (Zélia)

I believed that the students were getting involved. [...] We always left [the internship] crying. The patients at the [Hospital] Portugal deserve our respect. (Violeta)

DISCUSSION

The discipline of Psychiatric Nursing was offered for the first time in 1976, a period characterized by struggles in search of conjuncture changes, where the popular force denounced inhumane situations and demanded structuring social policies and re-democratizing the country. In this military dictatorship context, the nursing course was created at UFAL. A moment of more outstanding indebtedness of the country, foreign capital investment in the economic-financial sector. That influenced the political reform, including the educational reform, whose purpose was to support the capital, supply the market demands, make some classes accumulate capital, and avoid Brazilian workers’ qualifications to enable science and technology development^(17-18).

Besides, the 1970s were marked by the most significant reduction in investments in public health and social assistance policies, resulting in alarming rates of health indicators, conditions ratified by the World Health Organization for expanding medical and nursing schools in the country^(7-11). The resources required for the structuring of university courses were minimal^(9-11), revealing difficulties in teaching classes in adopted or inadequate spaces, such as under trees or in sheds, mentioned by this study’s participants.

Moreover, foreign capital has influenced American culture’s importation in Brazilian education. After the Second World War, the United States intended to establish a hegemonic policy in Latin America of capitalism and “democratization” to facilitate market control with the free trade zone through investments in education and international agreements. The Assuntos InterAmericanos (IAIA-1942) (Institute for Inter-American Affairs) and the United States Agency for International Development (USAID-1968) influenced the creation of the Serviço Especial de Saúde Pública - SESP (Special Public Health Service), and the arrival of Project HOPE in Brazil^(7-9).

The cultural impact of Project HOPE on health education in Alagoas has been reported in several studies^(7,9-11). The influence happened by some American nurses’ stay for the opening of the nursing course at UFAL. One of the interviewees stated that a nurse from HOPE in the discipline brought their learnings to the first class of the nursing course’s training process.

As argued by Bourdieu, one can consider this form of imposition of “other” culture as the establishment of a symbolic power; understanding of a universal culture that selects and imposes an ethical and political type of conduct, which disregards other cultures and assumes them as inferior, thus dominating them, materializing the symbolic violence without at least being noticed⁽¹⁹⁾. The same situation occurs when the North American professor brings her knowledge and culture and makes it a model to be incorporated into the new scenario, even though it has generated positive results such as transforming the humanized look on the person with mental illness.

In 1963, in the United States, the decree by President John F. Kennedy called the Community Mental Health Center Act, established as a goal the reduction of psychiatric disease, promoting mental health, so that government departments emerged with strong influence on academic training based on preventive proposals opposing the private hospital model and social reclusion^(20-21). This new American mental health context was conveyed by nurse June in her thinking and acting, which guided the discipline of Psychiatric Nursing at UFAL.

June’s concern in students’ training under care principles was contrary to the stigmatizing and excluding asylum model. Stigma used to highlight depreciating attributes creates a social identity of discredit and repulsion by the society^(22-23), a view responsible for the devaluation of the care provided to the person with mental disorders. Goffman⁽⁵⁾ states that, in total institutions, such as psychiatric hospitals, the internment robs the person of their identity, and the author classifies this fact as “mortification of the self”; this occurs since the internment, with the confinement of personal belongings, haircut, removal of clothes, glasses, personal hygiene materials, imposition of rules that violate the identity and disregard the singularity of the subject. June sought to implement respect for the integrality and privacy of the patient.

Goffman⁽⁵⁾ states that the “mutilation of the self” in psychiatric hospitals reflects itself in the inpatient acute psychological stress. It results in feelings of fear, anger, and aversion; an attempt to adapt to the situation in they are forced to live or the employ of tactic of intransigence in which they challenge the institution and refuse to collaborate with the staff. That may explain the patients’ aggressive impulses toward the students or their refusal to approach them, causing fear.

Stigma does not consider the subject’s integrity, interferes in interpersonal coexistence, dictates rules, and distances people. Its non-reproduction and the attempt to demystify it were among the professors’ and students’ significant challenges. The reflection of not wearing white clothes led the students to rethink their positions while presenting themselves as equals. The social representation of “wearing white” is a symbol of power, and not wearing it brings up the feeling of being seen not only as a professional but also as a person closer to the patient. Social representations play a relevant role, guide the interpretation of phenomena and decision-making; that is, they can be valuable tools for future professionals’ reflection⁽²⁴⁾.

The initial preparation of the students in the theoretical moment was essential to reduce stigmas, especially when there were only psychiatric hospitals for treatment; it was essential to sensitize them about psychological suffering, develop skills to deal with their own emotions, feelings of anxiety, fear, insecurity, and helplessness when experiencing the current health system⁽²⁵⁾. Everyday situations described by the interviewees, who sometimes felt relieved, sometimes uncomfortable, made them reflect on their behaviors and achieve personal maturity.

Another fact that deserves analysis is the name given to the discipline, “Psychiatric Nursing,” which is entirely understandable within that context when psychiatric knowledge was intensely used, and the Brazilian Psychiatric Reform had not yet been consolidated. It is noteworthy that this denomination is still present in current curricular matrices, including in many educational institutions in Latin America, dating back to historical processes and the non-incorporation of new principles after the redirection of mental health care models⁽²⁵⁾.

In the national nursing curricular reformulation in 1962, there was more encouragement to theoretical than practical classes, and curative areas were privileged. On the other hand, in this same period, the preventive psychiatry movement influenced contents such as mental disorders, family therapy, therapeutic relationship, use of psychotropic drugs, and aspects of personality development⁽²⁶⁾. These contents already pointed to professors’ concerns in 1976 (such as home visits, family history, and emotional aspects of students), even in the unfavorable context of practices carried out in insane asylums.

The curriculum reformulation in 1972 gained emphasis on the quality of care in defense of the deinstitutionalization of the person with mental illness. Despite the ideological advances, the theory continued to prioritize the study of psychopathologies⁽²⁶⁾, and the practical teaching in Alagoas continued in psychiatric hospitals due to the inexistence of community and open mental health care services.

The workload allocated to the discipline initially was 60 hours, less than the current 40%. Despite being considered a mandatory part, this workload was lower than other practical disciplines characterized as natural sciences and historically valued. Currently, psychiatry’s workload is still reduced in many courses, especially in the private education system, ratifying the same capital accumulation system and cost reduction to the minimum offer of credits required by law, probably because it is a field historically overlooked and stigmatized by society⁽²⁵⁾.

The panorama of social stigmas impacts the valorization of the field, giving the teaching of psychiatric nursing less academic prestige when compared to the other disciplines of the curricular matrix, generating less interest from students and professors, and, as it turns out, fewer professionals working with mental health^(25,27). The minute quantity of professionals in the field impacts the psychiatric hospitals studied and reaffirms the lack of investment and commitment to psychiatry^(20-23). It was not necessary to invest in the health of people who, in the social imaginary, were seen as unworthy, dishonorable, of questionable reputation, errant, unpredictable, violent, and who, finally, had a deteriorated social identity^(22,27).

Hunger, insanity, and lack of hygiene marked the psychiatric institution’s routine. Essential supplies were restricted and of low quality; purchases were insufficient for the high number of patients and caused students a feeling of impotence⁽⁵⁾. Moreover, professionals were numerically reduced and unqualified. In Alagoas, few nurses worked in the hospitals, and nursing assistants and auxiliaries did most of the work^(8-11), which probably would not be different from what happened in the state’s psychiatric hospitals.

The dynamics of interventions aimed at listening to and valuing the stigmatized subject stimulated the rescue, even if momentary, of the suffering person’s identity. For Goffman⁽²²⁾, the stigmatized individual prefers to be among people who understand and share their reality, like Professor Violeta. The presence of professors and students who implemented a humanized and empathetic assistance generally resulted in recognition and gratitude, even though the social stigma and discredit that “madness” brings and the imposition of such devaluation who work with it obscured this recognition.

Finally, implementing the discipline of Psychiatric Nursing evidenced many cultural, political, social, and critical challenges. The desire for a more humanized care in a period characterized by prejudice, underestimation, and disrespect for the family and the person with a mental disorder has led to the development of bold ways for professors and students to overcome these barriers’ limitations.

Study limitations

In order to broaden the production of information, other documents were sought, such as the menu of the discipline of Psychiatric Nursing, course plan, agreements, among others, in the general archives of UFAL and HEPR, in the archives of the course coordination and the Secretaria do Conselho Universitário (Secretariat of the University Board). However, they were lost over the years. This problem is common in historical studies due to the non-preservation and destruction of documents.

Contributions to the field of Nursing

This research represents a starting point for continuing the story in subsequent studies, comparing past, present, and their factors like the studies about the insertion of the Psychiatric Reform in this context, the contribution of Nursing to the achievement of psychiatric advances, and the difficulties experienced in this process.

CONCLUSION

This research was about the history of psychiatric nursing teaching at UFAL, from 1976 to 1981. The documental corpus analysis exposed the fragilities of the hospital psychiatric care scenarios at that time. The discipline’s practical classes were held when psychiatry was marked by the inauguration of specialized hospitals and a dehumanized health care practice, following patterns of the biomedical model and social isolation.

In Alagoas, the internment conditions caused the “mutilation of the self” to the person with mental illness, and the working conditions were also dreadful. The few active nursing professionals were overloaded and provided deficient assistance in scientific knowledge, logistics, and the quantity of food and supplies for the patients to be minimally assisted.

The emergence of the discipline of Psychiatric Nursing marked the need to maintain an academic education based on reformed principles of care, with the immersion of content and discussions arising from global movements and demands that criticized traditional mental health care models. So, it is in this panorama that the professors, worried about the situation of abandonment and mistreatment of people in mental distress, conduct their classes beyond the teaching of technical skills, but in the direction of teaching self-knowledge and psychological preparation of students, in order to sensitize them to a more humanized and less stigmatizing practice, which was different from the one routinely offered by hospitals at the time.

The study reinforces the need to deepen the knowledge of the history of psychiatric nursing in Alagoas and Brazil to intensify the teaching methods based on the principles and guidelines of a mental health policy reformed through struggles and anti-mental health conquests. It is necessary to keep alive the memory of the people who suffered from the old hospital-centered care model, to ratify that the teaching of mental health in any field of knowledge should be based on respect for the subject autonomy, in the valuation of their rights and, finally, in the rescue of their citizenship.

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Edited by

EDITOR IN CHIEF: Dulce Barbosa

ASSOCIATE EDITOR: Antonio José de Almeida Filho

Publication Dates

• Publication in this collection
  10 Sept 2021
• Date of issue
  2021

History

• Received
  10 Oct 2020
• Accepted
  15 Mar 2021