Construction of mental health care based on the experiences of a nursing student

Construcción de la atención en salud mental a partir de las experiencias de un estudiante de enfermería

ABSTRACT

Objective:

to report the experience of a nursing student with mental health care during a clinical internship.

Method:

an experience report based on data from a Singular Therapeutic Project developed by a nursing student during 16 days of practice in a Day Hospital as part of an undergraduate course. The findings were analyzed based on the theory of interpersonal relationships and psychosocial rehabilitation.

Results:

the care process was organized between the weeks and phases of the relationship in: 1) from the unknown to relationship of trust; 2) reflections and reframing as a care proposal; 3) from limitation to leading role; 4) from care resolution to mutual transformations.

Final considerations:

it was concluded that despite the limitations of the practice context, the student was able to conduct psychosocial interventions in mental health in line with the expected goals and produce meanings in both involved.

Descriptors:
Nursing; Mental Health; Clinical Clerkship; Psychiatric Rehabilitation; Interpersonal Relations

RESUMEN

Objetivo:

informar la experiencia de un estudiante de enfermería con atención de salud mental durante una pasantía clínica.

Método:

un informe de experiencia basado en datos de un proyecto terapéutico único desarrollado por un estudiante de enfermería durante 16 días de práctica en un Hospital Día como parte de un curso de pregrado. Los hallazgos fueron analizados en base a la teoría de las relaciones interpersonales y la rehabilitación psicosocial.

Resultados:

el proceso de cuidado se organizó entre las semanas y fases de la relación en: 1) de lo desconocido a la relación de confianza; 2) reflexiones y reencuadres como propuesta de cuidado; 3) de la limitación al protagonismo; 4) de la resolución del cuidado a las mutuas transformaciones.

Consideraciones finales:

se concluyó que, a pesar de las limitaciones del contexto de práctica, el alumno fue capaz de realizar intervenciones psicosociales en salud mental en línea con las metas esperadas y producir significados en ambos involucrados.

Descriptores:
Enfermería; Salud Mental; Prácticas Clínicas; Rehabilitación Psiquiátrica; Relaciones Interpersonales

RESUMO

Objetivo:

relatar a vivência de um estudante de enfermagem com o cuidado em saúde mental durante um estágio clínico.

Método:

relato de experiência realizado com base nos dados de um Projeto Terapêutico Singular desenvolvido por um estudante de enfermagem durante 16 dias de prática em um Hospital Dia como parte de uma disciplina de graduação. Os achados foram analisados com base na teoria do relacionamento interpessoal e na reabilitação psicossocial.

Resultados:

o processo de cuidar se organizou entre as semanas e as fases do relacionamento em: 1) do desconhecido à relação de confiança; 2) reflexões e ressignificações como proposta de cuidado; 3) da limitação ao protagonismo; 4) da resolução do cuidado às mútuas transformações.

Considerações finais:

concluiu-se que, apesar das limitações do contexto de prática, o estudante foi capaz de conduzir intervenções psicossociais em saúde mental alinhadas aos objetivos esperados e produzir significados, em ambos os envolvidos.

Descritores:
Enfermagem; Saúde Mental; Estágio Clínico; Reabilitação Psiquiátrica; Relações Interpessoais

INTRODUCTION

With the change in the mental health care model, from biomedical to psychosocial care, nurses needed to reinvent their practices. The actions hitherto focused on the biological aspect, did not respond to the real needs of the subject in psychological distress, because looking at subjectivity and the context of people’s lives became essential. With this, soft technologies become indispensable for nurses’ performance and they, with their immaterial resources, becomes their main work tool to work with the multidisciplinary team in comprehensive mental health care^(1-2).

To this end, nursing professionals must articulate two theories that are the basis for psychosocial care: the theory of Interpersonal Therapeutic Relationship (ITR), which systematizes and organizes assistance in the phases of guidance, identification, exploration and resolution, based on the development of relationship between nurses (subjects)⁽³⁾ and Psychosocial Rehabilitation, which aims to rehabilitate people in psychological distress as citizens through autonomy in the essential aspects of life (living, exchanges (work and income) and support network)^(4-5). This theoretical articulation is necessary, since ITR was developed with a focus on nursing care in hospital dynamics; therefore, it must match the multidisciplinary and community objectives of Psychosocial Rehabilitation, which is also the basis of current public policies. Moreover, basic resources such as therapeutic attitudes (empathy, acceptance, support, availability, etc.) and therapeutic communication techniques must follow the entire care process⁽³⁾.

With this theoretical apparatus, it is possible to structure between team and users of single therapeutic projects (PTS – Projetos Terapêuticos Singulares) services capable of guiding successful therapeutic interventions⁽⁶⁾. It is worth mentioning that we understand interventions here as all actions performed by nurses based on rehabilitative attitudes that involve the restoration of affective and social relationships of subjects and the regaining of their rights and social power in the community⁽⁴⁾.

The challenge of caring in nursing and mental health in the current model is also experienced by students in their training process. Even after a theoretical approach, they are commonly marked by difficulty of insertion in the field, crossed by stigma, insecurity and also by not understanding psychosocial interventions as nurses’ work, which results in impasses in clinical practice when identifying needs and especially in the consolidation of care^(1,7-9).

The prescriptive nature of nursing with the overvaluation of physical care, experienced most of the time by students as a result in health, can hinder using soft technologies within mental health. These actions are often not objective, palpable and conclusive. Therefore, it is considered important to explore students’ experiences with psychosocial clinic, in order to contribute with the possibilities of nursing interventions in mental health.

OBJECTIVE

To report the experience of a nursing student with mental health care during a clinical internship.

METHODS

Ethical aspects

Considering that the study is based on an experience report by the authors, there is no need for ethical review by a Research Ethics Committee.

Theoretical-methodological framework

Data analysis will be based on Peplau’s ITR theory⁽³⁾, through the phases of orientation, identification, exploration and resolution, and in fields of living, support network and work and income (exchanges), and principles of autonomy, contractuality and citizenship, from Psychosocial Rehabilitation, proposed by Benedetto Saraceno^(4-5).

Type of study

This is a qualitative, descriptive, report-type study, referring to the experiences of mental health interventions, carried out by a nursing student in his practice in the practical field.

Methodological procedures

The clinical internship composes the subject “Nursing in Mental and Psychiatric Health” of a undergraduate nursing course at a public university in the city of São Paulo. Among the objectives of this practice, the main one is constructing a PTS between student and user guided by the ITR theory phases and the psychosocial rehabilitation principles, a resource that was used as an object of analysis for this report.

Study setting

The clinical internship took place at a Psychosocial Rehabilitation Center and Day Hospital (CRHD - Centro de Reabilitação Psicossocial e Hospital Dia) of a Psychiatric Hospital in the city of São Paulo from August to September 2019, from 8 a.m. to 12 p.m., Monday to Thursday, totaling 16 days with 64 hours of practical activity. CRHD operates daily, open and voluntarily and provides care for individuals with mental disorders and their families. Its main objective is to contribute to the psychosocial rehabilitation of subjects in psychological distress and for that, it has several activities programmed by a multidisciplinary team, ranging from leisure, stimulating citizenship, psychotherapies, play therapy, complementary integrative practices, among others.

Data collection and organization

Data were collected from a PTS developed by a student during 16 days of mental health practices and delivered to the end of the practical field, considering the entire care process performed. Within this, all information related to the context of life of the user in question, the identified needs and the interventions developed by the student in the period were compiled. Data were organized in the 4 weeks of internship, named after the experiences prevalent in each moment as: week 1 - from the unknown to relationship of trust; week 2 - reflections and reframing as a care proposal; week 3 -from limitation to leading role; week 4 - from care resolution to mutual transformations.

Data analysis

The results will be analyzed in chronological order weekly and presented descriptively with aid of charts and figures.

RESULTS

Week 1 - From the unknown to relationship of trust

From the recognition of the internship field, the student started to approach the service users. The first week was marked, mainly, by the formulation of bonds and confidence building, starting the ITR development with the orientation phase. In the first days, the student chose to approach a user after identifying that other service and professional users used speeches with stigmatizing content considering their previous experience, wide media dissemination of the case and its relationship with justice and the approach to the study field of interest, maternal suffering. The points cited aroused interest and empathy on the part of the student. Thus, he made the first contact with the user, noting acceptance by the user. She was admitted to a hospital ward. During the day, I frequented the activities and space of CRHD and, therefore, it was possible to have daily contact.

Upon realizing the relationship of trust, the student organized individual meetings by developing therapeutic communication with techniques of expression, clarification, and validation (listening, verbalizing and showing acceptance and interest, asking open questions, keeping the focus on the subject, clarifying the that was said, to stimulate the expression of feelings, etc.), which made it possible to strengthen the bond, better understand the user’s experiences, her life history and the current condition. These meetings took place daily and lasted an average of 30 minutes, when possible, they were held in a totally private space, which was difficult due to limited space, number of users and the presence of police escorts.

The student and the user jointly identified primary mental health needs such as discomfort and lack of clarification regarding change in mood, exhaustion in the family relationship with weakened support network and great dissatisfaction in not being able to participate in activities outside CRHD space due to judicial restrictions. However, at this point, the student did not feel safe to intervene in this last issue. The joint survey of these needs comprised phase two of identification.

Week 2- Reflections and reframing as a care proposal

In response to the user’s demands, the actions developed by the student in phase three of exploration were guided by reflections. In order for the user to be able to name and recognize her feelings and through which situations they manifested, the student proposed an intervention that he named “Diary of Feelings”. It was instructed that she daily wrote reflections in a notebook provided by the student, regarding the events of her day and the feelings generated so that together they could identify these mood changes and their relationship with the context. This was organized with the date and the following sentence: “Write here all relevant events throughout your day and all the feelings generated before them.”

Daily, the student resumed what the user wrote and facilitated reflections. With that, it was possible to reframe the change in mood as something common to the daily life of the human being in the face of frustrating situations with intense suffering and not as a symptom of “mental illness”, which classified her as someone incapable. This intervention had a good feedback from the user, who wrote her daily feelings for 10 days during his internship.

With regard to the demand for exhaustion on family relationships and a weakened support network, in order to better understand their configuration and also their interaction with the social environment, the student used the Calgary Family Assessment Model. During the meetings, he built together with the user a genogram and ecomap, as shown in Figure 1 below.

Figure 1
Genogram and ecomap as a form of intervention, São Paulo, São Paulo, Brazil, 2019

This intervention allowed the user to talk about each family member and address the relationship prior to psychiatric hospitalization and also during this period. The reflections were very powerful and it was noticed that the family was a factor of exhaustion at times as well as the relationship between the family and the social environment, their beliefs, customs and ideologies. The need for the family to receive care by a mental health service was also evidenced, a fact that started to reflect on different forms of support among them.

Still this week, the student noticed some difficulty in walking the user due to fractures in her lower limbs, resulted from the moment of crisis. During one of the meetings, they identified, together, a physical need, with the report of pain and difficulty in walking, accompanied by a psychological need, as they stated that they used closed shoes to protect the marks of the injuries left by the fracture, which they referred to the memory of psychic changes.

The student made an integration with the professional physiotherapist, who indicated approaches to exercises that could soften the sensations, guiding the use of closed shoes for a long time after injuries, facing the consequences. It was noticed the insertion of the exercises in the user’s routine, who started using open shoes, exposing the marks and giving them a new meaning.

Week 3- From limitation to leading role

It was found that the psychiatric diagnosis was a limiter in the user’s life, as she used it to justify and reinforce her actions, thoughts, personality, and relationships. That week, still in identification and exploration phases, we tried to rethink this problem with the user, with the help of an instrument illustrated in Chart 1 below.

Chart 1
Systematization of Reflection: thinking about the past, present and future, São Paulo, São Paulo, Brazil, 2019

	Past	Present	Future
Habits	What would you like to do?	What do you usually do?	What do you think you can do?
Expectations	How did you imagine your life would be?	How do you imagine your life is?	How do you imagine your life will be?
Personal acknowledgment	Who do you believe it was?	Who do you believe you are?	Who do you believe it will be?

Responses from Chart 1 were used to reflect, with the user, that habits, desires and expectations undergo changes over time and that are not necessarily associated with the loss of her personality and potential. To compose this reflection, the student always sought to contextualize the user’s history and moment of life, shifting the place of diagnosis as the leading role of her life. From there, the user was able to locate past milestones in her life that she had never thought about, but that, at that moment, appeared and allowed her to rethink the present and the future. She listed self-care, family and work as important aspects to be worked on next.

Week 4- From care resolution to mutual transformations

In the last week, in the exploration and resolution phases, the student used an intervention based on the expanded concept of health, with a table referring to the potential for strengthening and exhaustion in the user’s life to rethink about the determinants of the health-disease process. The student aimed to promote an initial reflection with the identification of positive and negative points involving its entire historical context. It was observed that the positive points outweigh the negative ones, making it possible to focus on maintaining the strengthening potentials and dealing with those of exhaustion.

The “Feelings Diary” was also resumed, and as a way to better visualize it, the student proposed that they should make a “Feelings Graph” together (Figure 2) to monitor their mood and feelings throughout 10 days. She identified that, generally, on weekends, when she did not attend CRHD and spent more time in the ward, she presented a worsening of her mood named sadness and melancholy.

Figure 2
Feelings Graph, São Paulo, São Paulo, Brazil, 2019

In the closing process and with more security and bond with the Day Hospital multidisciplinary team, the student proposed a discussion of the case together with the sector nurse and the user herself. The user points out the desire to continue the “Diary of Feelings” and the nurse includes this proposal as part of the CRHD PTS. This possibility was important for the student to recognize that mental health care is continuous and demands availability and integration among professionals.

Finally, the student was able to observe personal and professional changes generated by the ITR process. He realized the initial difficulty in recognizing that, since the first week, he was taking care and building the therapeutic relationship, but, as the days went by, he identified that listening, communication and therapeutic attitudes were present in all meetings, making it possible to see as a work tool in mental health. Chart 2 below shows the interventions performed by the nursing student, briefly translating the joint construction of PTS.

Chart 2
Construction of mental health care by a nursing student, São Paulo, São Paulo, Brazil, 2019

Week-Relationship phase	Needs	Intervention	Psychosocial Rehabilitation Aspects
1 - Guidance and identification	Recognition of users as citizens of rights and desires; horizontal relationship. bond formation, trust; understanding life history; mood swings; weak family relationships and support network.	Reception; listening; feelings diary; genogram and ecomap.	Recognition of users as citizens of rights and desires; horizontal relationship.
2 - Identification and exploration	Pain and difficulty walking; embarrassment; impacts of the past on the present and future; inclusion of the family in care.	Articulation of multidisciplinary work; reflections.	Comprehensive care; autonomy;
3 - Identification and exploration	Diagnosis as a limiting factor; valuing the user as a comprehensive part of care.	Deconstruction; giving a new meaning to symptoms.	Co-responsibility.
4 - Exploration and resolution	Rescuing the care process; continuity of care.	Feelings Graph; strengthening and wear potentials; discussion of the case.	Job; support network; valuing skills; leading role; citizenship.

DISCUSSION

From the experience of the nursing student in mental health care, it is evident that the interventions developed were only possible through the relationship of trust built between those involved and user appreciation as an active participant in her care and life projects. The student chose and was chosen by the user in question and together they elaborated interventions that could be conducted by ITR during his internship, articulated with the objectives of Psychosocial Rehabilitation.

Peplau, in his theory, emphasizes the importance of the initial period of rapprochement between nurse-users in the phases of guidance and identification, as this is where the bond that initiates ITR takes place. The theory also predicts the overlapping of the relationship phases⁽³⁾, as observed in this study, in which the identification phase was present in three consecutive weeks. In the entire relational process, therapeutic communication is considered to be one of the most important lightweight technologies, as it enables reception, bonding, identification of needs and interventions and, therefore, must accompany professionals at all times^(2,6). Nursing students, despite having initial difficulties with the application of communication techniques, are able to use them with quality throughout clinical practice⁽⁸⁾, as was done by the student in this report.

Subjective and psychosocial needs are not easily accessed and sometimes they are faced with restrictions that go beyond the competences of the team^(4-5,8-9) and especially of students. On the other hand, absence of proposal standards in mental health allows the possibilities of care to be expanded and the proposals to be relevant and have real meanings⁽⁵⁾.

In this experience, the student was able to intervene, during the exploration phase, in the user’s self-stigmatization, promoting reflections on different meanings of what we usually name as signs, symptoms or impotencies related to mental disorders. Due to the history of human rights violations, individuals with psychiatric diagnoses often suffer from stigmatization and internalize negative stereotypes before suffering⁽¹⁾. When subjects believe that they are impotent in concerning their dynamics, there is the emergence of a state of inertia and a decrease in their condition to face difficulties, which is a problem that should always be addressed by professionals^(4-5).

When we work with Psychosocial Rehabilitation, there are two fundamental principles that guide the professional’s practice: autonomy and citizenship. Furthermore, it also aims to promote the user’s full contractuality in habitats, with their insertion at home and full relationships within it; social environment; and work as a social value^(4-5). In this regard, it is important to recognize that the complexity of some aspects identified in ITR are not susceptible to interventions or brief rehabilitation actions, as, in this case, affective relationships and judicial restriction and, therefore, will not reach the resolution phase. Therefore, working in a multidisciplinary team and ensuring continuity of care in the referral service itself is essential.

Nursing professionals working in mental health maintain their autonomous exercise, but integrate their care with other team members as a way of enabling expanded care⁽⁷⁾. This experience of multidisciplinary work was daily experienced and applied in clinical practice by the student in the construction of a PTS articulated with physiotherapist and the nursing team of the CRHD sector.

Moreover, throughout the experience, the student understood that he could integrate his prior knowledge of other fields of nursing with mental health, and, from there, use different strategies linking them with the objectives of PTS. The Calgary Family Assessment Model, genogram and ecomap, and the potential for strengthening and attrition are examples. The interactions of the individual with the family and the community are factors that directly impact individuals’ mental health. By recognizing these structures, professionals can encourage the family or the support network to stop being accomplices or victims of psychiatry, becoming a co-responsible and integral part of care and rehabilitation⁽⁵⁾.

These different actions carried out by the student through ITR strengthened the responses of psychosocial rehabilitation; therefore, they are considered potent interventions, since, in order to promote mental health, aspects of life that go well beyond physical health must be considered. It is a fact that the practice setting being a Day Hospital, within the facilities of a psychiatric hospital, with the user in hospital under police escort, is not potential for rehabilitation actions, but does not prevent the development of a relationship. It is necessary to expand the possibilities of reception, citizenship and social inclusion of users and family members through work in the Psychosocial Care Network (RAPS - Rede de Atenção Psicossocial) that guarantee long-term support beyond the limits of services⁽¹⁰⁾.

Study limitations

The limitations are associated with the complexity of the case together with the difficulty of integrating aspects of psychosocial rehabilitation due to the hospital practice setting as well as the scarcity of scientific productions with practical examples to enrich the discussion.

Contributions to nursing in mental health

This study contributes to alleviate anxieties related to the experience of nursing students facing mental health care, illustrating the opportunities for applications of theory in clinical practice using soft care technologies. Moreover, it can guide discussions on the topic in the academic education space and fill the research gap.

FINAL CONSIDERATIONS

The four weeks of practice put the student in touch with the complexity of the process of comprehensive mental health care, which produced real meanings in the lives of everyone involved in this construction. Despite the limitations of the practice context, the student developed, in the short term, together with users, a PTS aligned with ITR and Psychosocial Rehabilitation, with marks in the rescue of the leading role of the same in the current condition. The proposed nursing interventions responded to subjects’ health needs in psychological distress and also led to overcoming students’ personal limitations before psychosocial care.

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Edited by

EDITOR IN CHIEF: Dulce Barbosa

ASSOCIATE EDITOR: Hugo Fernandes

Publication Dates

• Publication in this collection
  28 May 2021
• Date of issue
  2021

History

• Received
  30 June 2020
• Accepted
  03 Oct 2020