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On-line version ISSN 1980-220X
Rev. esc. enferm. USP vol.43 no.4 São Paulo Dec. 2009
La enseñanza de la enfermería psiquiátrica/salud mental: su conexión con la Reforma Psiquiátrica y las directrices curriculares nacionales
Josicelia Dumêt FernandesI; Dora SadigurskyII; Rosana Maria de Oliveira SilvaIII; Aclair Bastos AmorimIV; Giselle Alves da Silva TeixeiraV; Maria da Conceição Filgueiras de AraújoVI
IPh.D. in Nursing. Full Professor
at School of Nursing at federal University of Bahia. Leader of the Study
and Research Group on Education, Ethics, and Nursing Practice, at School
of Nursing, federal University of Bahia. Researcher with CNPq. Salvador,
BA, Brazil. email@example.com
IIPh.D. in Nursing. Adjunct Professor at Federal University of Bahia. Leader of the Study and Research Group on Mental Health at School of Nursing at Federal University of Bahia. Salvador, BA, Brazil. firstname.lastname@example.org
IIIM.Sc. in Nursing. Adjunct Professor at School of Nursing at Federal University of Bahia. member of the Study and Research Group on Care, at School of Nursing at Federal University of Bahia. Salvador, BA, Brazil. email@example.com
IVUndergraduate at School of Nursing at Federal University of Bahia. Member of the Study and Research Group on Education, Ethics and Nursing Practice, School of Nursing at Federal University of Bahia. Holder of a PIBIC fellowship. Salvador, BA, Brazil. firstname.lastname@example.org
VUndergraduate at School of Nursing, Federal University of Bahia. Member of the Study and Research Group on Education, Ethics and Nursing Practice, School of Nursing at Federal University of Bahia. Holder of a PIBIC fellowship. Salvador, BA, Brazil. email@example.com
VIGraduate at School of Nursing, Federal University of Bahia. Member of the Study and Research Group on Education, Ethics and Nursing Practice, School of Nursing at Federal University of Bahia. Salvador, BA, Brazil. firstname.lastname@example.org
This theoretical study addresses the education system for Psychiatric Nursing in an increasingly changing world of accelerated scientific and technological modernization. The objective is to discuss the pedagogy in Psychiatric Nursing, and its interface with the principles of the Brazilian psychiatric reform and national curriculum guidelines of nursing undergraduate courses. The theoretical foundation of the study consisted of constructs of the Brazilian psychiatric reform and national curriculum guidelines of nursing undergraduate courses and their relationship to factors constituting the pedagogy in psychiatric nursing. The study shows that it is not enough to identify technical issues regarding contents and teaching, didactic procedures, methods and pedagogical techniques; it is necessary to implement changes, using a new perspective and by daring to question the nature of knowledge and institutional psychiatric practices.
Key words: Psychiatric nursing. Mental health. Education, nursing.
Estudio teórico acerca del proceso de formación en Enfermería Psiquiátrica y Salud Mental, frente a los crecientes cambios en el mundo globalizado y su acelerado proceso de modernización científica y tecnológica. Objetiva discutir el quehacer pedagógico en la enseñanza de Enfermería Psiquiátrica y Salud Mental, y su conexión con los principios de la Reforma Psiquiátrica y de las Directrices Curriculares Nacionales de los Cursos de Graduación en Enfermería. Para su sustentación teórica, adopta como referencia algunos constructos de la Reforma Psiquiátrica y de las Directrices Curriculares Nacionales del Curso de Graduación en Enfermería, y su relación con factores constituyentes del quehacer pedagógico en la Enfermería Psiquiátrica y Salud Mental. Evidencia que no basta apuntar cuestiones técnicas relativas a contenidos y enseñanza, procedimientos didácticos, métodos y técnicas pedagógicas; es necesario superar desafíos e implementar los cambios, guiándose por una nueva perspectiva, y osando colocar en cuestión la naturaleza del saber y de las prácticas institucionales psiquiátricas.
Descriptores: Enfermería psiquiátrica. Salud mental. Educación en enfermería.
The increasing changes in the globalized world and its fast process of scientific and technological modernization have demanded new and contextualized actions to further public policies with concrete expressions in the social areas, particularly in health and education.
These scenarios of changes find support in the Federal Constitution of 1988 which, by stating health as a right for everyone, establishes the social rights to health and education, among others, and attributes to the State the responsibility of human resource training, necessary for the implementation of the Unique Health System (SUS).
In education, constitutional determinations are explicit in the law that rules on national education LDB (Lei de Diretrizes e Bases da Educação Nacional)(1), which support the educational process in higher education through competency and skills development; cultural, technical and scientific improvement of the subject; flexibilization of the curricular programs; and the implementation of innovative pedagogic projects, in a perspective of change. These premises appoint the need to restructure courses, through the construction of Curricular Guidelines for every Undergraduate Course(2-4).
In the nursing area, these guidelines were approved through Resolution CNE/CES No. 03 from 11/07/2001(5), which defined the National Curricular Guidelines for Nursing Courses (NCG/NC). These guidelines evidence the need for commitment to the principles of the Brazilian Health Reform, with emphasis on the SUS and guarantees as to the comprehensiveness of care actions, and define the fundamental principles for the development of professionals who are critical, reflexive, inserted in the historical-social context, disciplined with ethical principles and able to intervene in health care problems/situations, which mental health care is part of.
In mental health, there are also guidelines for the transformation of knowledge and practices, social and cultural values and a new sociability among the subjects involved in mental health/disease. These guidelines are described in Law no. 10216 from April 06, 2001(6), which prescribes the protection and rights of people who have mental and behavioral disorders, on the part of the State, and redirect the mental health care model, favoring treatment in community-based services. Besides, at the end of 2001, the III National Conference on Mental Health emphasized care without exclusion, pointing to the integrality principle. In the following year, the establishment and operation of Psychosocial Care Centers (PCC) was regulated throughout the national territory, pointing to a reordination of the medical-psychiatric care model, which was centralized in psychiatric hospitals until then, to territory and community-based services.
In this context, the Psychosocial Care paradigm configures Mental Health in the SUS, changing mental health care in force until then, breaking with knowledge and practices and strengthening anti-asylum and differentiated practices to handle insanity. This paradigm is fundamentally put in practice in PCC which, based on the principles of the Psychiatric Reform (PR), constitute care spaces for mental suffering, rehabilitation, reception, guarantees of citizenship and production of new subjectivities for people with mental disorders(7-8).
In the present study, the authors understand that these change actions imply the need for professionals who are committed to care for the population's mental health; professionals who are able to overcome the paradigm of tutelage of the insane and insanity, able to comprehend and re-comprehend the psychosocial determinants of insanity; to transform knowledge and practices constituted so far regarding mental suffering; to articulate the acquired knowledge with new ways of sociability and production of social value involved in health and mental health; to perceive the complexity of their practices and effectively develop new actions as ways to think and act, reinventing ways to deal with the reality of mental suffering.
This reality requires, from educational institutions, the reconstruction of their Pedagogical Policy Projects in terms of mental health care, with a view to reorienting the educational process towards competency and skills development and exercise of the practices and knowledge necessary to respond to the principles proposed by the PR, i.e. a proposal of change in the pedagogical actions involved in the traditional Psychiatric Nursing care model, in tune with the change proposals of the National Mental Health Policy.
Some undergraduate nursing courses have already developed a professional education process with possibilities to respond to the psychosocial care needs of mental disorder patients, attempting to integrate knowledge on human beings and their health, to value students as subjects with knowledge that need to be respected and to develop the integration of the Psychiatric Nursing and Mental Health (PN/MH) with other subjects in the curricular program(9).
Nevertheless, considering the expansion policy of higher education in our country, and several declarations of professionals during events in the area, it can be perceived that this has not been the reality in most of the courses that face structural elements, which are not always favorable to the transformation process in health and nursing services. In several courses, a focus on the clinical model is also observed, in which the disease is still exclusively visualized as a set of symptoms that require interventions so as to achieve a state of mental balance. The prevailing teaching system is based on conservative pedagogical processes, aimed at the principles of asylum psychiatry(10).
It was also observed that teaching has not managed to develop the competencies needed for mental health and psychiatric nursing activities, which makes nurses seek alternatives in specialization courses to solve the lack of competence(11).
Besides, there is an unbalance between teaching and mental health care practice and current national mental health policies, which leads to the education of uncritical professionals, who are not reflexive and develop their practice essentially in the hospital scope, aimed at medicalization and based on the culture of social exclusion and segregation(12).
In the face of this reality, research needs to look at new pedagogical tendencies in Mental Health and Psychiatric Nursing (MH/PN) teaching from the perspective of PR and NCG/NC, favoring the development of critical/reflexive and ethical professionals and citizens.
The latter justifies the development of the present study which, through the analysis of theoretical constructs, proposes new practices for the areas, supporting the rupture with the traditional educational model in MH/PN, in other words, the rupture with knowledge transfer as a goal in itself, with the flexibility of curricular programs and subject contents, as well as the inflexibility of teacher and student roles, factors that hinder the critical/reflexive professional education. Thus, the intention is to support the education of nurses as subjects in knowledge production, in the construction of the health care model and in the provision of services aimed at Mental Health care in the SUS.
Therefore, this research is both necessary and relevant, as it aims to reflect on pedagogical actions in MH/PN teaching and its interface with the principles of the PR and the NCG/NC, aimed at contributing to the education of subjects who are able to articulate knowledge and practices in coping with the challenges of mental health care to the population, as well as in the reorientation of doing and knowing in the challenging journey towards putting in practice policies for mental health and education in nursing.
In order to meet this purpose, the present study is oriented by some conceptual and methodological reflections that can update and guide pedagogical actions in MH/PN teaching and their relation with constituent factors of PR and the NCG/NC.
This study involves human subjects neither directly nor indirectly, neither fully nor partially. The development is supported by a theoretical proposition, essentially but not exclusively based on studies about the Psychiatric Reform(7,10), the National Curricular Guidelines for Nursing Courses(2-5), Education in Mental Health and Psychiatric Nursing(8-13) and Contemporaneous Education(14-17). These studies have multiple subjects, with different knowledge, interests and perspectives that contribute to the comprehension of the study object. Support also comes from legal documents regarding the change in the educational process, i.e. Law No. 9.394/1996(1), which establishes the guidelines and bases of national education; Resolution CNE/CES No. 03/2001(5), which defines the National Curricular Guidelines for Nursing Courses; Law No. 10.216/2001(6), which prescribes the protection and rights of people who have mental disorders and redirects the mental health care model.
According to this option, and moved by the contemporaneous debate about the complexity of the subject, this study discusses the daily tasks that constitute pedagogical activity in MH/PN teaching, guided by some basic rules of PR and the NCG/NC, mainly in relation to the practical development of changes in MH/PN educational processes.
MENTAL HEALTH AND PSYCHIATRIC NURSING TEACHING BASED ON THE PRINCIPLES OF THE PSYCHIATRIC REFORM AND THE NATIONAL CURRICULAR GUIDELINES
The changes proposed in nursing education have demanded education to be more flexible, critical-reflexive, versatile and articulated with the job world, aimed at the education of professionals needed to consolidate the Unique Health System, assuring comprehensive health care(2,14).
In MH/PN teaching, these changes indicate the need to educate professionals who are able to act with a sense of social responsibility and commitment to the citizenship of people in mental suffering, based on the principles of the Health Reform, the SUS and, more specifically, the PR(8,10-11,13-14).
The PR process, contemporaneous to the Health Reform, reassured the need for a change in care for citizens' mental health, establishing the overcoming of the hegemonic and iatrogenic asylum paradigm and presenting real alternatives for health care and social inclusion of people with mental problems. The PR constitutes a policy that conjugates insanity with citizenship, treatment with dignity, efficacy with respect, science with ethics. A policy of transformation of knowledge and practices regarding insanity, involving actions to deinstitutionalize insanity, considering the economic, social and cultural matters involved in this process. A policy that brings new ways of seeing and handling insanity, involving matters not only associated to deinstitutionalization, but also to technical, administrative, legal and, fundamentally, ethical matters(9-10,13).
In the reordination of the national mental health care model, the PCC, in substitution of psychiatric hospitals, makes the PR concrete, characterized as spaces to exercise ethics, solidarity, comprehension, reception and coexistence with the differences, unpredictability and history of each subject. They are spaces that express ways to provide mental health care without characteristics of confinement or institutionalization; aim at the approach or resocialization of people with mental and behavioral disorders with the community; work with people's life situation in their social-family context; develop therapeutic actions with solidarity, affection and respect, instead of isolation and exclusion(7,10,13).
This context reveals the need to dismantle knowledge and practices constituted so far and consequently, to construct new ways of sociability and social value in care delivery to people with mental disorders.
Under this paradigm, MH/PN teaching faces the challenge of adopting a new point of view that, against the background of NCG/NC principles, tries to break with the focus of the classic care model, which is centered on the remission of disease symptoms. This is a challenge that requires the education of professionals with critical thinking, in order to analyze and intervene in health problems, oriented by ethical principles and the comprehension that the responsibility of metal health care does not end with the technical act, requiring creative, critical and reflexive knowledge to permit competent interventions.
Thus, the daily activities that constitute MH/PN teaching, in the face of contemporaneous changes, require a new look on insanity and pedagogical restructuration, based on the pillars of contemporaneous education, in order to qualify professionals who are able to learn how to learn, learn how to know, learn how to do, learn how to live together and learn how to be(15-16), guaranteeing the qualification of professionals who can act with autonomy and discernment(17), in order to assure high-quality, efficient and problem-solving comprehensive health care.
In MH/PN teaching, it is understood that learning how to know(2-3,15) involves learning how to know the new reality of psychosocial care spaces, build a new perspective on insanity and new mental health care modalities, think of proposals for the reformulation of traditional notions and strategies that involve care to people with mental disorders, deconstruct and reconstruct knowledge in the mental health area, seek strategies for the deconstruction of technical rationality, epistemologically transcending the concept of mental health/disease.
The authors also understand that, in the daily activity of MH/PN teaching, learning how to do(2-3,15) offers opportunities to develop competences for the transformation of mental health care knowledge and practices, to undertake actions aimed at the deinstitutionalization of insanity, to develop therapeutic patient/professional relations, to perceive care as an element of transformation of mental suffering experiences and feelings, to develop actions to receive and live with the differences, to exercise the ethics, solidarity and comprehension of the subject in his daily life.
Learning how to live together(2-3,15), in the pedagogical actions of MH/PN teaching, presents possibilities to understand the patient and his family, to develop team work as a supporting axis for psychosocial care actions, for the creation of other ways of thinking, living, seeing and working with insanity, for the development of interpersonal relations centered on comprehensive and receptive attitudes towards singularities and respect for differences in mental health care.
Learning how to be(2-3,15) favors conditions for complete professional development, with sensitiveness, personal responsibility, ethical and aesthetic sense, autonomous and critical thinking, creativity, scientific strictness and initiative.
This new look on insanity in daily MH/PN teaching presupposes the student as the subject of his own educational process, in which the latter aims for the development of the capability to learn how to learn; to articulate knowledge, to develop abilities and attitudes; to know how to seek information for problem solving and coping with unpredictable situations; the capability to act effectively in the face of different situations, based on but not limited to previously acquired knowledge(17).
Oriented by this educational aspect, pedagogical action in MH/PN reveals possibilities for competency-based education, indicating the need for experiences and opportunities in psychosocial care services and permitting development beyond the cognitive aspect. This means the capability to propose strategies for knowing how to act and transform mental health care practices, through the identification and mobilization of knowledge, so that it will support problem solving.
The competency-based educational process is also presented as an approach for continuity and rupture, in other words, continuity of the evolution process of the world, frontiers, technologies and life styles that currently require flexibility and creativity of professionals; and rupture with pedagogical practices that do not qualify subjects to act upon the complexity of daily situations(16-17).
The development of this ability through MH/PN teaching implies a critical and self-critical dialogue between knowledge and practices that may account for the complexity of the reality of patients' mental suffering.
In this dialogue between knowledge and practices, the articulation theory/practice is of fundamental importance as it establishes spaces to think about contents, approaches and methods for competency development, bringing the need to deconstruct the paradigm of the dichotomized knowledge between knowing and doing, theory and practice into the debate. Therefore, it is a dialectical relation that puts a set of knowledge at work that will support mental health care actions in the SUS(8,13).
The articulation between theory and practice in MH/PN teaching presupposes, thus, pedagogical actions that, transcending the walls of the academy, indicate the need to insert the subjects of the educational process into spaces for meeting, care production, rehabilitation, interpersonal relations, solidarity, reception and production of new subjectivities. Therefore, it indicates the need for insertion in spaces for psychosocial care delivery to people with mental disorders, centering MH/PN education on a continuous approach of the teaching world with the working world, involving attitudes of co-responsibility, the establishment of partnerships and cooperation, a horizontal and plural relation among the subjects of the educational process. These approaches are presented in the perspective of effective articulation that contributes not only to professional education, but also to changes in the production of mental health care services for the population(8,10,13).
The adoption of the competency-based reference framework in MH/PN teaching involves not only a set of actions or technical procedures the students need to achieve, but the articulation of a set of knowledge to solve existing problems in mental health care reality for coping with unpredictable situations. It involves, thus, the mobilization of intelligence to face the challenges of work in the production of a new doing and a new look upon insanity, which presupposes a new journey towards the construction of multidimensional knowledge and practice, in order to recover the singularity and produce the subjectivity of subjects with mental disorders.
The propositions of new MH/PN teaching practices presented here, lead to reflections about the reality of this process in concrete spaces of approximately 600 nursing courses, which are currently operating in the country. A great part of these courses operates in cities where there are no PCC; where mental health care is still performed in the traditional, hospital-centered model, based on notions of dangerousness and irresponsibility of mental disorder patient, complicating pedagogical actions that indicate the conjugation of insanity with citizenship.
In this context, new concerns arise: how has the psychosocial care paradigm been guiding MH/PN teaching? How have PR principles been articulated with the principles of the NCG/NC? Which pedagogical practices have been aimed at mental health production in its micro and macro context? What knowledge have the subjects involved in MH/PN education produced? How is research as an action strategy in innovative services like the PCC, so that the produced studies can ratify, modify or substitute conservative mental health care knowledge and practices? Which effective changes have been taking place in most undergraduate courses, particularly in terms of MH/PN teaching?
These questions underline the need for studies about the reformulation of nursing education, aimed at preparing critical, creative and reflexive subjects, capable of developing actions to break with the knowledge and practices of the traditional mental health model, as well as interfering in the social reality of services, in the perspective of psychosocial care. This educational process, however, should be based on strategies of renewal that are capable of facing the challenge of qualifying professionals that effectively contribute to the improvement of mental health care; capable of epistemologically transcending the concept of mental health/disease, of treatment/cure for delusions and hallucinations, of normality/abnormality; capable of building new realities and transforming what is given as natural and permanent. It should also be based on the search for teaching strategies that favor competency development of future professionals to integrate and mobilize the apprehended concepts in daily situations, aimed at problem solving. Besides, it should be based on the search for new pedagogical principles for nursing education, in the face of the difficulties of future graduates to mobilize what they have learned in practical situations developed during their educational process.
According to the above, it is understood that the pedagogical activity in MH/PN teaching is based on its interface with the principles of the PR and the NCG/NC and built on critical thinking, on the development of skills to reflect on and critically analyze society, the mental health care model, the educational process and the socio-educative relations of subjects in this process.
These actions, however, comprehend a relational dimension, expressing the subjects' internal challenge of living with the differences, besides integrating the parts and the whole that structure and organize their interactions with the world and themselves. Thus, they include an interpersonal and institutional relation and involve a new look upon insanity and the practical development of the changes suggested in the NCG/NC.
Hence, it is not enough to discuss about the change oriented by PR principles; the way the change is being addressed among teachers, students and professionals in practical scenarios needs closer attention. It is not enough to acknowledge the need to develop students' general and specific competencies; some aspects of the interface between the NCG/NC and the educational process in MH/PN need to be questioned. It is not enough to recognize the need to break with the prejudice towards insane persons; it needs to be put in practice, developing actions to demystify insanity, recover the dignity of insane persons; strategies are needed that permit the involvement of teaching in new mental health care practices. It is not enough to reformulate Pedagogical Policy Projects; they need to be put them into practice. It is not enough to point out technical questions regarding teaching contents, didactic procedures, pedagogical techniques and methods; it is necessary to overcome challenges and implement the changes, oriented by a new perspective, and to question the nature of knowing and psychiatric institutional practices.
Thus, the new configurations for MH/PN education are not limited to technical matters. They are oriented by the adoption of the theoretical-pedagogical framework that supports a significant and transforming learning, appropriate to the social and professional demands in the mental health area, emphasizing the experiences that approach students to the work reality, introducing new possibilities of care, civil rights, construction of anti-asylum knowledge and practices for mental health care.
Coping with these challenges involves opportunities to reflect about pedagogical working/doing in health and mental health, aimed at deconstructing the dichotomy between knowing and doing, towards the process of integration and mobilization of knowledge and actions that lead the student to knowledge aimed at the population's real conditions of life and health.
Finally, it should be clarified that this study does not intend to indicate paths courses should take in order to achieve the necessary transformations for the development of MH/PN teaching, but to elicit the debate and sketch out alternatives that indicate the need to transcend the traditional approaches based on classic psychiatry and the need to change paradigms, to break with practices and beliefs that stop us from making changes and facing the challenges presented in the new ways of dealing with mental suffering. This is, therefore, a contribution to the collective and critical debate, as well to the privilege of constructing new MH/PN teaching, emphasizing the consolidation of the SUS.
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