Nursing students and mental health education in primary care

Estudiantes de enfermería y la educación y salud mental en atención primaria

Abstracts

The University of Sao Paulo School of Nursing (EEUSP) went through a period of transition from undergraduate syllabus between the years 2009 and 2010. This change was made to integrate basic and clinical cycles and to reduce fragmentation of the disciplines. The mental health nursing education was included in many modules including the primary care. This qualitative study aimed to identify how the service offered to people with mental illness was performed by 20 undergraduate students in the context of primary care and how they were prepared. Data collection was conducted through semi-structured interviews, in August 2012, in EEUSP. After thematic analysis, we separated in categories: Teaching-learning process, Basic Health Unit and Mental health-illness process. The socially constructed conception of madness added to the problems related to academic training may result in lack of preparation in nursing mental health care.

Mental health; Primary health care; Teaching

En los años 2009 y 2010 la Escuela de Enfermería de la Universidad de São Paulo experimentó una transición curricular, cuya propuesta fue integrar disciplinas de ciclos básicos y clínicos y la desfragmentación. La educación de enfermería en salud mental se incluyó varios módulos que incluyen los cuidados básicos. El objetivo es conocer cómo se llevó a cabo la atención a personas con enfermedad mental por 20 estudiantes de enfermería en el contexto de la atención primaria, y la forma en que se prepararon para ello. La recolección de datos se realizó con entrevistas semiestructuradas, en agosto de 2012, en la EEUSP. Después del análisis temático formó las categorías: proceso de enseñanza-aprendizaje, Unidad Básica de Salud y el proceso salud-enfermedad mental. La concepción de la locura añade a los problemas socialmente construidos puede conducir a la formación académica en la educación de enfermería preparado para la atención de salud mental.

Salud mental; Atención primaria de salud; Enseñanza

De 2009 a 2010, a Escola de Enfermagem da Universidade de São Paulo (EEUSP) passou por transição curricular, cuja proposta era integrar os ciclos básico e clínico, desfragmentando as disciplinas. O ensino de enfermagem em saúde mental foi incluído em vários módulos que contêm os cuidados básicos. Este estudo qualitativo visou identificar como o atendimento às pessoas com doença mental foi realizado por 20 alunos da graduação em enfermagem no contexto da atenção básica, e como foram preparados. A coleta de dados foi realizada através de entrevistas semiestruturadas, em agosto de 2012, na EEUSP. Após a análise temática formaram-se as categorias: Processo ensino-aprendizagem, Unidade Básica de Saúde e Processo saúde-doença mental. A concepção da loucura construída socialmente, somada aos problemas relacionados à formação acadêmica, pode acarretar a formação de enfermeiros despreparados para o cuidado em saúde mental.

Saúde mental; Atenção primária à saúde; Ensino

INTRODUCTION

The Family Health Program (FHP) was created in 1994 and inserted in the Unified Health System (SUS). It aims to provide health care service to the individual and the family integrally and continuously in a way so that families are focused in their physical and social environments^(1).

In 2006, considering the experimental background and therefore, new proposals for change to the FHP, the Ordinance No. 648/GM was approved, in which the Primary Care Policy (PCP) is created. This policy aims to review the norms of the FHP and the Community Health Agents Program (CHAP). The inception of the FHP leads to creation of CHAP (1991), in the edge of changes in the health sector, with the intent of increasing user accessibility and increased investment in health promotion actions, considering that primary care (PC) may be increasingly qualified and resolute. With Ordinance No. 648/GM, it is defined that: FHP is not a program, but a Strategy (Family Health Strategy - FHS), because it does not provide a beginning, middle and end to the reorganization of services^{( 2 )}.

The nurses work in PC began in the 1970s, when the Administrative Reform of Health occurred. So, nursing responsibilities were: supervision, training, control, coordination of nursing; epidemiologic surveillance, community meetings, home visits and educational activities. Therefore, speaking of nursing practices presupposes the family-centered care within their physical and social environment.

The nurse in the FHS has duties that involve multiple levels of care. He/she is responsible for bond community-FHS, by assisting the health service user. In mental health (MH), there is need for specific professional support or changes in the training of staff^{( 3 , 4 )}. As expert support in MH, we believe it is essential for monitoring and supervising teams by Family Health Strategy Nucleus (FHSN) professionals, or planning by Psychosocial Care Center (PCC) professionals. In the sense of training of health professionals, we understand that it is in the construction and systemization of content that emphasize community-based MH, which will be possible integrality care aligned with the principles and guidelines presented in SUS.

In treating people with mental illness, the FHS also operates intensely and sometimes exclusively with medication. These and other difficulties, possibly have as a consequence the insecurity of professional and the population about the treatment, professional negligence, poor care and underreporting in MH^{( 4 )}.

Therefore, the formation and training of human resources is problematized, specifically nurses in MH. The educational process needs to be guided in social commitment, training critical professionals aligned with the public policies of the country, which emphasize psychosocial care, with the foundation principles of the SUS.

In EEUSP (The Ribeirao Preto School of Nursing, University of Sao Paulo), after assessment of the old syllabus (2002-2009), we started the process of undergraduate syllabus transition in this school of nurses.

This proposal was due to both, the difficulty in integrating basic and clinical cycles, and the fragmentation of disciplines. In 2010, EEUSP had the enrollment of the first class of participants in the new syllabus. This new syllabus has changed: structure, workload, disciplines, among others^{( 5 )}.

From the search for articles (Scientific Electronic Library Online and the Virtual Health Library), we found no studies that discusses the importance of the discipline of mental health in PC in the nursing syllabus. The few articles found were from medical schools, totaling two articles. We also found, three national researches of nursing education in the context of MH, but not specifically in PC.

Thus, we found the necessity of studying nursing education in the MH for PC. This study aimed to analyze the theoretical/practical perceptions of the undergraduate student in nursing care in MH.

METHODOLOGY

This study was part of the research Mental Health in the Territory: actions of the Family Health Strategy Nucleus-FHSN along the FHS teams, resulting in a monograph/final course assessment. This is an explanatory research with qualitative approach. The Explanatory research deepens the knowledge of why a particular phenomenon. Thus, we aimed to identify and analyze the phenomena studied; i.e. the teaching/learning of mental health nursing in PC from the perspective of nursing students, we based on the relationship between the interpretations and thoughts about the experience lived in mental health in PC, from the research participants^{( 6 , 7 , 19 )}.

The research was conducted through semi-structured interviews, which occurred in August 2012, individual and recorded in EEUSP^{( 6 , 7 )}.

In total, we interviewed 20 nursing students from EEUSP, who were enrolled in the sixth semester of the undergraduation course. Inclusion criteria were: students taking the discipline Nursing in the Primary Care in EEUSP, in 2010. We excluded the students who failed the discipline.

Thematic analysis of the transcribed interviews were conducted, aiming to discover the categories of meaning that comprise communication, taking into account the presence and frequency. The pre-analysis was performed after transcribing the interviews. On a second reading, units of analysis were highlighted, so later, we could be able to exemplify the analysis^{( 7 )}.

We organized the units of analysis in themes and subthemes, so that the major categories could be created. The study was approved by the Research Ethics Committee from EEUSP through process N. 39263 of 19/06/2012. The participants signed the Consent Form.

RESULTS AND DISCUSSION

In 2011, it was proposed, for the first time, in the new syllabus, the discipline of Nursing in Primary Care, which the contents of MH were: National Policy for Mental Health; Mental Health and Psychosocial field: elements for the nursing practice of mental health in PC; Epidemiology of the common mental disorders, alcohol use and assessment instruments for mental health in the FHS users; and synthesis of mental health^{( 5 )}.

This discipline aimed the instrumentalization of planning, implementation and evaluation of nursing care on PC, through the participation of health promotion projects directed at specific groups, considering the demographic and epidemiological characteristics of the region of the field internship^{( 5 )}.

The student, therefore, does not mandatorily have contact with people with mental illness. However, field activities are organized in internship field, where students are addressed as the subject of MH. These activities aim to recognize, among the working processes of BHU, actions directed at users with mental illnesses.

Despite the integration of nursing in MH in PC, professors opined to be a start, restricted by workload and lack of professors. It is evident, the need for proper training in the ​​mental health area in PC. The MH education in this scenario was not enough for many students, the lack of content resulted from low workload brought consequences such as: lack of preparation in the care, the non-demystification of MH stigma and lack of expectation in dealing with problems of MH in PC.

The results were grouped into three empirical categories: Teaching-learning process, Basic Health Unit and mental health-illness process. The discourses of the participants were identified with a code at the end of the sentence. Participants and their excerpts of discourses were numbered ordinarily (order of interview). Therefore, the coding is given by the letter I (interviewed) followed by student number, and the number of sentence.

Teaching-learning process

The evaluation of the teaching-learning process regards how the student is learning and the necessary review of the elements that constitutes the teaching practice. The purpose of the evaluation is to identify needs, allowing for better understanding of teacher-student situation within the course of education^{( 8 )}.

The analysis of the interviews allowed the learning of the MH theory taught in the discipline of Nursing in Primary Care, it was not enough, considering the preparation of undergraduates to meet the needs of MH users, while performing internships on PC.

Students explained themselves by saying that the focus of care in PC are others, i.e. the elderly, prenatal care, among others. However, daily PC teams deal with MH problems^{( 9 )}.

I didn't miss it. We focus on other things. (I14.10)

I could not understand ... Mental health is essential for primary care. (I17.10)

Other statements showed the need for theoretical content in MH for care at BHU, since MH is present in all areas of care.

It should be discussed in class, students should be prepared for this situation. (I15.8)

Subject that is addressed in all areas. (I15.10)

The FHS professionals have been asked to deal with substance abuse, depression and domestic violence, which has a high prevalence in the population, showing the necessity of training for PC professionals in the care of MH^{( 4 )}.

The unpreparedness of students in MH was cited in the statements. The student- person with mental illness relationship was seen as difficult, because they did not know how to identify, deal with and therefore, they did not know which conduct to follow.

I could not identify, I don't know if I handled them the right way. (I8.6)

I did not know what to do, what was happening, what to take note. (I12.13)

The domain of the therapeutic relationship allows nurses to use technology not only in the care of people with mental illness, but also in other areas of the profession. This tool allows the rescue of the essence of nursing that deals with human suffering and not only with their diseases^{( 10 )}.

It is noteworthy that students taking the course primary care discipline, had already taken the basis for educational activities in health, in which the MH has 28 of the 150 total hours of the module, developing theoretical content and group activities. This course is aimed at learning educational actions and interpersonal relationships in nursing practice.

This showed that research participants suffers the disagreement generated by stigma and insecurity in dealing with people with mental illness. Consequently, accused the lack of knowledge on psychiatric illness and perceived themselves as unprepared to care.

In one study, the statement of a caregiver of a person with mental illness, brought a contribution in demystifying and deconstructing the stigma of medical students, thus contributing to the enhancement of theoretical and behavioral content^{( 11 )}.

Some students justified their unpreparedness to the lack of theory offered in the classroom. The low workload in MH demanded a choice of theoretical content, so a search for the essential, difficulty the teaching-learning process.

We didn't received guidance on how to deal with mental health patients. (I20.5)

Besides students' demand for more specific preparation, they reaffirmed they had low workload for learning. It is worth noting that this discipline propose to teach the student to understand the individual in their integrality, not focusing specifically on the needs of MH, a fact that justifies the "zero workload" which was evidenced by one of the participants.

We should have had more lectures for mental health. (I2.2)

I don't remember any specific class. We had class guided towards children, adults, VD, but for mental health, none. (I15.6)

As student demand, it was mainly the need for lectures in MH, thus, the desire to learn about pathology of mental illness, to identify, deal with and conducting these cases in PC.

It would be more interesting if they focused on: diseases, how to detect, what to do. (I19.5)

The objectives of the discipline Nursing in Primary Care are related to student learning "provide nursing care to individuals, families and groups in different life cycles, guided by the social context, in the epidemiological profile in which they are inserted and in clinical dimensions, ethical and relational/interactional"^{( 12 )}.

Therefore, this discipline does not focus on pathology, but to care for the user. Paradoxically, in the statements, students reduced MH to disease or minimized the person as the disease^{( 12 )}. Thus, the discipline favored a focus on health promotion, providing opportunities for a holistic view of the user, demystifying the reductionist belief that the linear view of pathology can provide.

Still, some students mentioned that this discipline emphasized theoretical content related to family health, resulting in theoretical repetitions that could be dispensable.

We had a lot of content on family, but we had already had that in the first year, then, they could decrease the time on this subject and increase on mental power. (I16.17)

It was identified in the discourses, the segregation between MH and other areas of care. The instruments in MH, i.e. to know and to do such as therapeutic communication, the bond, the ambience, among others, are applied in all areas of nursing and therefore should not be segregated.

Some students expressed their desire to have a qualified professor in MH on stage for a more targeted guidance on the practices of MH.

The luck was that Professor Y has a good experience in mental health, and then she guided us. (I13.13)

Not all professors know enough about mental health, we could have a recycle for practice and theory to be more linked. (I16.20)

As we have more them one professor by training field, one of them could be mental. (I16.21)

The supervision in internship aims to guide the student in his/her human and professional development, dealing with learning difficulties. To do so, students suggested monitoring during internship from professors of PC and MH areas^{( 13 )}.

Participants also stated that their expectations were on the internships. Some said they had no expectations in relation to MH in PC. The learning procedures such as dressings, prenatal and care of the elderly caused greater expectation.

I didn't have a lot of expectation. The focus was to keep the link with family and such. (I14.8)

I didn't think I was going to have contact because of the focus of the classes. (I15.7)

The thematic sentences confirmed that despite the syllabus change, in students' perception, care is still fragmented.

We'll have the module of mental health, I hope we can see more.(I7.7)

The observation and execution of care in MH in PC are important means for learning. Despite the discourses reveal little, or none, expectation of learning in MH, the practice in BHU favored the observation of theoretical content in practical field, as some reports have revealed.

FHSN activities such as therapy groups, therapeutic communication, consultation in MH and conducting case studies were cited as learning opportunities.

I had the opportunity, my case study was with a patient who had depression. (I1.1)

I got close to the psychologist from the FHSN. (I1.5)

I participated in the group of mental health, people went to inquire information about the moment that they were experiencing. (I4.1)

Paradoxically, other students mentioned lack of experience:

I had no opportunity in primary care. (I3.1)

If a student went to BHU with the professor of mental health, he might have seen more.(I9.14)

In the teaching-learning process, thus the theory should favor the practice, supporting the process of nursing work. Through adequate supervision, professors assist in the care of people with mental illness, but also in the process of self-knowledge and personal growth itself^{( 14 )}.

BHU as scenario of mental health practice

In internships of the discipline, students were divided into groups, and each was directed to a BHU. On internship, the group of students was supervised and accompanied by professors of the EEUSP. Students observe and carry out activities and procedures.

The BHU teams was evaluated positively and negatively related to the work process. On the positive view, the staff was conceptualized with good provision for the teaching-learning process.

Some students characterized the teams as unprepared to care for MH. Referred that professionals showed in their practices, relations permeated by stigma and negligence in caring for people with mental illness.

These people, when they go through primary care, are undertreated, because of professional unpreparedness. (I17.7)

One study found that, most professionals are unprepared for care facing the MH, since the interviews brought many concerns by all healthcare team^{( 4 )}.

The work process consists of a directed activity to an end, the work object and the means of work. In health, we can translate the activity as caring, the object as the user of the health service, and the means as tools and resources available to care^{( 15 )}.

We identified statements that evaluated the work process in BHU. Among them, the rapid and ineffective service in care in MH, assess the environment and work process as a whole, respectively.

And not just half an hour while the doctor is writing the prescription. (I4.27)

I haven't seen a single effective work in primary care.(E4.24)

Several strategies of care were learned during activities that students had the opportunity to perform along with nurses, such as welcoming, guiding the use of medication and nursing visits. We observed the unpreparedness of the team in relation to assistance in MH, and the statements of surprised by the ability of nurses to deal with the direct user assistance with mental illness.

We [student and nurse] went to visit a boy who had schizophrenia. (I11.2)

Who really gives direct assistance is the nurse. It was very interesting, it surprised me. (IE11.10)

According to the Handbook of Nursing of the Ministry of Health, what is expected of a professional of nursing care in MH in PC, is that this professional enables a comprehensive care, offering the mentally ill family the needed support, so they can assume the role of inclusion agent, allowing the insertion in the community where they belong^{( 16 )}.

Mental health-illness process

The mental health-illness process represents a set of variables relationships that produce and shape the health and mental illness in a population. There are several conceptions, which may be found at the birth of psychiatry, following the biomedical model, as in most recent theories, following the social determinants of the health-illness process^{( 16 )}.

The conception of mental illness in the biomedical model is based on the description of signs and symptoms, whose protagonist of treatment are drugs. This view contrasts with the social determinants of the health-illness process, which includes health as a result of a social process that expresses quality of life, which is determined by political, economical, social, cultural, environmental, behavioral and biological factors^{( 9 )}.

The concept of mental illness was unveiled frequently in the discourse of students. This concept appears to be linked to both diagnoses and symptoms as related to psychosocial factors.

Depression, schizophrenia, aggressiveness and need for controlled medication were some of the images of the person with mental illness reported, which are related to the biological model. Moreover, it was observed the presence of reductionism of MH to mental illness^{( 9 )}.

The factors related to psychosocial aspect were isolation, victim of domestic violence, financial hardship, job abandonment, suicide attempts and family separation.

We will always find mental health anywhere. (I8.7)

The user of BHU lost her house, separated from her husband, lost her job, a series of things that led her to attempt suicide. (I16.14)

The definition of stigma appears as a pejorative sense due to the existence of a difference that generates unwanted disqualification for social acceptance. The lack of knowledge about mental health-illness process entails fear and segregation of the mentally ill^{( 17 )}.

The concept of mental illness directly influenced the expectations of students, in dealing with this population in PC internships. Part of this group revealed feelings of fear and apprehension.

Mental Health reminded me only of crazy people. (I4.19)

I was scared, I thought he was going to answer several things to me that he would hit me. (I11.8)

These concepts are socially constructed and reconstructed, including the core of the family, in which quality and way of living are essential to this understanding. It reveals a stigmatized view of the person with mental illness, apparently without even conceding the influence of content developed in the classroom^{( 16 - 18 )}.

CONCLUSION

In this research, it was possible to understand that teaching MH in the discipline of Nursing in Primary Care in EEUSP was not enough for many students. For them, the lack of content, resulted by low workload, had consequences, such as lack of preparation for care, the non-demystifying of the stigma of mental health/illness and lack of expectation in dealing with mental health problems in PC.

As a result, the undergraduate nursing student did not expect to find in the territory, people with mental disorders; probably associated with the idea expressed by some discourses of dangerousness, is the idea that "crazy" is hospitalized.

Students assessed the BHU teams as unprepared for care in MH, however, revealed learning situations in assisting these people. It can be inferred that learning in these situations is not an objective, such as prenatal or dressings and thus this opportunity becomes casual and sometimes not perceived/followed by students and professors.

Students highlighted the need to feel more supported to care for MH, with content and the presence of expert professors in the field, which unveiled a contradiction, since PC teaching is not a specialty. However, the need for planning in some specialties, including MH, is advocated in PCNP, as well as Mental Health Policy.

The discourse analysis led us to conclude that constant reflection and evaluation of the teaching process is necessary so that they can reduce the chances of future health professionals who may have greater difficulty in dealing with the care of people with mental illness.

Moreover, EEUSP, traditional school, that has professors who participated and actively participate in the Psychiatric Reform, must endeavor to train professionals who do not use common sense to think about the care of the insane and crazy. Therefore, we believe that there is a great need for education, in the academic learning process.

This study may help professors from EEUSP in the evaluation of the theme, and thus generate positive changes, enabling further research, making education more consistent in MH. As limitation of this study, we evidenced the fact we analyzed only one nursing school, demanding further research on the same theme, but in other scenarios. Thus, this publication aims to benefit other institutions of higher education and nursing technician, and generate awareness about the importance of nursing education in mental health in PC.

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Publication Dates

• Publication in this collection
  Mar 2014

History

• Received
  18 Mar 2013
• Accepted
  09 Jan 2014