Social representations of nurses of the Emergency Care Unit towards people with mental disorder

ABSTRACT Objective: To understand the Social Representations of nurses from an Emergency Care Unit about the care provided to people with mental disorders. Method: Qualitative exploratory study, supported by the theoretical and methodological framework of the Theory of Social Representations. Interviews were conducted from July to August 2021. The data were processed using the IRaMuTeQ software. Results: 22 nurses were interviewed. From the processed data, three discursive categories were constructed: the tortuousness of the Psycho-Social Care Network (RAPs): in search of a path; the abyss between the health professional and the person with mental disorder; and unveiling the care of nurses in the Mental Health Emergency Care Unit. Conclusion: We identified a lack of knowledge about the Psychosocial Care Network, anchoring elements associated with previous negative experiences that influence the professional-patient relationship, and nursing care permeated by cognitive barriers. Such findings are unprecedented in the locality studied and relevant to promote the qualification of the work of nurses in mental health in the Emergency Care Unit.


INTRODUCTION
The Brazilian Psychiatric Reform (BPR) proposes a collectively produced project of change in the model of attention and management of mental health care, replacing an asylums-based mental health model by a model of community services with strong territorial insertion (1) . Such movement had as target population people with severe and persistent mental disorders, in a greater situation of vulnerability and segregation, from which in the present research the mental health care is related to these patients. From this perspective, the Psychosocial Care Network (RAPs in the Portuguese acronym) was established, whose purpose is the creation, expansion and articulation of health care points for people with mental disorders (2) .
The RAPs is characterized by the diversification of care points and possibilities of arrangements for interventions in mental health (3) . In the scope of urgency and emergency care, this decentralization of care ensured that the reception of psychiatric urgency and emergency situations were no longer exclusive to health services specialized in mental health, which meant that the general urgency and emergency services also absorbed this demand.
A study (4) verified the predominance of unpreparedness of the teams of these services and of the places of attendance in these situations. Professionals dispute about the responsibility of emergency departments in attending people with mental disorders (5)(6)(7) , even claiming that the psychiatric hospital is the best direction for this type of demand (8) . There is a significant lack of knowledge about the flows and components of the RAPs and the non-recognition of urgency and emergency services as an integral part of this network (9) .
Based in the conceptions presented, there is an emerging need to understand which cognitive elements (images, concepts, categories, theories) are present in health professionals about mental health care in general urgency and emergency services and about the RAPs. For this, we used the Theory of Social Representations (TSR), which is a modality of practical knowledge, directed to communication and to the understanding of the social context in which we live. Thus, it is presented from forms of knowledge that reveal themselves as cognitive elements, which allow modeling what is given from the outside, from the relationships that individuals and groups constitute with the objects, acts and situations in social interactions (10) , in this study focused in the mental health care to people with mental disorders. Two fundamental processes stand out in the formation of Social Representations (SR), namely objectification and anchoring, the first being responsible for giving a representation the status of objective reality and the second for integrating and categorizing new information that will guide the understanding and action (11) .
Using these concepts, this study aimed to understand the SR of nurses of an Emergency Care Unit (UPA in the Portuguese acronym) about the care given to people with mental disorders.

Study deSign
This is a study with a qualitative methodological approach, with an exploratory focus, having TSR as its theoretical and methodological reference. Such theoretical contribution was coined by Serge Moscovici in 1961, and is characterized as a form of socially elaborated and shared knowledge, which contributes to the construction of a common reality for a social group, having importance in social life and in the elucidation of cognitive processes and social interactions (11) .
The recommendations of the Consolidated Criteria for Reporting Qualitative Research (COREQ) guide were followed for the construction of this study (12) .

PoPulation
Twenty-two nurses who are part of the staff Emergency Care Unit (UPA) participated in this study.

Setting
The research setting was a UPA in Três Lagoas, Mato Grosso do Sul, Brazil.

Selection criteria
Direct healthcare nurses of both genders with at least one year of experience in the UPA participated in the study. They agreed to participate individually, voluntarily and free of any coercion. Nurses who performed exclusively administrative activities were excluded.

SamPle definition
The exhaustion criterion (13) was used, in which all eligible subjects were approached.

data collection
Data were collected in July and August 2021, by means of interviews. For this purpose, a semi-structured script was used, composed of two sections: the first containing quantitative variables aimed at obtaining sociodemographic/professional characteristics, and the second composed of qualitative questions with the purpose of extracting the SRs of the nurses regarding their performance in mental health and about the RAPs.
The interviews were conducted by the responsible researcher, in the UPA, during the professionals' breaks, ensuring that the environment was reserved and provided privacy to them, respecting the health measures in place due to the Covid-19 pandemic.
The interviews lasted about an hour and the content was recorded in the data collection instrument itself and through audio recording, using a device for this purpose, with the consent of the participants. Afterwards, the speeches were transcribed in their entirety.

data analySiS and treatment
The data were collected into a Microsoft Word document, then transferred to a Notepad and organized to be processed by the software IRaMuTeQ (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) version 0.7 alpha 2, developed by Pierre Ratinaud in 2009, in order to build the text corpus.
Among the different processing possible through IRaMuTeQ, we used the Descending Hierarchical Classification (DHC), which classifies Text Segments (TS) according to their respective vocabularies and divides them according to the frequency of reduced forms, generating a dendogram that illustrates the relationships between these classes (14) .
In this processing, a total of 794 TS were obtained, of which 642 were classified, generating a utilization of 80.86% and a subvision in 6 classes. In this study, we considered the first 20 most significant evoked words in the classes, and the same subsidized the construction of three categories that portray the representational contents of nurses about the theme of the study.
Therefore, the categorical analysis unfolded from the classes processed by IRaMuTeQ, which considers the most relevant lexicons in relation to the processed text corpus. Thus, the software presents the TSs that are representative for the selected lexicons in the process of building the classes derived from the DHC.

ethical aSPectS
The study followed all the guidelines and legal prerogatives established by Resolutions 466/2012 and 510/2016, of the National Health Council. It was cleared by the Research Ethics Committee of the Federal University of Mato Grosso do Sul by Opinion No. 4.555.902/2021. All participants were instructed and clarified about the study, and given the Informed Consent Form (ICF), which was duly signed after acceptance to participate in the research. The confidentiality and anonymity of the participants was guaranteed through the use of the codename "Interviewee" followed by a number indicating the sequence in which the interviews were conducted.

RESULTS
Twenty-two nurses participated in the study: 16 (72.7%) were female and 6 (27.3%) were male; ages ranged from 26 to 58 years; average time of training in nursing was 12.5 years.
The professionals were mostly graduated in public institutions (n = 14; 63.6%); 12 (54.5%) reported not having had access to the necessary knowledge about mental health during their graduation. As for complementary education, 7 (31.8%) had completed a second undergraduate course, 21 (95.4%) had at least one finalized latu sensu specialization, and 3 (13.6%) had a strictu sensu postgraduate course in progress (academic master's degree).
As for specific knowledge in mental health, 1 (4.5%) reported specialization in this area, still in progress; 8 (36.4%) had taken some course related to mental health, but half (n = 4; 18.2%) more than 3 years ago. The great majority of professionals (n = 21; 95.4%) recognize the need to provide mental health care in the UPA, and all of them (n = 22; 100%) affirm that they face this kind of care frequently.
The processing was based on the lexicons identified as significant in the text corpus, which were extracted from the TS from the interviews, from which the excerpts were representative and relevant for each class extracted. Then, they were organized in the form of a dendogram, from which a categorical analysis was performed, which resulted in the identification of three categories according to the similarities identified among the classes: a) "The tortuousness of the RAPs: in search of a path"; b) "The chasm between the health professional and the person with mental disorder"; and c) "Unveiling the mental health care of nurses in the UPA" (Figure 1). The incipient recognition of the PCU as part of the RAPs can have a significant impact on the work and, therefore, on the way nurses perform their daily practice, specifically about mental health care. Thus, it is observed that some participants try to bring to the familiar something unknown in their consensual universes: Well, the Psychosocial Care Network covers as much mental health as people who use alcohol and drugs, who have this kind of dysfunction. (...). An awareness is being created in the municipality, but in a slow pace. One thing at a time (Interviewee 13).
Currently I see that it has improved. There is still an articulation, in a loose way, a little lost (...) (Interviewee 19) Furthermore, some professionals base their SR on structural weaknesses of the emergency service to justify the way they develop their mental health care to users arriving at the ED:   It is observed that the practice of mental health care is represented as something that has its own complexity and superior to other areas, causing discomfort and triggering negative feelings in professionals. Such feelings are expressly verbalized by another participant: Fear! I'm afraid because I've already been assaulted by a mental health patient, a disorder (...). If there is another colleague to attend to I prefer it. (Interviewee 08) It is identified that the feeling of fear reported by the professional is anchored in previous unsuccessful experiences in these types of care, and that such a situation caused a permanent fear of the professional to attend patients with mental health needs. Difficulties related to lack of preparation and lack of flows and routines for this type of care were also verbalized:  The lack of knowledge in mental health and of skills in the approach and welcoming of patients and their families was also verbalized:

I don't find it easy because it requires a peculiar thing. I sometimes can't understand the pathology very well. It's difficult, for me it's a little difficult. (Interviewee 10)
I have a lot of difficulty in this issue of dealing with psychiatric patients, because it is not an easy area, it is a very difficult area to deal with feelings, with emotions, with the psychological, with everything together and the family members as well (...) (Interviewee 21) From the TSs, it can be seen that the subjectivity and intersubjectivity of mental health care interfere substantially in the formation of SRs about this type of care, making it difficult to materialize this care into something practicable and applicable in the daily practice of an emergency service which, by its very nature, values objective care and quick results to the actions that are practiced. category 3: unveiling the mental health care Provided By nurSeS in the uPa Taken from the lexicons derived from classes 1 and 5, it portrays how the reception and follow-up of cases requiring mental health care in the PCU occurs, as verbalized by one interviewee: We welcome this patient. If it is a simpler case, we refer this patient to a doctor's office for a medical consultation (...) if it is an outbreak patient, (...), the approach has to be different. We approach this patient, classify him as red or yellow, and send him to the emergency room. And then we have to have another approach that is a little more aggressive, because if this patient is having an outbreak, he puts our assistance at risk, our assistance, the team at risk, and even himself (Interviewee 22) It is noteworthy in this statement that the representational contents about a patient in crisis are linked to segregating, repressive practices and a threat to everyone's safety. It can be seen that the professional is taken by the risk classification model and is not able to objectify a mental health care linked to the principles of BPR. The following excerpt, from another interviewee, exposes how the representations coexist with care models that reproduce the asylum practices: It can be noticed that one of the main concerns verbalized by the interviewees is focused on the performance of the technique itself, on how to make it more effective, and not on the patient as the object of care in the sense of creating strategies to alleviate his suffering. This situation is anchored in representations prior to the BPR in which the focus was on containing expressions of madness and silencing feelings and reactions. However, the existence of positive and successful initiatives by some nurses was also observed: I really enjoy talking, guiding the patient, trying to minimize the impact that the actions have on the patient and the family themselves. I feel good when I am successful (Interviewee 09) The following statements denote attempts to succeed in the care both to the patient with mental health needs and to his family, but permeated by incapacitating feelings: The last statements denote the existence of a core where there is the ideal of a perspective of an individual and family care based on the principles of BPR that can originate and re-signify, at an individual and collective level, the SR of mental health care in this context.

DISCUSSION
A social representation speaks as much as it shows, communicates as much as it expresses, produces and determines behaviors (10) . In light of this theory, it was possible to apprehend the perceptions of the participants about mental health care in the UPA through the identification of the existing languages and how this conjuncture marks the actions of the researched group.
The problem begins from the objectification of the important ignorance about the RAPs verbalized by the participants and, being it an element of articulation of the mental health care points and governed by guidelines that ensure a humanized, equitable and community-based care (2) , its non-recognition and the consequent disarticulation between services contributes significantly to a fragmented and unresolved assistance (8) .
It is noteworthy that the lack of knowledge about the current situation of the functioning of the RAPs in the country is, in fact, a reality and, with regard to the emergency network, there are even greater difficulties in the recognition of these services as its constituents (9) . In this context, it can be observed that such social reality is formed from the unfamiliar incorporated into the consensus universes of the research participants from the construction of the experienced reality (15) .
Another anchoring observed that supports the objectification of ignorance refers to the structural issues of the service to receive people with mental disorders, especially those in crisis, which does not provide a safe environment and the guarantee of secrecy, privacy and confidentiality of the patient (6,(16)(17)(18)(19)(20) .
It became evident that between health professionals and the person with mental disorder there is a chasm whose depth is proportional to the non-identification with the mental health area, the negative feelings triggered and the lack of preparation, knowledge and skills reported by the interviewees.
The negative feelings are recurrent in the health professionals in these services, such as frustration and intimidation (21) , dissatisfaction (22) , discomfort (7,21,22) and fear (7,23) . In some of the speeches we can observe that such feelings are anchored in previous negative experiences, which goes beyond the lack of training and suggests lack of personal preparation (17) . Considering that the SRs govern our relationship with the world and with others, guiding and organizing behaviors and social communications (11) , it is understood how such process is determinant in the practices performed, in this case in mental health care.
The non-appropriation of knowledge in mental health based on the principles of BPR and the remaining concepts of classical psychiatry make professionals anchor this care to outdated concepts and, added to the lack of established flows and protocols for this type of care, promote a gap between them and the users. The lack of specific knowledge and skills, experience and qualification in the area is recurrent among health professionals working in general urgencies and emergencies (5)(6)(7)(17)(18)(19)(20)(21)(24)(25)(26)(27) , as well as the lack of specific protocols for the care of psychiatric urgencies and emergencies (8,26) .
As for the mental health care provided by nurses in the UPA, it is observed that the reception starts with risk classification based on the Manchester Protocol, in which the non-urgent or slightly urgent cases can be solved in the usual way as in any other non-psychiatric situation. Patients in outbreak are classified as urgent, very urgent or emergency, receive immediate care, but with a repressive character, which indicates that the workers of the UPA find in containment and medication ways to deal with such phenomena and appease the crisis (28) .
The interventions in psychic crisis guided by controlling and repressive actions reproduce the influence of the asylum model. The justification for the use of physical, mechanical and chemical restraint would be to preserve the safety of the staff, which is observed in other studies (6,7,25,26) . Since SRs, if viewed in a passive way, are apprehended as a reflection in individual or collective consciousness (10) , this allows explaining why obsolete concepts and practices based on the anchoring and objectification elements that form them are still reproduced.
Despite such reproductions, there are attempts by professionals to achieve the best possible care within the existing conditions, and to establish effective communication with both the user and his family. Theoretical and practical knowledge, communication skills, and a respectful attitude toward the patient are essential competence requirements for assessing people with mental disorders (29) . Satisfactory levels of knowledge promote increased confidence, positive attitudes, empathy and improvement in the quality of care provided (5,30) seem to be the way to a care based on ethical and legal precepts and the realization of the rights of this public in health services, especially in emergency rooms.
Finally, the SR as elements that intervene in processes as varied as the dissemination and assimilation of knowledge, individual and collective development, definition of personal and social identities, expression of groups and social transformations (11) are essential to elucidate the current situation of health practices and provide elements to remodel them in order to enable advances, which can be applicable to the care provided by nurses about the present object of study target of this research.
As limitations, we emphasize that these findings may not represent the object of study for other nurses in other PCU, given the dynamics of SR.

CONCLUSION
This study allowed us to understand the SRs of nurses about mental health care developed in a PHU, as well as the conception of these professionals about the RAPs, showing many challenges and obstacles and some potentialities in the care model developed.
It was identified the scarcity of elements of anchoring and objectification about the RAPs, through the manifestation of little or no knowledge reported during the speeches, which favors a fragmented assistance between the points of care and harm in the resoluteness of cases and continuity of care. Regarding the professional-patient relationship, anchoring elements associated with previous negative experiences in mental health care were observed, which seems to cause a kind of permanent trauma in some professionals. Most of the time, nursing care is permeated by cognitive barriers that hinder adequate mental health care.
Such findings are unprecedented in the locality studied and capable of promoting a (re)signification of the work process of nurses in this scenario, qualifying their work, which consequently promotes the improvement of the work process in the UPA as a RAPs care point.