Práticas em serviço de saúde mental: interface com a satisfação profissional

This study aims at investigating the perceptions and feelings concerning professional practices in mental health services and is focused on issues related to work satisfaction. This is a descriptive study based on a qualitative approach which has been developed through three communitarian services involving 29 professionals. Empirical material was gathered though the target group. Once the content analysis was completed, the results were directed at the perceptions of professional practices, also highlighting all experienced dilemmas and obstacles related to work satisfaction. These obstacles serve to expose all of the difficulties faced by workers in light of requirements stemming from Brazilian Psychiatric Reform ideals which cause them to feel paralyzed, and also the lack of resources required to support professional practices. All of these factors exemplify an extreme situation - living and coping with the distressing feeling of being unable to accomplish their work as they believe it should be done.


INTRODUCTION
:22 This shows that all changes involved are not only the result of technical and scientific change, but also of political-ideological direction.
In the case of mental health substitute services, the object of work is a person whose singular characteristics and life situation goes beyond mental suffering and/or chemical dependency.In this regard, aiming at acting according to a psychosocial perspective, all authors 2 identified the need for teamwork strongly supported by horizontal relationships, dialogue and humbleness in light of mental suffering, as well as flexibility in practice among all of the professionals involved.
Mental health work involves certain specificities which require workers to be able to deal with humans, aiming at understanding them according to the perspective of health care comprehensiveness.It is mainly because this work involves dealing with suffering and mental illness on a daily basis that production in the work environment becomes intensely subjective and intersubjective.Therefore, workers are constantly exposed to a variety of situations which may result in higher or lower levels of (dis)satisfaction. 3 Faced with transactions related to professional practices in mental health specialized services, all professionals in this area are required to learn and perform "new" practices consistent with the Psychiatric Reform objectives within a context which remains full of prejudice-based conceptions, even when these practices are not generally used in community areas. 4Based on this reality, there are questions and difficulties related to finances, activities and appreciation of professionals. 5 For this reason, we reflect on the subjectivity of these professionals, their involvement with services and the perspective they have concerning their own work, because these factors directly influence their commitment to professional practices.Professional satisfaction is defined as the positive feelings experienced while performing practices related to demands for professional services. 6tisfaction involves intrinsic and extrinsic aspects related to the work environment which have consequences for several areas of workers' lives.Such elements are found in the environment in which work activities are accomplished, and they belong to two main groups: events and conditions (i.e.: wages, the job itself, promotion and appreciation, work conditions and work environment), and agents (colleagues and subordinates, supervision and coordination/management, institution/organization). 3 Some studies highlight that, within the mental health field, work dissatisfaction is directly related to changes in the work team, high rates of absenteeism and other actions which may negatively affect the quality of care. 7In addition, factors such as being exposed to the difficulties faced by patients, quality of life, apathy and lack of autonomy with regard to practices and resources, as well as relationships, directly influence the professional satisfaction of the mental health services staff. 8herefore, the following question is raised: how do professionals feel about their daily practice in the mental health specialized services?All of these facts were exposed aiming at identifying the perceptions and feelings of professionals toward their practices in mental health substitute services.

MATERIAL AND METHODS
This is a descriptive study based on a qualitative approach, developed in a municipality of 385,213 inhabitants located in the arid fields of Paraíba State, which contains 112 healthcare institutions (including five CAPS, or Brazilian Centers for Psycho-social Care).Approximately ten years ago, public psychiatric hospitals were deactivated during the Psychiatric Reform.During this same period, several substitute services were implemented, including three different services: CAPS III, CAPS to children and CAPS to people with alcohol and drug dependency.
In order to set the number of study participants, Ordinance number 336/2002 was considered, because this ordinance outlines the minimum number of higher education professionals required to operate this service.Therefore, the sample was intentionally comprised of 29 professionals: six nurses, eleven psychologists, two social workers, two physiotherapists, three speech therapists and five teachers who met the criteria for inclusion: being in a higher respective education position and Practices in mental health services: interface with professionals'… having at least six months of experience working in the institution.
The empirical data were attained from the target group through a data collection activity which allowed the participants to interact in a focus group discussing the topic 9 based on the following question: "what do you feel while performing your daily activities related to this service?"This technique was appropriate to build a diversity of knowledge concerning the object representation by adding individual interviews to the group dynamics.Therefore, three target groups were formed from January to February, each of them comprised by members of each service.Sessions lasted an average of one hour in duration, and each group was led by a monitor supported by two observers.The analysis performed was based on Content Thematic Analysis. 10Initially, the material was organized according to the general reading, which allows specification of the field on which the analysis should be focused (pre-analysis phase).Once this first stage is completed, the analytic description for corpus codification is accomplished.Focused on the empirical material mentioned above, a reference interpretation is finally performed, involving the reflection and settlement of speech content and aiming at determining their latent and dynamic senses.
This study was developed according to the guidelines provided in Resolution 196/96 of the Brazilian National Health Council, and was begun following the favorable opinion (Number 0620.0.133.000-10)issued by the UEPB Ethics in Research Committee, guaranteeing the bioethical principles of autonomy, non-maleficence, beneficence and justice.All patients signed an Informed Consent Form and, in order to preserve their anonymity, they were named P (Participant) followed by their respective registration number in the survey.Aiming at obtaining an overview of the work context and preservation of participants' anonymity, their professional training is hidden, as well as the specialized service in which they work.

RESULTS
Based on each participant's speech, their perceptions and feelings toward mental health professional practices were learned.This article describes the category named "Aspects related to professional satisfaction", which exposes the connection between the subcategories named "Demand for work" and "Professional needs which lead to endangerment of practices".

Demand for work
All aspects related to exhaustion when performing mental health service practices were highlighted by participants, because such aspects refer to exposure to factors which may affect their physical and emotional resistance.
[...] and, at the end of the day, I feel really tired because this is very exhausting work [...] (P12).
[...] I also agree with the notion of exhaustion stated by [participant number 12]; at the end of the day, I feel exhausted because we constantly deal with complicated cases [...] (P13).
[...] because the demand is huge and most cases are really serious, we should be working more; I mean, we should provide more assistance and look after them [...] these are really delicate cases.Sometimes, you may think you are doing the right thing and, without any intention otherwise, you may cause an unpleasant situation for a child (P18).
It has been found that demand for work is the main reason for exhaustion, stress and the sense of being overwhelmed by cases, because participants are exposed to all manner of difficulties related to the number and characteristics of patients assisted by them.This situation requires the participants to be constantly alert and focused on their work because they must deal with patients whose state of health is classified as "severe", "serious", and/ or "delicate".Is it important to point out that indicators motivating these patients' classifications have not been explored.

Lack of appreciation for professionals
Appreciation for the development of practices seems to be associated with an appreciation for the professionals themselves.Among all participants involved in this study, eight of them are public servants whose employment is governed by posts, careers and salaries, while the other participants are bound by temporary or CLT (Consolidated Labor Laws) employment agreements.Concerning the appreciation of the professionals, all participants stated that this is reflected in the appreciation shown toward their work; this implies not only offering financial incomes commensurate with their professional category and work accomplishment, but also investing in professional Macedo JQ, Lima HP, Alves MDS, Luis MAV, Braga VAB training and providing favorable working conditions with regards to materials, instruments and career progression plans.
I feel upset about being so distressed about all these questions related to CAPS, and in fact I don't feel appreciated.We all feel distressed because we earn a small wage with which we cannot even pay for therapeutic treatment, and the health risk premium is not enough even to pay for a health plan.We realize that we are working with so many questions raised concerning mental health, but without  As highlighted in the statements above, personal feelings involve not only feeling distress (which alone would be enough), but are also associated with the fact that the professionals' commitment is not appreciated by government agencies.In addition, a full time work week within the area of mental health often causes these professionals to feel overwhelmed due to improper work conditions, and also because they are not provided with a specific health plan; this aspect is considered by professionals as appreciation for their performance.
[...] and this makes us realize that our wages have so far been disappointing [laughs]; even so, we are so happy about what we have accomplished here.This is exactly why we are here!(P29).
Wages, an important factor in professional appreciation, do not approach the level expected; however, professionals feel happy about their work, and this reveals an ambivalent attitude towards the work accomplished and its respective financial compensation.
All speeches above point out that the distress felt by each participant while performing professional practices is related to feeling underappreciated, and this becomes evident through the indicators related to workload fulfillment, mental health demands, theoretical (educational) and personal investments not funded by the service and the need for emotional support.The two last aspects mentioned cannot be paid for by the participant due to "low wages" derived from such service.This fact highlights the notion that this work is strongly tied to altruism and feelings of self-worth.

Endangerment of practices
Professional practices in the mental health area have also been associated with a lack of material, financial, intersectorial and community resources which interfere in the actions developed and may affect the quality of the services provided.Subjective conditions also influence each professional and may cause frustration and feelings of distress when faced with the inability to solve problems during the professionals' daily practices.
I can't feel better because here we only have our bodies and minds to accomplish our goals.It has already been mentioned but here we don't have anything... not even an appropriate structure.There are so many things we need in order to help us to meet our professional goals and feel fulfilled [...] (P26).
Based on the statement above, it is possible to realize how this professional feels without the institutional support to provide high quality work, and also for professional fulfillment.According to the situation exposed, it seems that this professional can only count on himself as his/her most valuable resource, and this may be the reason why professionals define their work as a self-fulfilling activity.

To develop socio-cultural activities outside our local service, we need specific resources that we don't have. Even within our local service these resources are unavailable. Unfortunately, our hands are tied and we can only perform activities such as garage sales and small parties in order to raise funds to develop any type of work with our patients. It shouldn't be like this [...] (P8).
This statement complements the previous speech and provides us with more indicators related to needs, which make it difficult to accomplish work goals within the governmental guidelines.
Although we have our personal difficulties, and no matter how much we give of ourselves, some of us simply cannot leave CAPS behind due to the social process against which we must struggle, and which is one of the serious difficulties faced by this prejudicial society, which is especially important here [...] (P5).
As human beings, we are also affected by other peoples' anguish and, if we cannot withstand this, our distress level increases and we may feel paralyzed and only see difficulties and impossibilities everywhere; we become unable to move on with that case.In my opinion, Practices in mental health services: interface with professionals'… the biggest challenge is to withstand, deal with, and move on in situations of anguish [...] (P21).
It seems that facing such obstacles without accomplishing their work according to appropriate standards, as well as the failure to solve the demands presented by patients, may lead these professionals to experience personal conflicts accompanied by much distress, up to the point in which the feel paralyzed because they do not realize the mechanisms available to move on with these situations.
Below is diagram 1, which is based on the speeches provided in the subcategories above.Included in the diagram are the subcategories, as well as the aspects which compound and define the perceptions and feelings exposed by participants.

Diagram 1 -Perceptions concerning professional practices within analyzed CAPS
Outlined in this diagram are the professionals' perceptions in order to see the connections among them.It was found that the demand for work causes exhaustion and a sense of being overwhelmed, and this is increased by a lack of investment in innovative practice implementation, which has been identified as a standard for mental health care.In turn, this causes professionals to experience distress, just as the lack of investment causes them to define their work as a self-fulfilling activity only and, therefore, as a non-appreciated endeavor reflected by low wages and non-recognition of their fatigue.In addition, there is also a large number of patients with unique needs, as well as the demand for work performed without any material and logistics support.
In light of this scenario, the workers have only themselves, depending solely on their "body and mind" to accomplish their work; perhaps this is the reason why they feel "paralyzed" when they are unable to solve or move on with these cases, because their involvement with work is also psychically and physically expressed.

All modifications provided by Psychiatric
Reform direct the use of different interdisciplin-ary technologies for mental health services, such as intake procedures, therapeutic listening, individual therapeutic projects, the creation of bonds and family participation.All of these technologies require the professionals to be retrained, and their roles should be expanded within the mental health care team. 11mong the elements contributing to work overload are the concentration of daily functions in professional practice, the frequent contact with mental suffering and family and social contexts whose repercussions may affect the professionals' subjectivity, arousing all sorts of defensive mechanism. 12he professionals' speeches expose convictions similar to those exposed by the author 13 concerning the treatment applied to mental health workers.In her understanding, there is a connection between two speeches -one of them is explicit and the other is implicit -and these are described below.
:69-70 This speech is intended to be visible.fact is confirmed through the context in which professional participants of this study are involved, and this becomes more visible because the terms employed in this speech were carefully selected to describe the patients of this service, and also through reasons hidden in expressions such as "this is not a joke" and "hard cases" to describe the work developed with these patients.
:70 All factors mentioned above have been stated by the participants involved in this study, as well as how these factors affect their commitment to work in regards to meeting mental health service objectives in accordance with Brazilian mental health policies.Consequently, when they realize that they cannot achieve these objectives, they experience job dissatisfaction, as well as helplessness and feelings of distress when they are unable to move on with cases; finally, they feel "paralyzed" because they cannot find a viable solution.
In addition, political and cultural factors are unfavorable for service implementation because both the population and public agencies still consider social isolation to be the best option for psychiatric patients. 14This results in endangerment of practices and objectives expected in these "new" services.
Mental health is an underappreciated field when compared to other health areas, which have more attributes and technological support.Therefore, the demand for psychiatric assistance does not permit the respective professionals to be trained or appreciated. 13urthermore, the implementation of practice has also faced difficulties involving lack of trained professionals, financial support for work appreciation and material required for artistic activities because this study 5 has revealed that public agencies only provide medication.Surprisingly, this was the only factor required for these services to operate.
Whenever professionals discuss the difficulties involved in obtaining resources, they refer to the CAPSs financing discussion, which has been examined through theoretical studies. 5,15A service is implemented based on new technologies and psychosocial care, while financing occurs via the Authorization of Highly Complex Procedures (which is known in Brazil as APAC), related to the clinical diagnosis.
Regarding investment in the process of deinstitutionalization, professionals stated that lack of autonomy may influence professional fulfillment because resources and the possibility of social openness are insufficient within this context.This fact is supported by a study developed in this area. 14ork dissatisfaction may result in decreasing self-fulfillment in professional activities.This is revealed through feelings such as poor motivation, low self-esteem and inadequacy.Therefore, professionals working in this area must struggle daily against suffering patients and their own personal needs, without neglecting their own health. 16n light of these facts, it is important to highlight the difficulty in obtaining all of the necessary materials required to accomplish activities, whether they are artistic, cultural or leisure activities, so that CAPSs patients can enjoy all of the social opportunities currently available.Also, professionals are concerned about the difficulties in providing adequate care, such as establishing networks, family support, partnerships and community-based projects, which may assist in the psychosocial rehabilitation and inclusion of patients.
Providing care to CAPS patients is often defined by participants as a self-fulfilling act.This can be understood from three different perspectives: biological -which is related to the desire to relieve others' suffering, but which causes stress to professionals; religious-which is intrinsically related to kindness; and professional-which refers to the obligation of those who are committed to do as much as they can for those who are suffering. 16It is also clear that actions performed in these services have an impact far beyond professional practice and within the subjective conditions of these professionals, given that they face a dilemma between being aware of those who are suffering because they must provide humanized care for them, and at the same time feeling discouraged due to the suffering faced during their professional practice on a daily basis. 16ithin this context, mental health service professionals realize that they act as instruments in assisting patients to overcome obstacles and claim their rights concerning social inclusion.However, Practices in mental health services: interface with professionals'… these professionals also refer to helplessness and feelings of distress in the face of public attitudes toward professional practices required in this service, which place many intersectorial resources out of the professionals' reach.
Mental health does not infer a lack of distress or a uniform level of comfort, but it does mean hope in achieving goals and objectives which are set.People live not only for satisfaction, but also for desire.If desire is no longer possible, it may lead to exhaustion and suffering. 17n addition, lack of investment in professional training was highlighted because job stability and comparable wages are fundamental to achieving objectives and transforming the practices required in psychosocial care.Aiming at solving this situation, authors 18 have pointed out the need to take appropriate measures concerning management commitment in holding job competitions for professionals in this area.
Work organization according to tasks and professional relations impacts the worker's psychological status, and may result in pleasure/ suffering, depending on how important the respective task is to a worker, and also whether relationships involve appreciation, cooperation, confidence and solidarity.Therefore, pleasure/ suffering is associated with workers' subjective relationship with their work in such a way that, when interacting with others, they experience and share tasks influenced by personal values.Pleasure is experienced through the feeling that work is appreciated. 17or the participants, appreciation also involves investment in the professionals concerning their health, taking into account that their professional practice results in emotional strain; appreciation also involves providing wages and work conditions adequate for the demands and public agency requirements.

CONCLUSION
This study seems to have revealed the deadlock situation faced by workers in meeting the Brazilian Psychiatric Reform requirements, as recommended by mental health policies, because they feel committed to it without having he necessary resources for professional practices.The main perception of participants is that they can only count on themselves and their personal resources without the institutional support required for a high quality professional practice.They also describe a threshold situation -experiencing and coping with the distressful feeling of not accomplishing their work as they believe it should (and could) be done.
In addition, professional practices within the mental health substitute services analyzed in this study are considered exhausting due to difficulties in obtaining the resources needed, and also because of demands which go far beyond the work area and may result in endangerment of practices and services objectives.This situation is accentuated due to the fact that investments are considered by professionals as insufficient when compared with the requirements demanded from them.
As this area is constantly trying to set new practices, mental health professionals are essential for the achievement of Psychiatric Reform.However, it is clear that these professionals need to be supported because they are responsible for the provision of mental health services.Support must come from public authorities and societal engagement concerning questions related to professional demands, autonomy in practice development and professional appreciation.
In spite of the enlightenment provided by this study, there are limitations concerning the method used in this study, which involved intentional and nonrandom sampling that makes it impossible to mainstream the results.Finally, it is suggested that others carry out further in-depth studies concerning questions related to work conditions and the psychological exhaustion of professionals working in mental health substitute services.
an appreciation of our work.A 40 hour workload involves a theoretical investment as well as a personal investment but in all actuality does not offer us any resources to invest in our work, [...] because, currently, our wages for a 40 hour workweek are the lowest [...] in Brazil, which is around R$1.200,00 [...].Actually, our wages are outdated by about five years [...] (P14).
A mental health 40-hour workweek is no joke.It isn't easy [...] (P15).This is not even humane; I mean, this should be prohibited [Mental health 40 hours work] (P21).