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INTRODUCTION
The Curriculum Guidelines for Nursing Courses (Diretrizes Curriculares para os Cursos de Enfermagem, DCNs/ENF)1 are references for the education of competent and critical professionals committed to the health of the population, being contemporary to Law No. 10,216 of the Psychiatric Reform.2 Both reinforce the importance of articulation between the field of education, health and mental health, and are legal documents guiding the nursing education in mental health.3
The Pedagogical Political Projects (PPP) of the undergraduate nursing courses are guided by the DCNs/ENF1 and should provide bases to guide nurses in intervening on the problems/situations of the health-disease process at the individual and collective level. Given the current scenario of political and ideological setbacks that the country experiences, with reduced investments in the psychosocial care model and in the incentive to the financing of psychiatric hospitals, set by Ordinance 3,588/17,4-5 the dialog between the DCNs/ENF and the principles of the Psychiatric Reform aims to strengthen the education of nurses, giving them the basis for a significant positioning in the solidification of the psychosocial care model.
With these changes in the area of mental health, it is observed that social actors in this field, namely, service professionals and users/families, are articulating to support the proposals of the Psychosocial Care Network (Rede de Atenção Psicossocial, RAPS), legitimized by ordinance 3,088/2011,6 which highlights the community-based mental health care, created from the Primary Health Care (PHC).
Therefore, the education of general nurses should offer them skills so that they can: provide primary care in mental health; early identify patients in/with psychological distress/mental disorder; act in the treatment of stable psychiatric conditions, mental health/physical comorbidities, prevention and promotion of mental health; take responsibility for care together with other RAPS professionals and services; and refer patients to specialized services when necessary.7
A study that investigates the difficulties experienced by APS nurses and the care provided in mental health demands points a gap between the execution of mental health actions and their real competences. The study emphasizes that these professionals understand the needs of care, but do not feel prepared to conduct therapeutic actions in this context and do not seek knowledge, and health institutions do not promote continuing education that strengthens them.8 That said, it is urgent to strengthen education so that nurses’ actions are not limited to the medicalization of suffering, counseling without deepening the problem and unnecessary referrals to specialized mental health services.
Being aware of the importance of contributing to the insertion of mental health in PHC, the authors assumed that the courses and disciplines of mental health nursing in public higher education institutions (HEIs) in the country face challenges to promote an education that helps the general nurse in dealing with mental health issues in PHC. This study aims to analyze limitations, strategies, importance and obstacles in the mental health education in undergraduate nursing, focused on the role of nurses in Primary Health Care.
METHOD
An exploratory descriptive study using a convenience sample, with professors of undergraduate/teaching credential nursing courses who work in mental health nursing disciplines of public HEIs in the five regions of the country. In view of the follow-up of studies on the mental health education theme, and for logistical reasons, the private HEIs in the country were not contemplated.
Initially, a search was made for public HEIs, including the several campuses, in the e-MEC System9 of the Ministry of Education, a platform that stores data from HEIs in the country, to compose the research scenario, registering 281 HEIs.
Subsequently, to survey the nursing courses of these HEIs, the researchers used the filters ‘Undergraduate Courses’, ‘Nursing’, ‘General area: health and social welfare’, ‘Specific area: health’, ‘Detailed area: Nursing and Primary Care (basic care)’, ‘course area: Nursing’, ‘free course: yes’, ‘type: distance and on-site’, ‘degree: bachelor’s and postgraduate’ and ‘status: active’, and found 144 registered Nursing courses.
In the HEIs that have more than one campus, their websites were searched to find mental health professors, totaling 180 in this process. At the end, the sample studied was composed of 103 professors, representing 89 public HEIs in the country.
Inclusion criteria included: being a nurse and a teacher of a public HEI and teaching the Mental Health discipline. Exclusion criteria included: professors who teach the discipline, but are not nurses (thus two psychologists were excluded), and those who did not answer the questionnaire within the deadline of data collection. To develop the research, the personal information of the coordinator/head of the HEIs was obtained and a letter was sent requesting the names of the possible professors who work in the area of Mental Health. The feedback was insufficient, moving to a new strategy to contact them through the survey of their email on the institution’s websites and/or on the Lattes platform.
Data was collected from September 2017 to February 2018, at the Informatics Laboratory of the Nursing School of the University of São Paulo, with a self-administered questionnaire prepared by the authors in googleforms format, with 18 closed questions with “Yes” and “No” answers and five literature-based open questions, submitted to pretest with two professors from public HEIs, later excluded from the final collection. The questionnaire included socio-demographic data; characterization of the HEIs; description of the mental health teaching process; and of mental health/psychiatry teaching to work in mental health in PHC.
Data was entered into a spreadsheet using Excel 2010 and quantitatively analyzed. For statistical analysis, the researchers used the Statistical Package for the Social Sciences(SPSS) 2.0 to determine the frequency distribution among the identified variables. 95% confidence level, Fisher’s exact test and Pearson’s chi-square (χ2) test were used, which showed significance among the results with a p-value<0.05.
The project is in agreement with the guidelines of Resolution 466/2012, approved by the National Health Council. All participants signed the Free and Informed Consent Form.
RESULTS
Sociodemographic data of the sample
From the sample of HEIs (n=89), the researchers found more than one professor of the mental health discipline. Of these, 67 (65%) work in Federal HEIs, 1 (1%) in Regional HEIs and 33 (32%) in State HEIs. Seven are from the North (6.8%), 29 from the Northeast (28.2%), 23 from the South (22.3%), 6 from the Midwest (5.8%), and 38 from the Southeast (36.9%) of Brazil. There was a predominance of female professors (73.8%), with Master (35.3%) and Doctorate (52.9%) degrees and a Postdoctoral research fellowship in progress (11.8%), graduated between 5 and 20 years (53.7%) and >20 years ago (42.7%). They have been teachers for 1 to 10 years (38.9%), for more than 10 to 20 years (33%) and for more than 20 years (27.2%); they have worked in care for less than 1 year (17.5%), for 1 to 10 years (47.6%), for more than 10 to 20 years (18.5%), and for more than 20 years (15.5%).
Data on mental health education in the Nursing courses of the HEIs
The mean of class hours for mental health content throughout the undergraduate curriculum was 150 hours, ranging from 15 to 600, in specific mental health disciplines. In some HEIs, mental health content is conducted across the curriculum within other disciplines. Regarding the internships of the mental health discipline, the professors reported that the same happens in Psychiatric Hospital (29, 28.9%), Psychiatric Emergency (21, 20.4%), General Hospital Psychiatric Ward (Enfermaria de Psiquiatria em Hospital Geral, EPHG) (24, 23.3%), Psychosocial Care Center (Centro de Atenção Psicossocial, CAPS) for alcohol and drugs (70, 68%), adult CAPS (96, 93.2%), child and youth CAPS (18, 17.5%), Basic Health Unit (Unidade Básica de Saúde, UBS) (42, 40.8%), Therapeutic Community (Comunidade Terapêutica, CT) (5, 4.9%) and Street Clinic (Consultório na Rua, CR) (3, 2.9%). The discipline of mental health is theoretical-practical for most courses (98%). For 65% of the professors, the total class hours of the subject is insufficient to teach the desired content.
Limitations in courses/HEI x mental health education/PHC.
Table 1 shows the professors’ perspectives regarding the limitations for mental health education in PHC, as well as the strategies when they use this field. Of the study sample, 23.3% of the professors have internships only in PHC, and 35.9% do not use this field. Although 11.7% did not indicate limitations, 48.5% say that in the pedagogical planning of the mental health discipline, other practice scenarios are prioritized, and 46.6% stated that the class hours are not sufficient to expand them beyond specialized services. Not being what the course proposes and not being a limitation was pointed by 29.2%. The strategies used by professors are within the scope of PHC.
Table 1 Limitations and strategies in mental health education in Primary Health Care. São Paulo, SP, Brazil, 2018. (n=103)
| Limitations and Strategies | n | % |
|---|---|---|
| Limitations for teaching mental health in Primary Health Care | ||
| Prioritization of other scenarios based on Primary Health Care | 50 | 48.5 |
| Few class hours to expand teaching beyond specialty mental health settings | 48 | 46.6 |
| Faculty missing to expand teaching beyond specialty mental health scenarios | 40 | 38.8 |
| It is not what the course proposes | 18 | 17.5 |
| There are no limitations | 12 | 11.7 |
| Others | 29 | 28.2 |
| When performed, conducted by | ||
| Not performed | 37 | 35.9 |
| Participation in home visits in mental health | 45 | 43.7 |
| Participation in educational activities at the Basic Health Unit | 35 | 34.0 |
| Participation in active searches for mental health cases | 30 | 29.1 |
| Participation in therapeutic groups at the Basic Health Unit | 19 | 18.4 |
| Participation in meeting using matrix support | 16 | 15.5 |
| In Street Clinic activities | 04 | 3.9 |
| Internship only in Primary Health Care | 24 | 23.3 |
Note: each item had more than one answer.
Among other limitations for not conducting mental health education in PHC, the professors listed the absence of proposals for mental health education in this field (n=6); little focus of UBS on mental health actions (n=1); lack of successful mental health experiences in PHC to compose the student’s teaching-learning process (n=1); PHC professionals’ lack of receptiveness to welcoming students (n=1); work resistance in the Health/Psychosocial Care Network (n=3); lack of a specific mental health discipline in the undergraduate course (n=1); city dynamics do not favor mental health in PHC (n=2); PHC’ lack of structure (n=3); nonexistent mental health approach in PHC (n=4); lack of interaction between the Collective Health and Mental Health disciplines of the curriculum (n=4); lack of awareness among faculty about the importance of integrating mental health in PHC (n=1) and little emphasis on mental health teaching in the psychosocial approach (n=1).
In Table 2 it can be seen that there are several practice scenarios where mental health teaching is conducted. Adult CAPS practice occurs in all regions. CAPS focused on child and youth care does not exist in the Midwest region. It occurs mostly in the Psychiatric Hospital in the Southeast, when compared to other regions of the country. The Street Clinic is only used in the South region. The Therapeutic Community has been used as a practice scenario by the Northeast and Southeast regions. The UBS is used as a scenario by all regions; however, the region that uses it most is the South, followed by the Northeast and Southeast.
Table 2 Scenarios of mental health education by region of the country. São Paulo, SP, Brazil, 2018. (n=103)
| Practice scenarios | North | Northeast | Midwest | Southeast | South | p-value V | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | ||
| Psychiatric hospital | 1 | 14.3 | 08 | 27.6 | 01 | 16.7 | 16 | 42.1 | 03 | 13.0 | 0.120 |
| Psychiatric emergency | 1 | 14.3 | 08 | 27.6 | 01 | 16.7 | 06 | 15.8 | 05 | 21.7 | 0.798 |
| General hospital | 2 | 42.9 | 02 | 6.9 | 01 | 16.7 | 09 | 23.7 | 09 | 39.1 | 0.034 |
| CAPS AD* | 6 | 85.7 | 21 | 72.4 | 02 | 33.3 | 28 | 73.7 | 13 | 56.5 | 0.163 |
| CAPS adults† | 6 | 85.7 | 28 | 96.6 | 06 | 100 | 34 | 89.5 | 22 | 95.7 | 0.580 |
| CAPSi‡ | 3 | 42.9 | 09 | 31.0 | - | - | 01 | 2.6 | 05 | 21.7 | 0.003 |
| Basic health unit | 2 | 28.6 | 11 | 37.9 | 02 | 33.3 | 10 | 26.3 | 17 | 73.9 | 0.005 |
| Therapeutic community | - | - | 02 | 6.9 | - | - | 03 | 7.9 | - | - | 0.582 |
| Street clinic | - | - | - | - | - | - | - | - | 03 | 13.0 | 0.070 |
Fisher’s and Pearson’s chi-square tests (χ2), p<0.05. *Psychosocial Care Center, alcohol and drugs; † Psychosocial Care Center, adults; ‡Psychosocial Care Center, children-youth.
Importance and obstacle in HEIs x mental health education/PHC
In Table 3, 23.3% (n=24) of the professors who stated teaching mental health only in PHC, 58.3% (p=0.006) believe that they can support the future nurse to work in mental health in this area. As an obstacle to teaching mental health education, 87.5% point the lack of connection between Collective and Mental Health disciplines.
Table 3 Importance and obstacle in teaching mental health in Primary Health Care. São Paulo, SP, Brazil, 2018. (n=24) *
| Importance and Obstacle | n | % | p-value V |
|---|---|---|---|
| Because it supports mental health actions in Primary Health Care | 14 | 58.3 | 0.006 |
| Lack of articulation between Collective Health and Mental Health disciplines to teach mental health in Primary Health Care | 21 | 87.5 | 0.028 |
*Professors who stated teaching mental health only at PHC. Fisher’s and Pearson’s chi-square tests (χ2), p<0.05.
Extensionist projects in mental health education; mental health at school; Mental Health Academic Leagues’ activities; workshops; photo shows; community therapy; psychoeducation and case follow-up activities stand out as means used in the teaching-learning process of mental health only in PHC.
DISCUSSION
Considering that PHC is the scenario for conducting effective practices and for care accountability, the management of the mental health demands should happen through a logic that individualizes and contextualizes health needs and evades the dynamics of unqualified referrals to other services.10
Then brought the reflection that, when receiving subjects with different health needs, expressed by complex demands in the biopsychosocial context, PHC nurses should take mental health actions based on training processes that meet the demands of the individual/family/community and affirm their prominence, and should have skills and competencies required by the context and primary health care/mental health policies.
In this sense, the education of the mental health nursing professor needs to be based on the psychosocial paradigm in order to lead transformations in the education of future nurses. A study on the education of mental health nursing professors of public HEIs in Brazil points out that their beliefs and motivations regarding the psychosocial care model influences teaching and knowledge production.11
Moreover, in order to address the contemporary issues of valuing the subject’s autonomy and citizenship, it is a condition that the education of mental health nursing professors, who are human resources creator, enables them to be professionals capable of support patients in psychological distress/with mental disorder, through instruments of the therapeutic relationship. For such, the education offered must be based on a historical-political-social-theoretical framework, distancing from the institutionalizing and excluding care model.
Although in Brazil mental health nursing education has been compulsory since 1949, there is no specific legislation that standardizes the curriculum of the disciplines, and the lack of a specific mental health discipline represents a limiting data in nursing education, which could seriously compromise assistance. A recent research identified that in more than 3% of the curricular structures of public and private HEIs in the country, there is no discipline related to the area.11 Therefore, it is a challenge for the competent bodies and HEIs to train and hire mental health nursing professors, able to minimally prepare the general nurse in this area of knowledge, able to conduct mental health actions in PHC.
At present, limitations regarding the prioritization of other scenarios based on PHC, insufficient class hours to expand internship fields beyond the specialty in mental health, and not being a proposition of the course imply decision-making by those who make up the courses and the mental health discipline, namely HEI professors. It is up to them to recognize the importance and transversality of mental health in the field of health and in the commitment of HEIs to the education of professionals committed to the population’s needs.
The PHC professionals’ lack of receptivity to receive students in the context of the teaching-learning process of mental health as another limitation found in the study is confronted with the objective I of Article 2 of the Organizational Contracts for Public Health-Education Action (Contratos Organizativos de Ação Pública Ensino-Saúde, COAPES), which guides the guarantee of scenarios for undergraduate training, as a measure of strengthening the integration between teaching, services and community within the Unified Health System.12
The professors highlighted the resistance and barriers imposed by public administrations of primary services that make it difficult to teach mental health in PHC. But they are also unwilling to teach in this field as a confrontation and even construction of proposals for assistance and pedagogical intervention. Possibly, the thought that in PHC there are no successful actions of mental health to offer to the student may be linked to the lack of understanding that in making health, also makes mental health. A logic based on the devaluation of mild mental suffering to the prejudice of more complex ones, which are severe and persistent mental disorders, and linked to the education based on psychiatrization and medicalization of suffering during teacher education.13
The non-proposition of offering mental health education in PHC deserves reconsideration especially when prioritizing the Psychiatric Hospital and even the Therapeutic Communities, scenarios that distance themselves from community-based care. However, the consensus and dissents regarding the decision by the fields of practice depend on the value given to the theoretical references that support the Pedagogical Project of the Course, which fortunately is not isolated, but in its construction requires the collective commitment of several agents.
Thus, to break with the traditional psychiatric model and consolidate the knowledge necessary for care, from the perspective of the RAPS, the academic education cannot be forged in spaces that are not configured and aligned to qualify the education process that supports innovative practices.
However, with the lack of professors in the HEIs, the expansion of mental health nursing teaching beyond specialized spaces is compromised. Without an education in mental health nursing according to public policies, the theoretical-scientific, critical-reflexive delays are obstacles for nurses to follow the constant changes and contribute to the consolidation of the Psychiatric Reform.
The mean of class hours (150 hours/class) of the courses indicated by professors to develop mental health content is considered low to expand practical teaching, but this topic does not seem to answer the real reasons that lead them to prioritize traditional and specialized practice fields. As shown in a recent review study, the mean of class hours of the mental health disciplines in Brazil was 104.6 hours/class, although lower than other Latin American countries (177 hours), which exceeds the mean of the national reality.11
This finding requires close attention to the purposes of the courses in view of the requirements of the Unified Health System, and calls for articulation between professors and coordinators in planning. As a measure to optimize practical teaching in PHC, the HEIs can use partnerships with nurses in this field, as collaborators, through the creation of an academic care project.
On the other hand, to negotiate the increase in class hours, the professors can use as indicators the students’ self-assessment regarding their learning and the contents offered in the mental health discipline. However, it is emphasized that just increasing the number of class hours will not bring the effective solution if there is no conceptual alignment for the education. An alternative is to maintain/structure mental health education across specific disciplines or shared throughout the course, as mental health is present in various fields, favoring the reinforcement of its multidimensional aspects.
Collective Health and Mental Health, as areas of knowledge and practice, are articulated to meet health-related needs as a social and public interest phenomenon, and intertwine to meet mental health needs. For HEI professors, there is no articulation between these disciplines in the discussion of related contents, as well as in conducting a joint practice. Recognizing that one area has much to offer to the other, and changing this circumstance, helps to face obstacles and provide mental health education in PHC with broader perspectives towards reality.
Professors do not believe that the PHC scenario enables successful experiences in everyday practices and demonstrate a reductionist conception of the extent of mental health. It is believed that they think the demands of psychic distress/mental disorder are not vigorous for learning, leading teaching to classic scenarios such as Psychiatric Hospitals and/or CAPS. Considering that it is in PHC that people with common mental disorders seek shelter, understanding and care for their needs,13 using this field creates and expands a locus of care, and encourages general nurses for a broader praxis.
The fragility of the municipal health networks, which do not invest in primary mental health care, is due to the dynamics of functioning of the local RAPS, which has in PHC one of its components, interfering in the choice of this field by professors as a powerful space for care and practical teaching.
Another aspect of analysis concerns the lack of awareness among faculty about the importance of mental health education linked to PHC, a limitation that goes against global initiatives that underpin the strengthening of the primary care network and the precepts of anti-asylum movements.14 The non-instrumentalization of nurses generates insecurity to handle mental health cases, and their inexperience in dealing with these cases is a major challenge to be overcome.
According to notebook 34 “Mental Health of Primary Care” of the Ministry of Health,15 PHC services are the most accessible, available and accepted by the community, and act to improve the health and social reintegration process, and reduce stigma.16 In this sense, there is a need for transformation in the academic education of nurses, as they represent the largest workforce of PHC and are responsible for providing services, especially for their proximity to family and communities, as well as being a strategic resource to deal with major health demands.7
A small portion of the sample states that there is no limitation to conduct mental health education in PHC; however, the appropriation of this area of expertise is small (n=24), but it is considered an advance. When the professors are inserted in PHC, they use some technologies in teaching, such as educational activities, home visits, matrix support, street practice and therapeutic groups; these last two, although little used, are complex care strategies, address the heterogeneity of the several users, broaden and base the future nurse’s perspective on their commitment to mental health demands, as well as sustaining them by avoiding unnecessary referrals.
With deinstitutionalization, it is suggested that mental health care should be performed in territorial- and community-based services; however, returning to social life is difficult for the user and family.17 In the findings of this study, the professors use home visiting to access the population as this is an important way to reduce the search for specialized services, as well as to reduce mental health hospitalization rates.18
The extension activities in mental health proposed by the public HEIs has been a choice of professors for teaching mental health in PHC, and offers the student the opportunity to develop in articulation with the social reality. The Mental Health Academic Leagues stand out for taking health promotion actions in the community, as well as recovery, maintenance and rehabilitation actions, in addition to promoting in the student the scientific reasoning and critical thinking that add values and differential in their formation.19 On the other hand, extension activities are part of the triad of university education and offer advances that impact on the transformation of the community and enable the construction of knowledge in a professional citizen education.20
The limitation of this study is the logistical impossibility of covering all the public HEIs in the country, due to the delayed return of the questionnaires. However, it was possible to capture the national scenario regarding the confrontations that mental health professors experience in the reality of theoretical-practical teaching so that it can be contemplated in PHC. It advances in the construction of knowledge in the mental health area by evidencing through a significant sample that the curricular arrangements of undergraduate nursing courses face vulnerabilities to provide an education that is aligned with the Mental Health Policy.
CONCLUSIONS
A debate is opened on the technical, ethical, social and political challenges that public HEI professors face to provide a mental health education in undergraduate nursing that supports the role of nurses in PHC. The hypothesis that mental health nursing professors of the HEIs face challenges due to limitations and barriers in the institutional spheres is confirmed, but it also places them as protagonists of a transformation.
Professors who provide mental health education only in PHC believe in the power of this field to support mental health education. At the time of the creation of new National Curriculum Guidelines for Nursing, filling these gaps in education is necessary to strengthen the teaching-research-extension mental health triad that fosters a more aligned PHC practice.
It is noteworthy that the choice of the psychiatric hospital as a place of internship needs to be rethought, as well as the lack of articulation between the Mental Health and Collective Health disciplines, and inter-disciplinarity as a proposal to provide education to an expanded care clinic is valued.
