Nursing and the Teaching of Mental Health Care in Brazil

Luciane P. Kantorski*

Leandro B. de Pinho**

* PhD in Nursing. Nursing and Obstetrics Faculty of Universidade Federal de Pelotas, FEO-UFPel.
 Av. Duque de Caxias, 250. CEP: 96030-002 – Pelotas – RS – Brazil.

** PhD Psychiatric Nursing Student. Nursing Faculty of Universidade Federal de Mato Grosso, UFMT.
 Av. Fernando Corrêa da Costa, 8780 S/N – Cuiabá – MT – Brazil. E-mail address for contact: Lbpinho@uol.com.br



Citation:
Kantorski L.P and De Pinho L.B.  (2007). Nursing and the Teaching of Mental Health
Care in Brazil    International Journal of Psychosocial Rehabilitation. 12 (1),  23-35

Acknowledgments:  We thanks CNPq and FAPERGS for financial support

Abstract
This study aims at presenting the configuration of psychiatric nursing teaching in Brazil. A questionnaire concerning psychiatric nursing teaching was sent to 15 nursing schools. A qualitative analysis of the answers was done and the data were grouped according to the characterization of the teaching board and of teaching itself, including the offered disciplines, teaching schedules, place for practical classes, contents approached and extension projects. The obtained results evidenced the recent concern of most schools in offering the students contact with new devices of care to mentally ill individuals, supported on the principles of psychosocial attention, which highlight the need to humanize attendance through entailment, receptivity, and the inclusion of the family in the process of attendance and re-socialization.

Keywords: teaching, psychiatric nursing, mental health.

Introduction
In 1949, the Brazilian legislation determined the obligatoriness of the teaching of psychiatric nursing in nursing graduation courses in the country. Since then, the theme of the teaching in the area has been object of investigation concerning the approached contents and the academic preparation for the execution of nursing care in mental health.

Studying the teaching of psychiatric nursing and mental health has been, for a long time, a present concern in Brazilian nursing, as it can be observed through several works such as those of Ungaretti (1958), Fernandes (1959), Minzoni (1966), Foregatto & Saeki (1973), Arantes (1973), Fernandes (1979, 1982), Fraga et al (1986), and those of Stefanelli (1986), Lobato (1989), Silva (1991), Proença (1993), Braga (1993; 1998), Barros (1996) Kantorski & Silva (2001) and Alencastre et al. (2000).

This thematic has been focused under different aspects over the years, and in the current context the relevance of this debate has been highlighted in the face of the legality of new curricular proposals in Brazilian nursing, as well as specifities regarding the transformation of care practices in mental health. In this article we aim at characterizing the graduation teaching in psychiatric nursing and mental health.

Method
In this study we performed a qualitative, descriptive and analytic research. The proposed instrument was a questionnaire applied to teachers of psychiatric nursing and mental health from 15 nursing schools of the state of Rio Grande do Sul, southern Brazil.

As a first methodological procedure, we sent a letter to the Nursing Schools informing them about the purpose of our study, the objectives and methodological procedures of the research in order to obtain the agreement of the studied institutions.

We also sent them the questionnaire, instrument of this research, and a free and clarified agreement document to be signed by the informants respecting ethical procedures due to the Brazilian legislation for research involving human beings. The questionnaire consisting of open and closed questions concerning the teaching of psychiatric nursing was sent to 15 nursing schools. Nine of those schools returned the questionnaire filled in.

Regarding the operationalization of data, the following steps were accomplished: ordering, classification, and final analysis. The ordering of data, obtained through the questionnaire, occurred after successive re-readings of the whole material and after data grouping and organization from the meditation on the purpose of the research, resulting generic thematics which will be specified in the results. Data classification occurred from attempts to determine the set of information presented in the questionnaire considering the central convergences and divergences verified.

Data were grouped according to the characterization of the teaching board and of teaching itself, including offered disciplines, teaching schedules, places where the practical classes were taught, contents approached and extension projects. These data were analyzed from the following thematics: contextualization of the trajectory of mentally ill individuals in history and new devices of care in mental health.

We will briefly present (Table 1) a characterization of the teachers in the field of psychiatric nursing and mental health, from the studied institutions, who answered the research instrument.

In the analysis of data obtained through the questionnaire, two thematics concentrated the anxieties and meditations about the teaching process in nursing schools. Such thematics are: the contextualization of the trajectory of mentally ill individuals in history and the presentation to nursing students of new devices of care in mental health.

Results
Contextualization of the trajectory of the mentally ill individual in history
According to Kalkman (1974), until 1880, nursing practice in psychiatric hospitals served the custody of the patient and it was based on Florence’s principles, which were: the cleanness of wards, personal hygiene, fresh air and exercises, good sleeping conditions and adequate feeding.

In Brazil, up to the First Republic nursing assistance had only a healing character and it was performed by religious people. Hospital employees were Charity Sisters (a group of nuns), who held administrative power, and laymen, usually former patients or servants.

From the opening of Pedro II Hospital, in 1852, in Rio de Janeiro, a dispute of power between the Charity Sisters and the doctors took place. In Brazil, the context of dispute between the Charity Sisters and the psychiatrists represented a dispute for the hegemony in this new space – the hospital – which included the medical profession claim of bringing together exclusively the knowledge and the power of intervention and sequestration of madness, and also the administrative power to admit, scrutinize, classify, and to discharge people from madhouses (Machado et al., 1978).

In 1890, Pedro II Hospital became nationalized and its name was changed to ‘Hospício Nacional de Alienados’. Doctors ascended to power ad nuns left the hospitals. Due to the shortage of employees the Government had to appeal to French nurses. In this context, on September 27th, 1890, the Professional Schools of Nurses of the ‘Hospício Nacional de Alienados’ (Alfredo Pinto School) was created, officially beginning the teaching of nursing in Brazil (Kantorski & Miron, 2002).

Foucault (1993), Goffman (1990), Castel (1978, 1987), approaching the history of madness, the birth of psychiatry and the medical procedures concerning madness, instituted since the classic, middle and modern ages, reinforce that madhouses, which in the classic age had as their main function to serve as guest-houses, started to constitute themselves in cloistering and internment institutions which have picked up modern medicine hospital connotation and have to cope with modern economical, political and social demands.

Birman & Costa (1994) assert that after Second World War the context regarding the therapeutic impotence of psychiatry, the high levels of chronic stages of mental illness and social incapacitation made the theoretical field of assistential psychiatry reach another dimension, configuring two significant periods of criticism and reformist propositions, to be known: movements of criticism to asylum structure involving reformulations circumscribed inside the madhouses, such as institutional psychotherapy (in France) and therapeutic communities (in England and in the United States), reaching its extreme with family therapies; and in a second moment sectional or preventive psychiatry (in the United States) which in a certain way overcomes the previous proposals, expanding the reformations to beyond the asylum space and introducing psychiatry in the public space with its new object, that is, mental health. Amarante (1995, p. 29) complements this discussion by adding the emergency of anti-psychiatry (England) and the Italian experiences which emerge from Basaglia as ruptures with the reform proposals presented so far, for questioning “...the medical-psychiatric device itself and the institutions and therapeutic devices related to it.”

The psychiatry trends of reformist character, have built a more humanized knowledge and performance directed to the patient as a whole, emphasizing biologic, psychological, and socio-cultural aspects involved in this process. And, for that, it was necessary to explore the particularities concerning the psychic suffering and its trajectory over the years.

Understanding the history of madness in the world and all the problematic which underlies its trajectory, is part of the curriculum of universities such as 1, 3, 5, 6, 7, and 9, which emphasize the need to de-stigmatize the mad individual, stimulating nursing students to have contact with mentally ill individuals.

Prejudice toward mentally ill individuals is still accentuated in our society. In this scene, universities, and in particular the teaching of psychiatric nursing – object of our study – have taken up an important role towards the de-stigmatization of the mentally ill individual, redefining the space of the disease, which despite being important in the patient’s life does not totalize him. The referred deconstruction goes through the capacity of teaching to re-place the individual who suffers, while a human being with family, friends, desires, limitations and deprivations, and whose needs health services and its professionals – among them, the nurses – must be able to welcome, to assist, and to look after.

New devices of care in mental health
The need to present nursing students with new devices of care to mentally ill individuals is part of the syllabus in such schools as 1, 3, 5, 8, and 9. The development of practical classes in the basic attention network, outpatient clinics, and other community mental health services and the problematization of several forms of intervention in mental health predominant in our society articulate themselves with the principles of new mental health policies in the country. These policies stress the need to accomplish the principles of hierarchization of health attendance and the consequent promotion of activities that might replace those primarily institutionalized ones, putting to practice the concepts of assistance to the human being as a whole, through the importance of entailment with the patient, receptivity, the therapeutic relationship, and through the inclusion of the family as part of this therapeutics, and the preparation of the patient for social re-insertion.

We verify (Table 2) the therapeutic and /or practical presence of contents related to care devices, such as Psychosocial Attention Centers, as open services which provide care to individuals with severe and persistent mental illness, in a daily regime with a multi-professional staff, based on individualized therapeutic plans which aim at individual’s psychosocial rehabilitation.

Institution 1, though developing its practical classes exclusively in psychiatric internment units, tries to instrument students through theoretical contents, aiming at the contact with mentally ill individuals in different assistance and community services. It approaches the individual - professional interpersonal relation as a therapeutic possibility, emphasizing self-care and re-socialization.

Institution 4 develops its work by offering individual nursing consultations, individual and group therapeutic actions and home visits.

Institution 2, however, develops its practical classes in the psychiatric hospital, preconizing the relation student - psychiatric patient through interpersonal therapeutic relation. The emphasis on psychopathologies of the psychic functions and the main groups of mental illness direct the teaching of the discipline, which highlights the classical hospital-centered point-of-view in the teaching of the institution.

Institution 7 proposes the insertion of students in several levels of health attention (outpatient clinics, community, hospitals) to enable them to develop nursing interventions in situations of psychic suffering, so much linked to mental illness itself as to other painful situations which the individuals may be undergoing (victims of terminal disease, patients in pre-surgical situation, among others). For such, besides curricular activities of the discipline, the institution keeps an extra-curricular agenda for the performance of theoretical discussions about the situations experienced in practical classes, through the Group of Nursing Studies in Mental Health, which is coordinated by teachers of the area and in which students of the course partake. It also holds a Group of Socio-therapy in which students who are attending the discipline of Nursing in Mental Health take part.

In case we analyze the institutions which have inserted themselves in services typically constituted in the context of recent transformations in Brazilian psychiatric assistance, such as Psychosocial Attention Centers, we are to highlight the following ones: 2, 5, 6, 7, 8, and 9. Out of the 9 institutions which answered the research instrument, 6 have clearly demonstrated a curricular concern regarding the education of generalist nurses. Such concern is expressed through the insertion of the student in the practical field, anchored to mental health services which have been structured supported on principles of psychiatric reform.

In 1989, Bill number 3.657/89 authored by deputy Paulo Delgado was presented to the Brazilian National Congress, being approved only in April 2001, predicting the re-structuring of Brazilian psychiatric assistance with the progressive replacement of madhouses by new treatment and receptivity devices.

In the last two decades, the psychiatric reform movement in Brazil has been strongly influenced by the Italian democratic psychiatry movement. The progressive incorporation of psychiatry reform principles is materialize in the Brazilian context through regulations 189/1991 and 224/1992 from the Health Ministry and through the creation of new services. Regulations 189 and 224 have established the remuneration of new procedures, such as: individual and group consultations to professionals such as nurses, psychologists and social assistants; attendance in therapeutic workshops, psychosocial attendance centers, day-hospital, emergency and internment in general hospitals; they also regulated and defined minimum patterns for running mental health services aiming at the construction of a diversified assistance network. In February 19th, 2002, governmental regulation 336 classified Psychosocial Attention Centers in crescent order by comprised population and by complexity, defining minimum professional staff, establishing its target clientele – severe and persistent disturbance cases – and determining its functioning in a specific area independent of any hospital structure.

We can see, through data presented on table 3, and other information obtained from the questionnaire, that these changes demanded curricular reformulations which, until 2000, in some schools coincided with the increasing of disciplines teaching schedules, especially concerning practice hours, such as the case of institutions 8 and 9. In institution 8, students have the disciplines of Mental Health I (60 theoretical hours per semester) and Mental Health II (120 theoretical-practical hours per semester); and in institution 9, students have classes on the disciplines of Mental Health (60 theoretical hours + 30 practical hours per semester) and Psychiatric Nursing (30 theoretical hours + 60 practical hours per semester) totalizing 180 hours per semester.

Other institutions, such as 3, 4 and 6, carried on with their original curricular schedules, but re-adapted training schedules, allowing more hours for practical classes in community services. In institution 2, the unification of the disciplines of Psychiatric Nursing and Mental Health with the Supervised Training in a discipline called Psychiatric Nursing and Mental Health increased teaching schedules, but practical classes still converged to Psychiatric Hospitals. However, the new proposal of the discipline intends to include the graduation student within the community by offering practical classes in two Psychosocial Attention Centers, allowing the students to get in contact with new alternatives of attention to mentally ill individuals.

In institution 7, the disciplines of Psychology Applied to Health (30hs) and Methodologies and Dynamics of Group Work (60hs) were incorporated to the curriculum, increasing the schedule of the area in 90 hours. Institution 1 was the only in which there was a decrease in teaching schedule for Psychiatric Nursing II (theoretical-practical) from 180 to 150 hours per semester. This change created problems to the community services due to the increase on the number of students in the practical field concentrated in only two days-a-week, causing a lack of continuity to the patients’ attendance. The development of a new methodological proposal, aiming at the unification between theory and practice in the very spot where the practical classes take place, caused a change which both teachers and, specially, students emphasized as positive, for favoring and facilitating the learning process.

We can observe that some content choices are basically reflected upon the academic life and the development of future professionals, who will work in the area, such as the scarce inclusion of contents concerning the systematization of health, family participation in patient’s treatment, the psychosocial rehabilitation and transformation of practices and services in metal health. However, a change concerning previous studies has been taking form, especially when the study widens and includes both, public and private universities. As we can see on Table 3, previously presented, new concepts and contents concerning the changes in the context of psychiatric practices have started to mix with the classical psychiatry contents.

The inclusion of contents concerning the new theoretical referentials of psychiatric reform and the development of practical classes in the mental health services network (including psychosocial attention centers and nucleuses, day-hospitals, shielded boarding houses, psychiatric units in general hospitals, therapeutic workshops) to the nursing graduation curricula retake the academic space as a living laboratory for production, constitution, formation, and socialization of knowledge which is inserted in a psychosocial attention paradigm process of transformation.

Besides curricular changes, it was possible to notice a concern from schools in offering a complementary formation to nursing students and in assisting the community, through university extension projects (Table 4). Six institutions, out of the 9 which answered the questionnaire, develop extension projects, focusing on mental health care practices to individuals and groups, extra-curricular academic formation, improvement level formation for workers in the area of mental health.

We noticed that the total teaching schedule varies from 150 to 270 hours per semester, distributed between theoretical and/or practical disciplines. The places where trainings are carried out vary from large scale hospitals and internment units in general hospitals to basic attention units, psychosocial attention centers, and so on.

We highlight the recent concern of most Nursing Schools in offering the students the contact with new care devices to mentally ill individuals, based on the psychosocial attention principles, which stress the need to humanize the attendance through entailment, receptivity, and the inclusion of the family in the process of assistance and re-socialization.

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