Teaching-Learning Process from Service Teaching of Mental Health Nursing : Experience Report

Results: In-service teaching provided reflections on the residents' conceptions of nurses' performance in mental health services. The key posts were the insertion in the specific nursing care, the construction of the multiprofessional work process, the recognition of their professional identity. Therapeutic relationship and communication, receptiveness, co-responsibility of care and the construction of links with clients, family and work colleagues for the solution of the problems.


Background
The National Mental Health Policy was developed from the Brazilian Psychiatric Reform movement, and seeks, to the present day, to transform care to the person with mental disorder [1].Regulated by Law No. 10.216 of 2001, which provides for the rights of people with mental disorders and users of alcohol or other drugs, it advocates the substitution of the Asylum Model for Psychosocial Care, avoiding social isolation and promoting social interaction with the family and the community [1].Thus, the access, reception, bonding and follow-up of people in psychological distress is the responsibility of the territorialized services [2].
Substitutive modalities were inserted for the treatment of the mental health user, the Psychosocial Care Centers (CAPS), the Residential Therapeutic Services (SRT), the Coexistence Centers (Cecos), the Mental Health Infirmary in general hospitals and the basic health units (BHU), under the approach of community-based insertion and from the perspective of health promotion and disease prevention [1].
That context has passed through the care practice of mental health professionals, directing reflections and adaptations to that care scenario, along with political-pedagogical transformations that base the academic formation process.In this formative context, and in accordance with that configuration of health care and team performance, the Unified Health System (SUS), in Brazil, responsible for the qualification of human resources, developed the multiprofessional health residency program [3].
The Residency Program aims at the training of professionals with a profile to act in the (SUS).It consists of a process of service education and training for multiprofessional teamwork that contributes to a new ethics of care, based on permanent education and the logic of the extended clinic.Thus, it provides professional recognition and mutual collaboration, involving the health professions into a common goal, which is to provide full attention to the population health [4].
In this sense, and under the aegis of the fundamentals, teaching and practice of nursing care, the present article proposes to describe the conceptions of resident nurses on the nurses' performance in mental health services.

Methods
This is a descriptive/reflective study of the experience-report type, carried out from experiences of nurses from the Multiprofessional Residency Program in Mental Health (RESMEN), in their first year of insertion and performance as residents.
RESMEN, a lato sensu post-graduation, is attached to the Center for Studies in Collective Health (NESC), of the Health Sciences Center of the Federal University of Paraíba (CCS/UFPB), and develops theoretical and practical-theoretical activities in mental health care services in the municipalities of Cabedelo and João Pessoa, PB.The rotations last for three months and are performed by the resident team, which consists of a nurse, pharmacist, psychologist, occupational therapist and social worker.
This study is guided by the theoretical presuppositions of the Brazilian Psychiatric Reform and is structured from the Methodology of Problematization through the use of the Arch of Charles Maguerez, first presented by Bordenave and Pereira (1982) [5], organized in five stages: 1. observation of reality (construction of the problem); 2. identification of key points; 3. theorization; 4. solution hypotheses; 5. application to reality.
The problematization promotes the sense of critical insertion in reality, extraction of the elements of meaningful learning.Knowledge is elaborated through the action-reflection-action movement considering the context, the personal implications and the interactions between the different subjects that learn and teach [6].It is a methodological path that allows the intellectual autonomy, aiming at critical and creative thinking, as well as at the preparation for political action and the exercise of citizenship [7].

Observation of Reality (Construction of the Problem)
The subject observes the environment surrounding him/her, choosing aspects that need to be developed, worked, reviewed or improved [7].
The first phase of the Arch of Charles Maguerez provided resident nurses with conceptions about the work process of nurses and the multiprofessional team, related to the care practice, stimulating the development of critical thinking and clinical reasoning, building their autonomy to act in different care scenarios.
In this sense, it became possible to observe the activities in which nurses were inserted at the health services: reception/triage, workshops/operating group, qualified listening, bureaucratic and/or administrative activities, medical consultations/interconsultation, active search, home visit and team meeting.Furthermore, the nurse must take care of the users' clinical health, interact with other team members and perform other specific mental health care actions, inserting him/herself into a context of interdisciplinary action.
The conceptions of resident nurses, based on reality observation, focused on the difficulties presented by nurses to be inserted in the multiprofessional context and to perform the specific attributions of mental health care, due to the lack of understanding about their performance.Such reality contributes and reinforces the existence of a professional identity conflict.
In the emergency department and in the CAPS, the nurse's practice remains in line with the clinical model, following the evolution of signs and symptoms, clinical manifestations and administrative and bureaucratic activities.There was little autonomy for decision-making in mental health care related to the dependence on the medical decision-making, causing a fragility in the interpersonal relationship/ therapeutic relationship among nurses, users and their families.
Therefore, the study problem was determined, which is the nurse's role in mental health services.

Identification of Key Points
The identification of the key points of the subject in question and the variables that determine that situation guide the search for the answer of the problem [7].
The identified key points were the performance in the specific care of mental health nursing, the construction of the multiprofessional work process, and the recognition of the professional identity of the mental health nurse.
The highlighted variables that may relate to the studied problem were the following: weaknesses in the academic training that prioritizes uniprofessional assistance; understanding of the multiprofessional logic as execution of all activities unrelated to the area of knowledge domain of nursing; understanding that its performance is broad and nonspecific; adopting a well-adjusted and task-oriented approach; weaknesses in the technical-scientific competence to act in mental health.

Theorization
Theorization, the third stage of the Arch of Charles Maguerez, is the moment when the subjects perceive the problem, understand the phenomenon and the determining factors, relating experiences and situations according to theoretical principles [7].
Understanding the problem of this study requires a brief historical retrospective on the insertion of nursing in mental health.Nursing is an old profession that has care as the essence of its performance; however, initially, the so-called Psychiatric Nursing was under the aegis of the medicalization of mad-ness and asylum care.Therefore, the nursing activity was restricted to the maintenance of the asylum order through surveillance, repression, coercion, violence and disciplinary order, without considering the crazy person as the protagonist of his/her own life and care [2].
From 1890 to 1930, the nursing training for the psychiatric area focused on actions of medication administration, hydrotherapy, feeding, hygiene, assisting physicians in psychiatric procedures, aiming at the patient's physical needs [2].
From the 1970s, nurses who worked at those mental hospitals started a process of questioning the asylum model of psychiatric care, and they envisioned a community approach aimed at providing mental health care outside the hospital walls, without isolating the individual from his/her place of life production, whether the family and/or community [2].
The reflections and changes in that care scenario included contributions of theorists in the field of Psychiatric Nursing about the therapeutic relationship, in order to transform nursing care [2], collaborating for the reintegration and reorganization of the person with mental disorder.The psychosocial model has required adaptations in the way of care, and the nurse needs to develop user-centered interventions, promoting autonomy and co-responsibility for health care [8].
Nevertheless, the nurses' work in mental health still focuses on the individual, overvaluing pharmacological treatment, the execution of technical procedures, hygiene and comfort measures to the detriment of relational technologies [2,8] due to concern with the technicism and the biological valorization of human beings to the detriment of their potentialities and complexities of life, social, emotional and spiritual needs [9].
The key points of this study, the insertion in the specific nursing care in mental health, the construction of the multiprofessional work process and the recognition of its professional identity have related to the feelings of technical and scientific unpreparedness to act in the area, causing a entanglement of roles, confusion of professional identity and anguish related to the insertion of the nurse.Thus, the incentive to the permanent education of the nurses in mental health presents as a strategy to collaborate to the appropriate insertion of the nurse, in those care scenarios.
The transformations experienced by Mental Health care point to the need for a process of academic formation focused on multiprofessional teamwork.Nonetheless, current educational models in Brazil prioritize uniprofessional and often disjointed health education between the teaching and the actual health needs of the population, pointing to a further challenge of the health and educational systems in training professionals with that profile.
In this sense, in order to overcome that problem, the interprofessional education used by Multiprofessional Residency programs in Health has stimulated the resident to develop skills common to all professions, specific competences of each area and collaborative skills [4], and encouraged reflective action of care regarding the population's health needs [10].Nurses, when maturing their professional identity based on those competencies, can strengthen their field of action and have a better understanding of their insertion in the production of care in substitutive services, based on relational and/or light technologies.
In this context, nurses' training should promote critical reflection and clinical judgment so that they are able to build a multidisciplinary work process, to empower people, to promote autonomy and participation, to develop qualified listening of clients' needs and expectations, to encourage self-care and the exchange of knowledge and experiences among patients [9].
Moreover, academic training needs to prioritize the care production as the focus of health work, reproducing the logic of care of the expanded cli-nic, transforming the fundamentals and practices of nursing care [8].Important technologies that permeate mental health care stand out, such as receptiveness, bonding and co-responsibility, which appear as strong strategies for the care production [8,9].
The contributions of the residents related to the Permanent Education, which presupposes a meeting between the world of work and of academic formation, in which "teaching" and "learning" enter into the routine of health services, consider the pre-existent knowledge and experiences of the professionals [11].The logic of meaningful learning prioritizes the transformation of practices through collective problematization in the daily work of the teams in the work environment; that reflection movement seeks an approximation of the routine of SUS professionals and the real needs and health demands of the users [11].

Solution Hypotheses
The fourth stage of the Arch of Charles Maguerez consists of elaborating feasible alternatives to solve the identified problems, critically and creatively, from the confrontation between theory and reality [7].
In order to solve the difficulties related to the specific actions of nursing in mental health, one suggests the therapeutic relationship, the therapeutic communication, the receptiveness, the co-responsibility of the care with the user and family and the formation of bonds with that clientele.
The Popular Health Education (EPS) presents as an important strategy to solve the daily problems of nursing care in mental health.One of the challenges of SUS related to health education is the articulation among teaching, service and community, and an expected practice is to strengthen social participation in that context, in which Popular Education emerges to narrow the distance between the health services and the population [10].EPS considers and values the reality of the user and his/her family, promoting the autonomy of the individuals by focusing on the formation of critical, conscious and constructive subjects of their history, promoting the empowerment about their health care, considering the person to the detriment of his/her illness [10,[12][13] One of the challenges of SUS to the formation in Health is the articulation of the teaching with the service and the community.In the formation, the educational practices of approaching teachingservice to the community should be (re)thought in the perspective of strengthening social participation in the mentioned system, highlighting, for that, Popular Health Education as a way to narrow the distance between health services and the population.
The theorization provided reflections on academic training based on clinical judgment centered on hard and light-hard technologies, under the aegis of hospitals, for the care production, in comparison with the reality of community-based services, especially those directed to mental health, which prioritize the care focused on the singularity of the subject and the use of light technologies.
Those suggestions for solutions address the problem of multiprofessionality, since, once the nurses take over their place, work and the different possibilities of producing care in mental health, they will understand that their contributions to the multiprofessional team are essential to optimize work, thus strengthening the construction of their professional identity.It is necessary to build bonds with team members in order to make the work environment pleasant and win partners who share the same clinical/psychosocial judgment, building a work process according to the Expanded Clinic.

Application to Reality
The involved subjects acquire new knowledge to transform the observed reality (Prado, 2012) [7].The nurse of each service developed care production actions, performed in conjunction with the resident nurses, stimulating the insertion and actuation of the care nurse in a practice based on theoretical and scientific assumptions.In addition, there were discussions and reflections of that action and training of therapeutic communication techniques through in-service education.
As for the difficulty of insertion in the multiprofessional team, the actions of the resident nurses focused on promoting the nurses' empowerment about their competencies and strengthening their professional identity, stimulating the co-responsibility for the health care of the user and his/her family.
The reality of the insertion of the resident nurse has been a dynamic process and built up during the time of permanence at the service.It aims at improving the practice of mental health care, stimulating the work process based on the construction of a link with the user, interdisciplinarity and a new meaning and appreciation of nurses' knowledge.In this way, it collaborates for an action that is willing to overcome difficulties and in harmony with the fundamentals and practices of technical-scientific nursing care of knowing to do and knowing to care.
In this context, considering that RESMEN relies on continuing education through in-service education as a tool to subsidize transformations in care practice and mental health education, the researchers of this study encouraged professionals to include, in their work process, the action-reflection movement with the purpose of problematizing their assistance.

Conclusions
This study identified the Arch of Charles Maguerez as a methodological instrument to base, organize and evaluate teaching-learning process, collaborating for the training of resident nurses in Mental Health.That method promoted a theoretical-scientific coherence of the problematizing know-how of reality in the daily work, collaborating to elucidate emerging problems that were once unnoticed, since it leads the researcher to think and reflect exhaustively on the points that are desired to work and intervene, subsidizing transformations.
The residents also realized the importance of the Multiprofessional Residency Program that allows the exchange of experiences among different knowledge centers, as well as the construction of clinicalcritical-reflexive thinking, as well as the interaction with the care professionals that are at the services.Through Health Education, Popular Education and Permanent Education, they promoted, with those professionals, reflections about the praxis of the Mental Health Nursing.In addition, the use of the Arch of Charles Maguerez provided resident nurses with the perception of the action-reflection-action movement as essential to understand the reality of the produced care and collaborate for the nurses' performance and the process of changes from the routine of Mental Health services.