ORIGINAL RESEARCH
Knowledge and practices in urgent and emergency psychiatric care
Lucidio Clebeson de OliveiraI; Richardson Augusto Rosendo da SilvaII
I
Nurse. Master in Nursing. Professor at the State University of Rio Grande
do Norte and the Nova Esperança Nursing School in Mossoró, Mossoró, Rio
Grande do Norte - RN, Brazil. E-mail:
lucidioclebeson@hotmail.com
II
Nurse. PhD in Nursing. Professor at the Federal University of Rio Grande do
Norte. Lecturer at the Graduate Program in Nursing, Natal, Rio Grande do
Norte/RN, Brazil. E-mail: rirosendo@yahoo.com
DOI: http://dx.doi.org/10.12957/reuerj.2017.10726
ABSTRACT
Objective: to identify the difficulties in implementation of emergency care for users in psychiatric suffering in the Mobile Emergency Care Service (SAMU). Method: in this qualitative study of 34 SAMU nursing personnel in a town in Northeast Brazil, data were collected by semi-structured interview, and analyzed using the thematic analysis technique. The study was approved by the human research ethics committee (CAAE 17326513.0.0000.5537). Results: the categories that emerged from the interviewees' discourse were: barriers in urgent and emergency psychiatric care and strategies to establish comprehensive urgent and emergency psychiatric care. These conditions are explained by inappropriate care being offered and by the absence of a mental health services system capable of solving the problems. Conclusion: the lack of an organized, hierarchical mental health care system constitutes an obstacle to fulfilling the guidelines of the Psychiatric Reform in practice.
Keywords: Nursing; mental health; psychiatric nursing; nursing care; psychiatric emergency services.
INTRODUCTION
The history of mental health in Brazil is permeated by struggles of society in the pursue of changes in health care practice and management models, with especial emphasis for the Brazilian psychiatric reform. This reform was inserted in a context of international changes against violence in asylums and towards replacing that violence with cultural and legal initiatives, by modifying the context and the relationship of society with the mentally ill1.
The Brazilian Psychiatric Reform (BPR) was a social and political process that aimed to deconstruct the logic of exclusion in asylums in favor of new care strategies for individuals in psychic distress. The consequences of this process are evident in the current policy, legislation and mental health services in Brazil2,3.
In this scenario of deinstitutionalization, it has become necessary to create services to welcome back into society individuals who come out of psychiatric institutions. From this perspective, mental health services in the country have been decentralized and are currently organized in a growing and hierarchical complex network consisting of three levels of assistance: basic, intermediate and high complexity care.4.
It should be noted that despite the achievements of the BPR, the network of substitute services is currently overloaded, since other problems are treated in the mental health network, such as the growing problematic use of alcohol and other drugs, and the growing demand by users affected by non-adherence to continuous and long-term treatment5.
However, this legal transfer of responsibility attributing new and specific demands to professionals and services should also be accompanied by a phase of preparation and training of those who provide such assistance so that this may be resolute and comprehensive, because the care of mentally ill patients require specific competences2.
In the case of the SAMU (Mobile Emergency Care Service), according to Decree 2,048/GM, the professional qualification of the team is made at the time the service is installed in a city. In that training, only two hours are devoted to mental health interventions. Furthermore, such training is exclusively theoretical, without any practical component2.
In the reality of SAMU, this situation is even more serious because this urgency and emergency service has historically denied or does not practice what the psychic crises require, namely, empathy, dialogue, co-responsibility, humanization, subjectivity and creativity6.
With the purpose of pointing out strategies for the pursue of a consolidated and expanded integral assistance to this public, this study aimed to identify the difficulties faced in the implementation of emergent care to users under psychiatric suffering in the Mobile Emergency Care Service.
LITERATURE REVIEW
The reforms that have occurred in mental health care in Brazil have redirected the care model, previously focused on asylums, toward a diversified and articulated out-of-hospital care network. Psychiatric hospitalizations have been therefore directed primarily to patients with mental disorders who presented severe and acute conditions. The network of substitute services has assumed a new role in structuring and operating the network of mental health services, fostering a better relationship among them7,8.
Once partially resolved the question of deinstitutionalization, as the supply of psychiatric beds in general hospitals still faces resistance, new challenges and demands arise in relation to the mental health policy in Brazil3,8.
Among the current challenges, there is an operational gap in psychiatric urgencies and emergencies that has led to stressing situations when trying to provide humanized assistance to mentally ill patients. These patients receive improvised care in unspecialized institutions and even with non-medical approaches such as police services.7,8.
Psychiatric urgencies and emergencies can be characterized as situations in which individuals present a disorder of thought, emotion or behavior, in need of immediate medical attention to avoid greater damages to the psychic, physical and social health of the patients and eliminate possible risks to their life or to the integrity of others5,7.
The term psychiatric crisis is used to characterize psychiatric urgencies and emergencies that involve diverse situations such as psychoses, ideations, suicide attempts, and organic brain depressions and syndromes. These are moments in which the psychic suffering becomes intense, generating disruption of the social, familiar and psychic life of the individuals, and a rupture with the social context4,8.
The use of the emergency room of general hospitals such as Psychiatric Emergency Services (PES) is backed by the National Mental Health Policy, which at the same time that avoids the isolation of psychiatry, also tries to reduce the stigmatization of mental illness. However, mechanical restraint practices are also widely observed in the PES, especially those related to general hospitals and pre-hospital mobile emergency services 8,9.
Between the lines of these actions are power relations that characterize classical psychiatry and its authority to take the body as the object of its practices. Such practices go against the ideals of the Brazilian Psychiatric Reform and hamper the care of psychiatric patients in the emergent pre-hospital care9.
METHODOLOGY
This is a descriptive study with a qualitative approach carried out in the SAMU of the city of Mossoró/RN, northeast of Brazil, from October to December 2013.
The service was chosen because it is responsible for assisting users in situation of psychiatric urgency and emergency, thus meeting the proposed questions and objectives.
The research had the nursing professionals - 12 nurses and 30 nursing technicians - working in the SAMU of the city of Mossoró/RN, and who act directly in the provision of care, as population. The sample consisted of 34 nursing professionals, nine of whom were nurses and 25 were nursing technicians who work in the SAMU. As inclusion criteria, we included workers who have worked in the area for a period of one year or more and who deal with direct assistance to users of the service.
A semi-structured interview script with open and closed questions was used as data collection instrument. The interview was conducted individually, at the SAMU's headquarters in Mossoró. All interviews were recorded with the acquiescence of the interviewees and later transcribed verbatim.
The content analysis technique in thematic modality was used to analyze the data, which per se "consists in discovering thenuclei of meaning that compose a communication, whose presence or frequency means something to the analytic object targeted" [italics in the original]10: 316.
Thus, the thematic content analysis of the interviewees' discourse gave rise to two categories, namely: barriers to psychiatric urgency and emergency care and strategies to consolidate comprehensive care for psychiatric urgencies and emergencies.
It should be emphasized that this research was submitted to the Ethics Committee of Research with human beings of the Federal University of Rio Grande do Norte, which was approved with CAAE nº 17326513.0.0000.5537. In order to guarantee the confidentiality of the participants, their speeches were identified in the results and discussion sections by the letter "I" followed by numbers from 1 to 34.
RESULTS AND DISCUSSION
Obstacles to psychiatric urgency and emergency care
The Urgency and Emergency area comprises pre-hospital care provided in the place where the victim is. This type of care requires qualified professionals, as emotional control and the ability to act with logical and rapid reasoning is necessary to avoid further and irreparable damages 11.
With regard to the difficulties faced by the nursing professionals of the SAMU in the provision of care to subjects in psychiatric urgencies or emergencies, problems of interaction with the patients' relatives were found, as well as problems associated to the management, where the lack of articulation between services hinders the provision of resolute assistance.
It is difficult to carry out comprehensive care as advocated by the Unified Health System (SUS), since it is impossible to speak in comprehensiveness when services are in fact fragmented. In the reality studied, there was no effective referral system to make continuity possible.
[...] providing care for a psychiatric user in an emergency is not easy, we must be prepared because the family does not collaborate ... the family throws all responsibility on the team. (I11)
[...] there is also the fact of the lack of commitment of the manager to want to do something to improve the care network for psychiatric patients [...] everything is very precarious, beds are lacking in hospitals, the policy for these users is not implemented. (I1)
[...] the worst is the lack of continuity of care [...] we assist these patients today and most of the times we never see them again, we do not know if they were rehabilitated or reintegrated into society [...] care is not at all resolute; controlling and medicating patients in mental crisis, and hospitalization is a wasted effort. (I9)
Psychiatric urgency and emergency services occupy a strategic place as a gateway for users with mental disorders, in situation of crisis, in the SUS. However, they represent a problematic point in the Psychosocial Care Network (PCN) because they are in the last level before the psychiatric hospitalization. In most cases, these services prioritize sedation and referral to hospitalization in cases of psychic crisis, strengthening the crisis/emergency/hospitalization chain as if this was the main, if not the only, alternative to contain the crisis9.
The agility in the management of patients, essential for the proper functioning of an emergency service, may imply some limitations regarding both the treatment of patients and the training of health professionals for performance in this type of service. In general, psychiatric emergency services lack enough beds for better observation and follow-up of the clinical picture, what leads to an early decision for hospitalization 11.
In most Brazilian cities these services are still insufficient and are not prepared and adequate to assist this clientele. In this sense, situations of psychiatric emergency represent an immense challenge7.
This reality is clear in the speeches of the interviewees when they report the difficulties of referral of patients in psychiatric urgencies and emergencies after performing the care.
[...] sometimes there are no places to refer the patient in crisis [...] when we assist a psychiatric patient we need to take him to the general hospital, because the psychiatric hospital does not receive them without a referral [...] this interferes the dynamics of SAMU [...] our work is limited (I2)
[...] there is no doubt that health services are disorganized here in the city ... we have no backing [...] there are no 24-hour PSCCs (I11)
According to Decree 2,048/GM, one of the roles of SAMU during the service is "to recognize the need to call other actors into action in the care of psychiatric urgencies, when the safety of PHC teams is at risk (aggressive victims that pose risk for themselves and for others)" 2:76. However, it is not true that every psychiatric patient in crisis is potentially aggressive, as this is a reflection of prejudice and lack of preparation for intervention in psychiatric emergencies9.
In the present study, it was observed that the need for police protection in the provision of care of patients in psychiatric crisis was common:
[...] when the patient is in psychiatric crisis, I'll call the police right away ... the cops help us contain aggressive psychiatric patients (I4)
[...] I am afraid of being beaten, so I ask for help from the police. (I1)
Care for patients in psychiatric crisis is often carried out in a fragmented way, and it is understood as a set of techniques and procedures to be applied. Generally, professionals are impatient and fail to consider the reasons that lead patients with mental disorders, in some situations, to manifest aggressive behaviors7. The therapeutic communication approach, taking into account non-verbal expressions, may contribute to decrease or eliminate the aggressive behavior of the patients12.
This aspect was clear in the speeches of the interviewees, when they mention the difficulty of continuing the service, believing it to be the psychiatric hospital the best destination for these patients.
[...] the psychiatric hospital only receives patients when they have already been referred by a psychiatrist, but the psychiatrist is there until one p.m. only, thus in the other hours the patient is referred to the general hospital or to the ECU (Emergency Care Units), and there he is often sedated ... the ECU professionals are not prepared to deal with these patients ... they did not receive training ... the doctor usually takes advantage of the fact that the patient is with a family member and as he has already been medicated, the doctor sends them away [...] there is no continuity of treatment (I9)
It is necessary that urgency and emergency services, both in their mobile or fixed component, perceive the moment of the psychic crisis as fundamental to foster reception and understanding of the subjectivity manifested during the intensification of suffering of the user, seeking the interlocution between professionals and patients, and thus promoting humanized care9.
If therapeutic communication is not present in the assistance to the user in psychiatric crisis, this can bring harmful consequences to the patient, because his detachment from reality experienced at that moment does not imply the absence of sensations, affections and anxieties specific to their human condition, for the most strange that the situation may seem 13.
A study demonstrated that the challenges to be faced in the nursing work to deal with humanized care in mental health range from the weaknesses in nurses' skills and abilities to deal with the new focus of mental health care to the lack of material resources and the overlapping of activities resulting from the service demands14. However, nurses pointed out responsibility, commitment and ethical care as strategies to humanize mental health care and help them overcome their limitations15.
Strategies to consolidate comprehensive care to psychiatric urgencies and emergencies
The effective integration of a psychiatric emergency service with the other mental health services available in the region is a decisive factor for the proper functioning of both the emergency unit and the psychiatric care system as a whole16.
However, in the studied reality, a great difficulty was observed in the use of strategies for provision of comprehensive care, in view of the fact that the lack of knowledge of professionals about the organization of the psychosocial care network and the obstacles posed by the disarticulation between health services, with lack of essential spaces such as the Psychosocial Care Center three (PSCC III), make the assistance fragmented and little resolute.
PSCC III primarily serves people with intense psychological distress due to serious and persistent mental disorders, including those related to the use of psychoactive substances, and other clinical situations that make it impossible to establish social bonds and carry out life projects. It provides 24-hour care, including holidays and weekends, and offers clinical support and night care to other mental health services, including the Psychosocial Care Center - Alcohol and Drugs (PSCC AD)17.
This scenario was evident in the speeches of the interviewed professionals when they were inquired about their understanding of the psychiatric reform and whether mental health care services offered adequate assistance to users in situations of psychiatric urgency and emergency.
[...] psychiatric reform advocates the reduction of psychiatric beds and the increase of other services to care for these patients [...] in order to improve care, alternative services need to be created (I8)
[...] I believe that in order to solve the problem of care once and for all, it would be important to articulate the health services, the SAMU, PSCCs and the referral psychiatric service [...]
[...] practices have not changed; care is based on patient restraint and sedation (I14)
In this way, it is important to emphasize that the Psychiatric Reform is not only a theoretical change, but a reconstruction of practice, new supports, new concepts of health and illness, of normality and madness. It is not limited to the creation of outpatient systems, but of spaces and forms of health care16. Furthermore, adequate investment in material resources, and especially in human resources, is a fundamental structural dimension for the consolidation of the Psychiatric Reform 18.
The Ministry of Health of Brazil considers that the mental health care network should be constituted by several health care services according to the population criteria and the demands of the cities. This network can count on mental health actions in primary care, PSCC, Residential Therapeutic Services (RTS), beds in general hospitals, outpatient clinics, among others16.
The city where the study was conducted does not yet have an organized and articulated network of mental health services. This reality is clear in the speeches of the interviewed nursing professionals.
[...] I observe the lack of organization of mental health services every day; we do have where to take psychiatric patients in crisis [...] I see as a solution the implantation of therapeutic residences, this would help a lot in our work. (I9)
[...] we all know that there is a lack of articulation between the primary health care network and other services, as well as a lack of services that can adequately assist these patients. (I19)
This situation impairs the accomplishment of comprehensive care, because in order to ensure quality care, it is necessary that the network of mental health services be organized and hierarchical, so as to guarantee the continuity of care.
Those who end up negatively affected by the lack of organization of the network are the users and their families. They would benefit from a collaborative care among the different SUS health services, so that they could meet the particular needs and demands of their users14.
In this sense, it is necessary that the SAMU be articulated with the specialized components of the mental health care network in two ways: through an internal articulation of services, which cannot be exclusively focused on bureaucratic or procedural aspects and needs to advance into the centrality assumed by the subjectivity of users in crisis; and an external articulation, in which the service may demonstrate the capacity to absorb knowledge and resources external to its practices19.
It is important to emphasize that when it comes to a holistic approach, this is reflected in practices based on the articulation between clinic and Collective Health in all levels of SUS care, both in general health care services and in specific mental health sectors, gravitating around the needs of the user9. This completeness will only be achieved through the exchange of knowledge/practices and change in the established power relations, through the institution of an interdisciplinary work logic 20.
A viable alternative would be the elaboration of specific protocols for care of psychiatric urgencies and emergencies, considering that the care provided to this clientele must be based on general protocols of the SAMU.
[...] one way to improve it would be to develop mental health protocols to guide the care. (I20)
[...] we follow the protocols of basic and advanced life support, but nothing specific to mental health, [...] it would be important to use protocols specific to mental health. (I7)
The thinking and the practice of following a protocol bring a particular problematic to our discussion on psychiatric emergencies: mental health care does not follow specific protocols. In this way, the formatting of rigid practices, such as those propagated in the SAMU, when it comes to mental health, ends up contributing to an even bigger problem than to a solution21.
In this sense, it is important to advance in the understanding of psychiatric urgency and emergency as events that demand reception, dialogue, approximation between the subjects involved and respect to the needs of each user. Therefore, it is necessary to articulate the SAMU and the mental health network in order to build up knowledge and practices for the effective consolidation of an integral and humanized approach 13.
CONCLUSION
Psychiatric urgencies and emergencies are increasingly frequent in the SAMU, stressing the need to offer adequate nursing care to this clientele in a resolute and humanized way.
In this sense, the professionals who deal with these patients must receive adequate training to perform an appropriate care, because the degree of care required does not come from advanced technologies, but from the appropriate contact and care.
With regard to the network of mental health services in the city studied, a fragmented assistance was found. There is no an organized and hierarchical network, which makes it difficult to carry out a humanized and resolutive assistance.
Finally, as strategies in the search for consolidation and expansion of an integral assistance to this public, we identified the creation of protocols for the care of psychiatric urgencies and emergencies, the improvement of the articulation between the SAMU and the mental health network, as well as the permanent education of professionals working in this service.
REFERENCES
1.Andrade EV, Bezerra Júnior B. Uma reflexão acerca da prevenção da violência a partir de um estudo sobre a agressividade humana. Ciênc Saúde Coletiva [online] 2009 [cited on Jul 24, 2014]; 14 (2): 445-53. Available on: http://www.scielo.br/scielo.php?pid=S141381232009000200013&script=sci_arttext
2.Ministério da Saúde (Br). Portaria 2.048/GM, de 05 de novembro de 2002. Dispõe sobre o funcionamento dos Serviços de Urgência e Emergência. Brasília (DF): Ministério da Saúde; 2002.
3.Bonfada D, Guimaraes J. Serviço de atendimento móvel de urgência (SAMU) e a assistência às urgências psiquiátricas. (Dissertação mestrado). Natal: Universidade Federal do Rio Grande do Norte; 2010.
4.Ministério da Saúde (Br). Secretaria de Atenção à Saúde. DAPE. Coordenação Geral de Saúde Mental. Reforma dos Psiquiátricos e Política de Saúde Mental no Brasil. Brasília (DF): Ministério da Saúde; 2005.
5.Del-Ben CM, Teng CT. Psychiatric emergency: challenges and vicissitudes. Rev bras psiquiatr [periódico online] 2010 [cited on July 14, 2014]; 32 (supl. II): 68-9. Available on: http://www.scielo.br/pdf/rbp/v32s2/en_v32s 2a01.pdf
6. Bonfada D, Guimaraes J, Miranda F, Brito AAC. Reforma psiquiátrica brasileira: conhecimentos dos profissionais de saúde do serviço de atendimento móvel de urgência. Esc Anna Nery [periódico online] 2013 [cited on July 2014, 28] 17(2): 227-33. Available on: http://www.scielo.br/scielo.php?pid=S1414-81452013000200004&script=sci_abstract&tlng=pt
7.Ikuta CY, Santos MA, Badagnan HF, Donato ECSG, Zanetti ACG. Conhecimento dos profissionais de enfermagem em situações de emergência psiquiátrica: revisão integrativa. Rev Eletr Enf [online] 2013 [cited on Dec 10, 2016]; 15(4): 1034-42. Available on: http://dx.doi.org/10.5216/ree.v15i4.20954
8. Soares FRR, Miranda FAN, Medeiros SM. Análise contextual do atendimento a emergências psiquiátricas. Rev enferm UFPE [periódico online] 2013 [cited on Jul 25, 2017]; 7(esp): 4269-77. Available on: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/4350
9. Brito AAC, Bonfada D, Guimarães J. Onde a reforma ainda não chegou: ecos da assistência às urgências psiquiátricas. Physis Revista de Saúde Coletiva [online] 2015 [cited on July 17 2017]; 25 (4): 1293-1312. Available on: http://dx.doi.org/10.1590/S0103-73312015000400013
10. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 10ª ed. São Paulo: Hucitec; 2007.
11.Bonfada D, Guimarães J. Serviço de Atendimento Móvel de Urgência e as urgências psiquiátricas. Psicol estud [periódico online] 2012 [cited on Nov 09, 2014]; 17(2): 227-36. Available on: http://www.scielo.br/pdf/pe/v17n2/v17n2a0 5.pdf
12. Bosi MLM, Carvalho LB, Ximenes VM, Melo AKS, Godoy MGC. Inovação em saúde mental sob a ótica de usuários de um movimento comunitário no nordeste do Brasil. Ciênc saúde coletiva [periódico online] 2012 [cited on Nov 09, 2016]; 17 (3): 643-51. Available on: http://www.scielo.br/pdf/csc/v17n3/v17n3a10.pdf
13.Silva DS, Azevedo DM. A Reforma Psiquiátrica na visão de quem cuida: percepções de profissionais do serviço residencial terapêutico. Esc Anna Nery [periódico online] 2011 [cited on 09 nov 2014]; 15(3): 587-94. Available on: http://www.scielo.br/pdf/ean/v15n3/a21v15 n3.pdf
14.Oliveira LC, Silva RAR, Medeiros MN, Queiroz JC, Guimarães J. Cuidar humanizado: descobrindo as possibilidades na prática da enfermagem em saúde mental. Rev pesqui cuid fundam (Online) [periódico online]. 2015 [cited on Nov 09, 2014]; 7(1): 1774-82. Available on: http://saudepublica.bvs.br/pesquisa/resource/pt/bde-26691
15.Neto AVL, Nunes VMA, Fernandes RL, Barbosa IML, Carvalho GRP. Humanização e acolhimento em emergência hospitalar: fatores condicionantes sob o olhar dos enfermeiros. Rev pesqui cuid fundam [periódico online] 2013 [cited on Nov 02, 2016]; 5(4): 519-28. Available on: http://portal.revistas.bvs.br/index.php?search
16.Santos ACTS, Nascimento YCM, Lucena TS, Rodrigues PMDS, Brêda MZ, Santos GF. Serviço de atendimento móvel de urgência às urgências e emergências psiquiátricas. Rev enferm UFPE on line. [Internet] 2014 [cited on: May 01, 2015] 8(6): 1586-96. Available on: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/download/5946/9279
17.Ministério da Saúde (Br). Portaria 3.088/GM, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde (SUS). Brasília (DF): Ministério da Saúde; 2011.
18.Andrade AB, Bosi MLM. Qualidade do cuidado em dois centros de atenção psicossocial sob o olhar de usuários. Saúde soc [periódico online] 2015 [cited Aug 07, 2017]; 24(3): 887-900. Available on: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S010412902015000300887&lng=pt
19.Machado DKS, Camatta MW. Apoio matricial como ferramenta de articulação entre a Saúde Mental e a Atenção Primária à Saúde. Cad saúde colet [periódico online] 2013 [cited Aug 07, 2017]; 21(2): 224-32. Available on: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-462X2013000200018&lng=pt
20.Paes LG, Schimith MD, Barbosa TM, Righi LB. Rede de atenção em saúde mental na perspectiva dos coordenadores de serviços de saúde. Trabalho, Educação e Saúde [periódico online] 2013 [cited Aug 07, 2017]; 11(2): 395-409. Available on: https://dx.doi.org/10.1590/S1981-77462013000200008
21.Azevedo EB, Ferreira-Filha MO. Práticas inclusivas na rede de atenção à saúde mental: entre dificuldades e facilidades. Rev Ciênc Saúde. [Internet] 2012 [cited on Nov 13, 2014]; 5(2): 60-70. Available on: http://revistaseletronicas.pucrs.br/ojs/index. php/faenfi/article/viewFile/10657/8205