Mental health nursing consultations in priMary health care

The aim of this research was to understand the importance of mental health nursing consultation in Primary Health Care. A qualitative, descriptive approach was used with seven participants; the nurses who made up the Family Health Care Strategy Team linked to a Health Care Center. Data were obtained from interviews and from a discussion group. All of the nurses considered mental health nursing consultation important as a monitoring strategy, for strengthening the link with the patient throughout the care, for extending nursing participation in case discussions with the multi-professional health team and because it contributes to resolving mental health cases.


Introduction
Psychiatric Reform in Brazil gained force from the 1990s onwards with mental health activities and services becoming included in public health care policies.The passing of Law n° 10,216 created Psychosocial Care Centers and Residential Treatment Services, signifying a high to medium complexity relationship (1) .Primary Health Care (PHC), in line with the historical, political and social moment through which health care in Brazil was passing, was not directly involved in mental health care activities or in other levels of complexity.
There were three significant periods in its evolution.The first, between 1980 and 2000, highlights certain experiences of including minimal mental health care teams, including psychologists, psychiatrists and social care workers, in Primary Health Care Units.The second, between 2001 and 2008, saw the creation of national health care directives for mental health in Primary Care.From 2001 onwards, there were workshops for consensus on techniques between the National Mental Health Coordinator, the Primary Health Care Department and the International Seminars on Mental Health.The third period, 2008 to Bolsoni EB, Heusy IPM, Silva ZF, Padilha MI, Rodrigues J. current, was then mental health care activities became institutionalized in Primary Health Care, with the establishment of Family Health Care Support Centers.This became an essential tool in increasing access and monitoring at this level of care (2) .
PHC is the users' gateway to accessing public health care services.Thus, PHC should be based on Unified Health Care System -Sistema Único de Saúde (SUS) principles such as universality, accessibility, connection, longterm care, comprehensiveness, responsibility, humanization, equality and social participation.Management and professional practice guided by such principles provide the population with quality health care (3) .The Family Health Care Strategy (FHS) which operates within Primary Health Care, has invested in promoting health, preventing disease and improving quality of life, including for those with mental illness (4) .
Thus, one way of improving care, in line with SUS principles for Primary Care nursing, is mental health care nursing consultation, providing autonomy, professional recognition and opportunities to interact with the individual sufferer and their family.Nursing consultation is deemed to be one of the actions that best represents the professional in this category, allowing systematic care to take place and basic needs affected to be identified.It can be done in the form of nursing problems or individually and the care given to each person can be planned, delivered and evaluated (5) .In this context, the research question of the study was: what is the importance of mental health nursing consultation in Primary Health Care?The overall aim of the study was to understand the importance of mental health nursing consultation in Primary Health Care.

Method
A qualitative, descriptive approach was chosen.Data were obtained using two research techniques; a semi-structured interview and discussion groups.The study was conducted in the city of Florianópolis, Santa Catarina, and the study participants consisted of seven nurses who formed the Family Health Care Strategy Team, linked to a Health Care Center (HCC).This number included all professionals of this category in the HCC studied.The nurses who participated in the study were aged between 26 and 43, mainly female, had graduated between 3 and 8 years previously and had been working in the same Health Care Center between 2 months and 3 years.As for post-graduate education, one of the nurses had no further studies, five were specialists in family health and one had a Master's in public health.
The interviews were scheduled with the professionals in their workplace.Two discussion groups also took place with the same nurses, in order to obtain a collective view of the object of the study.This technique enabled the object to be understood through dialogue between individuals in the group, chosen for this purpose by the researcher (6) .
Inclusion criteria for participants were: working for the service during the time the field work took place.The interviews and discussion groups were conducted at the HCC in April and May 2014, in quiet, private locations so as to restrict the information to the researchers.Content analysis was used to treat the data (7) .The interviews were transcribed and the data organized and, after reading, interpreted and de-codified, seeking common codes for categorization.The study closely followed research ethics for human beings and was approved by the Research Ethics Committee of the Universidade Federal de Santa Catarina (UFSC), nº 538,836.

Mental health nursing consultation in primary health care
Conducting consultations as an essential nursing activity to promote health is directly linked to primary care provision.In mental health, this contributes to long-term PHC and broadens activities used in designing the Individual Treatment Project (ITP).
According to Ordinance/SS/GAB/ nº26/2014, of the Municipal Prefecture of Florianópolis, Art.21, during the workday all professionals, including nurses, should deliver care meeting both spontaneous and programmed demand/continuous care (8) .Among the nursing duties included in the Florianópolis Primary Care Services Portfolio, as well as meeting spontaneous and programmed demand, the nursing professional should also classify risk/vulnerability, provide emergency/urgent clinical/surgical care to those with acute/severe psychological suffering.In home care, attention should be provided to users with mental health disorders who have difficulty socializing/ are isolated and/or have poor adherence to treatment (8) .Programmed demand is the nursing consultation, specifically the nurses' work process that contributes to more efficacious performance.Thus, systematic care enables the knowledge of those receiving care, obtaining support for the user's autonomy, enabling basic needs within the individual to be identified (9) .Given the reports below, it can be seen that consultations are not conducted on specific days for each specialty, such as women's health, children's health or elderly health, among others, but according to demand, as shown below.
We don't have a time reserved for a specific type of consultation, we don't have a time reserved for anything, we make appointments as need arises… So it never happens that there is a consultation just for psychological suffering, just for mental health, you know?[...] patients who turn up, who I identify as mental health, we normally make an appointment for them with me the following week..

. (N3).
There's not a lot of programmed demand in mental health, there's more spontaneous demand, when someone is in a crisis or for a situation that needs to be monitored, it's more with the psychologist, psychiatrist [...] They are more consultations to renew prescriptions, that kind of think, there is very little demand for nursing [..

.] (N1).
It was low risk, we medicated and asked her to come back in 5 days… for another consultation and she returned to see me again, programmed, she was better then, but she needed medication and so we referred her to a psychologist together, so it was just that one time, and then we stayed with the specialist psychologist..

. (N6).
The nurses reported that, in mental health, they did not carry out programmed nursing consultations as there was no way to schedule consultations for this type of demand.They also reported observing users' mental health in other types of care and felt prepared to carry out the consultation.The user is advised to return for a programmed consultation and, if necessary, referred to a specialist or to professionals at the Family Health Care Support Center -Núcleo de Apoio à Saúde da Família (NASF).
Planning mental health nursing consultations, together with the support team, consists of identifying nursing care needs for the individual family or community, proposing strategic actions that assist in promoting health (10) .

The importance of mental health nursing consultation in primary health care
In primary health care, mental health nursing consultations are private nunrsing actions that prioritize the individual expressing their difficulties, identifying them and seeking resolution together with a professional.Moreover, the nurse supports the individual in seeking to recover.Nursing acts on the mental health of the individuals, aiming to equilibrate emotions, adaptations and stress levels (9) .The nurse's function is that of an agent of treatment who, based on the consultation, establishes a treatment relationship with the individual.The psycho-social care model proposes to move the focus from medical care to the subject's needs, requiring professional action that goes beyond professional domains.The nurse is challenged to make available their technical knowledge and extra skill with the unforeseen and diversity of their day-to-day work (9) .
Nursing consultation is an important mental health care tool, it aids in understanding and comprehending the individual as an individual but also as part of a collective and a family, thus aiding in the development of actions that have repercussions for the user, their family and their community (11) .In the consultation, the nurses promote, restore and recover mental health of individuals, families and communities.Their abilities are based on psycho-social care, personality theory and human behavior (9) .

evolution… if we deal with one patient for the first time today, and establish an action plan for them we need to do consultations, to see if what we planned for them is working out, if they are sticking to it, and if we need to make adjustments in the future... (N4).
She was crying a lot, we welcomed her.I'm going to make an appointment for you to come back, ok?And she's like: ok, next week I'll come for the appointment [...]There are a lot of patients who create a link with you, they always want to see you, so you're the one who has to see them, you can't go telling them go to the psychologist, go on... So, it's you who has to deal with them (N3).
I see it like this, it's a team, nursing is part of it.So it's really important to participate in the process.The nursing consultation is important in establishing a link, and not leave the link only with the doctor, but with the team... (N5).
The nursing consultation is a private tool of the nurse for monitoring care groups such as pregnancy, children or the elderly.However, in mental health, the nursing consultation stands out for the opportunity to provide individualized care to a suffering individual, for the autonomy achieved by this professional category and for the activity and resolution of the nurse as part of the multi-professional team.
Mental health care consists of an exchange between the general and specialist, this currently posing a challenge in the teaching/ service relationship.The specialist needs to be available to develop the exchange of knowledge with those working in general medicine, and this exchange of know-how between professionals is necessary for the supervision and mutual growth of the team, providing humanized and effective care.

Stages of mental health nursing consultations in primary health care
In order for nursing consultation to take place systematically within PHC, stages need to be followed in carrying out the consultation, such as the way the work process is organized and the systematization of comprehensive care.The stages for carrying out mental health nursing consultations are: collecting the individual's medical history, psychological examination, physical examination (differing from the commonly proposed consultation), nurse's comments/observations, nursing diagnoses, proposed treatment or prescription.The individual's medical history consists of the following items: identification, principal complaint, history of the current illness, medical history, social history, family history, care needs and level of autonomy (12)(13) .
Communication is essential in the medical history, as it creates openness between the professional and the user for the latter to feel comfortable in expressing their complaints, sentiments and emotions.This is when the professional has the opportunity to get to know, understand and be aware of aspects of the individual's history that affect their way of living and of acting.The psychological examination evaluates psychological functions and the nurse should evaluate: overall presentation, language and thought, sensory perception, emotion and mood, attention and concentration, memory, orientation and awareness (14).
The physical examination is an important tool as those suffering psychologically have a higher frequency of physical pathologies than the rest of the population.This examination may be a way of bringing together user and professional when conducted respectfully.The exam should be conducted from head to toe at the stages are inspection, palpation, percussion and auscultation (12) .
After the above steps come the commentary and observations from the nurse, the time at which the professional notes all the situations noticed, for example family relationships, behavior, appearance, emotion, feelings, impressions that they evaluated for this subject (12) .It is an opportunity for the nurse to put their knowledge and ideas into practice, posing questions, demonstrating their involvement and empathy and making themselves available to help the patient understand their afflictions.
The nursing diagnosis is obtained from analyzing the data collected.Some nurses prefer to use forms with pre-established diagnoses in the consultation, others prefer listing the problems raised and planning one or more interventions for each of them.The proposed treatment or nursing prescription is the set of interventions or actions to be carried out by the nurses themselves, the nursing team and the multi-professional team (12) .
The interventions defined may be individual or group, for the individual or even for the family.Objectives, goals and time limits to be met need to be included for each proposed intervention.This process is evaluated continuously and, depending on the result, new strategies must be sought, new referrals made or behavior used maintained (12) .One of the interviewees developed a strategy for collecting the medical history in the consultation, as follows.

The first thing is to identify the individuals, patient and professional, collect the data, the history, listen to the patient and be aware of all of their needs… the physical examination, analysis, inter-consultation and we open or close referrals as needed [...]. I have a script for mental health needs. I let them talk and note down the main points, all of the important points and a work together with them and we plan their care together... (N5).
In this statement, we can see how the interviewee systematizes the nursing consultation.This type of proceeding is important in organizing the service and each professional should seek training in order to be sure of the care provided, seeking, together with the patient, the appropriate way to take co-responsibility for adherence to care.

They talk about their complaint, directed by certain questions and I take down the history then, if necessary, I do the physical examination and talk with the appropriate professional, if necessary I refer them to the psychologist or to a doctor to refer to the CAPS [...]. I spend more time on the S, in SOAP, the O is more of a mental health complaint, I don't do the whole physical examination. The issue is the analysis, P [...]. I spend more time organizing the points that I listed in S [...] (N3).
The stages of mental health nursing consultation are the same as those of a general nursing consultation, although there is greater emphasis on listening to identify psychological suffering and on the psychological examination, with the aim of creating a care plan that includes all of the individual's interests and needs.As a work process, irrespective of the area (mental health, gynecology, obstetrics or gerontology, among others) the nursing process observes the same structure and can be used at different moments in practice (14) .For a mental health nursing consultation, it is necessary to establish an appropriate environment, with privacy and no interruptions, in order for the individual to feel comfortable discussing their complaints.In the physical exam, one must be aware of the signs and symptoms related to the individual's physiological or psychological condition.Another differential concerns the listening and the treatment relationship, in which one cannot always take on the role of speaker or listener but must change places.Listening to the other means being able to let their emotion find expression.The nurse should show the other how to be aware and sensitive (15)(16) .

Personal limitations for mental health nursing consultations
In order to conduct mental health nursing consultations, the personal limitations of the professionals need to be recognized, as well as establishing goals for overcoming these limitations.The nurse listens to stories of lives similar to their own, or to someone from their family and thus end up seeing themselves in the other and creating a mix of emotions between the professional and the personal.The nurse's feelings and impressions can be a product of many factors, such as professional clinical experience and aspects of transfer and contratransfer, prejudices, personal values which are unavoidably brought to the consultation, although they are often the product of intuition which, shaped by study or by maturing clinical practice, may lead to treatment actions (12) .
In the interpersonal communication and relationship process, the individuals share experiences, ideas and feelings, with subjectivity on both parts.When the nurse consciously recognizes their emotions during this relationship, positive or otherwise, they can control, rather than repress, them and use them intentionally and positively in the interactions.When there is emotional involvement, relationships certainly become more authentic and real, which is what is desirable in care nowadays (17) .Interaction is permeated by subjectivity, fruit of professional practice, from which factors emerge which Bolsoni EB, Heusy IPM, Silva ZF, Padilha MI, Rodrigues J.
go beyond the physical examination as they concern the characteristics and peculiarities of the subject.When the subject causes disquiet in the health care professional, beyond their conscious mind, emotions are mobilized, knowledge, gestures and emotions with the capacity for therapeutic clarification and potential are awakened (18)(19) .As the professionals reported, emotional involvement is important in the treatment relationship, although it is difficult to describe when dealing with mental health.The fact of relating to others, listening carefully, may awake feelings and emotions in the professional that do not need to be repressed, but need to be controlled and expressed, so as not to hold on to such feelings or feel harmed, to provide the subject with professional, humanized care.It is necessary, therefore, that the professional find alternatives for expressing their anxieties, seeking self-awareness, as they also feel insecure and concerned, common feelings in those who work in health care.This feeling of humanity from the professional towards the other, within their experiences of mental suffering related by the individual, encourages the capacity to listen with empathy, view the individual as similar and, without judgement, come to their own understanding as a person and as a professional (14) .Even when considering the emotions and feelings inherent to the professionals as inherent to our existence, there are reports of not being able to deal with the case of the other individual, being unsure of how to resolve it.Given these personal limitations, it is essential that the nurse understands whether they are in a condition to deal with the individual, reflecting on their own limitations, capabilities and motivations and accepting when they are not in a psychological condition to deal with certain situations (14) .

Final Considerations
The complexity of nursing consultations lies in the relationships between the two fields of health care practice and management: primary care and mental health.Their intersection is strengthened when the demand for mental health is not perceived as a fragmentation of comprehensive care for specialist care.The relationship between primary care and mental health proposed that care be relational and collaborative, as they are two fields of knowledge that are related and one does not outweigh the other.
The study achieved the objective of understanding the importance of mental health nursing consultations in Primary Health Care.The statements of the study participants showed that they considered mental health nursing consultations to be an important tool in establishing and strengthening the link with the sufferer and for long-term monitoring of care for those with mental disorders.
The context involving nursing consultations is permeated by the way work is organized in the health care unit, including meeting spontaneous and programmed demand.In the nursing care, in spontaneous demand, when the needs involve mental health, the individual is welcomed, listened to carefully, with empathy and respect.This being the case, the nurse identifies the need for monitoring and a nursing consultation focused on mental health is scheduled for the patient's return.One of the limitations observed in this study was the fragility of the nurses in highlighting knowhow that may extend knowledge in the field of mental health.In nursing consultations with specific demands.
's difficult for me to deal with mental health cases.