The applicabiliTy of The nursing process in caring for psychiaTric paTienTs : an inTegraTive review

s available in the selected databases, within a 10-year-period (January 2002 to September 2012) describing the nursing process in psychiatric nursing practice. Data were collected from the articles included in the integrative review using an instrument designed and validated by Ursi (13). Regarding their evaluation, the articles were classified according to their level of evidence, consisting of a hierarchical category that takes into consideration the research design, this being representative of the strength of the evidence (13). This hierarchical classification contains different levels for evaluating evidence from the research (13). In this study, two reviewers searched for and selected articles from the literature independently.

The applicabiliTy of The nursing process in caring for psychiaTric paTienTs: an inTegraTive review Murielle Badin 1 Ana Paula Rigon Francischetti Garcia 2 Vanessa Pellegrino Toledo 3 The aim of this study was to conduct an integrative review of the literature on the applicability of the nursing process in psychiatric nursing care.The following databases were searched for indexed articles Literatura Latino-Americana e do Caribe em Ciências da Saúde and the National Library of Medicine.Studies in English and in Portuguese between January 2002 and September 2012 were included.The final sample consisted of nine articles.The studies showed evidence of the applicability of the nursing process in psychiatric nursing, favoring qualified and systematized care.The nursing process is a methodology that promotes comprehensive patient care for those with mental illness.There are few studies on the subject and more research into this topic is needed.
treatment and retake their place in society (2)(3)(4) .Thus, the psychiatric nurse as an agent of treatment, using the Nursing Process (NP) to support their professional activity, is able to systematize nursing activities and contribute to developing an individualized care plan for each patient, this being an instrument which assists in qualified care, one of the objectives of which is to motivate the patient to adhere to the proposed treatment (5)(6) .
As NP is a model for organizing nursing care, collecting patient data and thus allowing the care needs, health problems or vital processes contained in their responses to be identified, heling to define the need for professional action, the results of which are evaluated, with the Systematization of Nursing Care used as a way of organizing and operationalizing NP (5,7) .
NP is organized into five stages: patient history and diagnosis, planning, implementation and evaluation, which must be recorded in the patient's medical records and which, when used properly, encourages better communication between the health care team members, enabling them to identify alterations in the patient's state of health (7)(8)(9) .
In the context of psychiatric nursing, the treatment relationship established between the nurse and patient encourages application of the NP, enabling a treatment project to be constructed by the nurse and patient, contributing to outlining the nurse's field of action and aiding in decision making, care planning and evaluating the care provided (5)(6) .Another aspect of developing NP to be highlighted is the use of taxonomies so as to standardize the language used among the nursing professionals for a more dynamic interaction between them (5) .
This study is, then, justified given the importance of the use of NP in clinical practice in psychiatric nursing, providing qualified care and conveying autonomy on psychiatric nurses in their work, enabling care to be organized so as to consider the subjectivity of the patients,

Introduction
Proposals to reform psychiatric care originated in the mid-1950s in the US and Europe.In this context, complaints about violence, observations of abandonment, segregation and chronic clinical status of those admitted to psychiatric hospitals showed up the deficiencies of these institutions in conducting the treatment supposed to be carried out there.Moreover, there was pressure for health and social reform, as well as from human rights movements, to reformulate health care models for these populations (1) .
Thus, de-institutionalization movements appeared in several countries, demanding new forms of treatment for those with mental illness and the transfer of psychiatric care from hospitals to structured services in the community (1) .
In Brazil, various sectors of civil society were influenced by reformist movements from the United States and Europe, fighting for patients' rights (1) .The national mental health policy was thus created, based on progressively reducing the number of beds in psychiatric wards and hospitals and extending and consolidating the community based outof-hospital care network, which included Psychosocial Care Centers -Centros de Atenção Psicossocial (CAPS) and Residential Treatment Services (1)(2)(3) .
This mode of care is based on the dehospitalization paradigm and on the psychosocial rehabilitation of those who are mentally ill through implementing social, educational, occupational, behavioral and cognitive interventions, encouraging reintegration into society (1)(2)(3) .The aim is to assist the subject in developing skills for social, work and leisure interactions and for relating to friends and relatives (1)(2)(3) .
In this scenario of reforms, psychiatric nurses take on a new role, an agent of treatment, developing care aimed at the treatment relationship established with the patient, helping them develop as a person and to feel part of society (4) .Thus, acts of nursing are no longer centered on physical care, as in observing patient behavior, and they take on activities aimed at the subjectivity of the individuals, encouraging them to take on an active position in their own Badin M, Garcia APRF, Toledo VP.

Method
The method employed was that of an integrative review of the literature with the aim of bringing together and synthesizing studies on a specific topic, so as to enable a conclusion to be reached, facilitating the decision making process in relation to actions and interventions that could provide more effective health care (10)(11) .
The following stages were followed in constructing this review: questioning, searching the literature, categorizing and evaluating the studies included, interpreting the results and presenting the synthesis of the knowledge (12) .
Therefore, the research question was drawn up by applying the PICO strategy: patient, intervention, comparator and outcome, these being essential elements in drawing up a research question when searching for evidence in the literature (11) .
Thus, "P" is psychiatric patients, "I" the applicability of NP in psychiatric nursing care, "C" the comparison between the results obtained and "O" the presence of evidence in the literature on the use of NP in the context of psychiatric nursing, resulting in the following question: is there evidence in the literature of the applicability of NP in psychiatric nursing care?Two databases were consulted from which to select publications, namely: the National Library of Medicine (PubMed) and the Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), with different search strategies being used and two controlled descriptors.The controlled descriptor is a term given to structured and organized vocabulary to be used in indexing the articles in the databases, being a descriptor of the topic and therefore, Health Science Descriptors (DeCS/Bireme) and the Medical Subject Headings (MeSH/PubMed) were consulted and the following identified: nursing processes and psychiatric nursing (11) .The search of the literature was conducted between September 2012 and January 2013.
The inclusion criteria were: articles published in English or in Portuguese, with abstracts available in the selected databases, within a 10-year-period (January 2002 to September 2012) describing the nursing process in psychiatric nursing practice.
Data were collected from the articles included in the integrative review using an instrument designed and validated by Ursi (13) .
Regarding their evaluation, the articles were classified according to their level of evidence, consisting of a hierarchical category that takes into consideration the research design, this being representative of the strength of the evidence (13) .This hierarchical classification contains different levels for evaluating evidence from the research (13) .In this study, two reviewers searched for and selected articles from the literature independently.

Results
The search in the PubMed databases took place in two stages; in the first, the terms nursing process and psychiatric nursing were combined, applying the following filters to the search: last five years for publication date, Portuguese or English language.A total of 849 studies were thus identified, of which 80 were preselected from their titles and abstracts.After a complete reading, 73 were eliminated as not conforming to the proposed subject.In the second stage, a filter was set for the period 01/01/2002 to 31/12/2007 and 1,259 studies were identified, of which 14 were pre-selected from their titles and abstracts.After complete reading, however, none of them were found to match the inclusion criteria for this review.In total, then, 2,108 articles were identified in PubMed and seven were included in this review.
As for the search in the Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) database, the same descriptors were used as described above.We identified 105 studies and pre-selected 84 from their titles and abstracts, of which 27 were read in full and two were found to discuss teaching psychiatric nursing; five had already been identified in the PubMed search; two covered historical aspects of psychiatric nursing practice; two explored the issue of Psychiatric Reform; 16 did not describe the applicability of NP in psychiatric nursing care; thus, of the 27 articles, two were included in this review.
In total, 2,208 studies were identified (2,108-PubMed, 100-LILACS), and the final sample was made up of nine articles, five of which were found only in PubMed, two of which only appeared in LILACS and two studies which appeared in both databases.Figure 1   collected, selected, analyzed and interpreted and a conclusion drawn, justifying its classification as a case study (16,22) .The five primary studies were conducted in the following locations: one in a care home (20%), another in a hospital outpatients (20%), two (40%) in psychiatric hospitals and one (20%) in a foundation providing mental health hospitalization and services.
As for the year of publication, it was found that seven (77.7%) were published after the year 2002, with a homogenous distribution between 2007 (22.2%) and 2010 (22.2%).Articles from 2003, 2005, 2006 and 2012 were not selected as they did not meet the inclusion criteria for this review.Thus, the greatest concentrations of articles selected were found in the years 2002, 2007 and 2010.
Regarding country of origin, four of the studies (44.4%) were by Brazilian researchers, two (22.2%) were by American researchers, one (11.1%)by Thai authors and two (22.2%) by Dutch authors.
The type of studies found were as follows: three (33.3%)were literature reviews, one (11.1%)was a systematic review, with no classification for the level of evidence, and another (11.1%) was a quantitative (prospective observational) study with evidence level IV, four (44.4%) were qualitative studies classified as evidence level IV, of which two (22.2%) were case studies (13) .
It is noteworthy that one of these studies did not have an explicit design, but it was possible to classify it as a case study, as it was limited to units-cases to be evaluated and data were

Discussion
In Brazil, Psychiatric Reform was based on de-institutionalizing the mentally ill, encouraging the deconstruction of the lunatic asylum model and reorganizing nursing care, culminating in the appearance of a new mental health care paradigm and new forms of treatment, as well as changes to the ethicalprofessional attitude in caring for patients with mental health disorders (23)(24) .
Thus, care activities in psychiatric and mental health nursing are a complex field in which knowledge, concepts and experience are articulated, making it necessary to study and publish the results of research, enabling psychiatric nurses to reflect on their practice and the knowledge which structures their actions (25) .
Given this, four of the studies (44.4%) analyzed were by Brazilian authors, indicating the initiative, on the part of Brazilian nurses, to divulge practice, encouraging growth, recognition and a process of reflection on the actions of nursing professionals, strengthening practice and meeting the above mentioned need to disseminate knowledge in the field of psychiatric and mental health nursing (25- 26) .It is noteworthy that these four studies (44.4%) were published in Brazilian scientific journals, and two of which were published in the Brazilian Journal of Nursing -Revista Brasileira de Enfermagem.
Still on the topic of disseminating research in the area of psychiatric and mental health nursing, according to the reference used to classify the level of evidence, no strength of evidence is attributed to the literature reviews, although the constant growth generated by research and the demands of Evidence-Based Practice (EBP) nowadays, calls for the collection, analysis and synthesis of knowledge from already existing research (27) .
Moreover, literature reviews can be used to review research, varying the methods used, for example, systematic review or meta-analysis, among others, enabling the dissemination of the results from various pieces of research in one single study (27) .
With the modification of the care model in psychiatric nursing, the actions of the nurse aim to promote mental health, aiding the subject suffering from mental illness to deal with it and to understand the significance of their mental disorder, at the same time as providing assistance to the patient's family (23) .
For the nurse to perform their role, their need to use their perception and observation, interpret the reality observed, outline the field of activity and make decisions, plan care, evaluate the development of their care activities, all of which belong to NP and guide the interpersonal and treatment relationship (23) .Thus, one of the studies analyzed showed that the nurse in a care home, a communitybased service, used the NP in the treatment of one of the residents with a long-standing mental disorder, resulting in an improvement in the clinical status (14) , in this way, in the context of psychiatric nursing care, the focus of the NP is aimed a goals and based on a decision-making or problem resolving model that aims to improve patients' response to health problems and, in the patient in question, the goal was to better deal with their psychological suffering (5,14,28) .
Another aspect to be considered in caring for patients with mental illness is adherence to treatment, defined as the degree to which patients adopt the health care professional's recommendations (6) , s two of the studies indicated that applying Irving's NP enabled two patients with mental disorders to adhere to treatment (15,19) , as it strengthened the treatment relationship between the nurse and the patient through developing the stages of the NP together, the linked between the subject and the nursing professional grew much closer (5) .
At the same time, the NO contributes to constructing the treatment project as it enables the subjects' needs and responses to the health problems to be known, encouraging the drawing up of an individualized nursing care plan (5) .
Another of the four studies described the development of all NP stages together with a patient with Bipolar Disorder undergoing treatment at a hospital outpatients' (18) .The patient's history was drawn up, based on reports, data from medical records and input from professionals at the hospital, key points in need of intervention were identified and nursing diagnoses drawn up, followed by solutions for the identified problems and, later, these were evaluated to see if they had been achieved (18) .
Carrying out the NP for this bipolar patient resulted in improvements in their response to the illness, showing that the NP is a continuous process that remains as long as there is interaction between the patient and the nursing professional, leading to changes in the patient's physical or behavioral responses (18,28) .
Likewise, another of the studies, consisting of a systematic review, dealt with nursing care for children and adolescents with bipolar disorder, indicating that setting up a history of the patient's mood swings, evaluating and identifying signs and symptoms, developing a plan to deal with crisis and nursing interventions, showing the application of different stages of the NP in the context of psychiatric nursing care (19,28) .
Moreover, the studies show that a formal record of applying the NP was made, summarizing the data collected about the patient and their family, as well as interaction with the collective, at a specific moment in the subject's health-illness process, which will serve to guide the patient's treatment as well as proving the NP has been carried out (6) .
Another of the studies portrayed the issue of identifying nursing phenomena identified in articles in journals on nursing care for adults admitted to psychiatric wards, concluding that in psychiatric nursing care, it is necessary to name and record the patients' problems and causes/related factors and triggers, as well as signs and symptoms (20) .Thus, the use of the nursing diagnosis encourages nurse autonomy and describes the patient's condition, facilitating the prescription of interventions and creation of parameters to guide the results (28) .
One of the studies showed that the actions carried out by nurses at the psychiatric ward of a university hospital using the NP as the work methodology so as to make care more dynamic, highlighted the importance of recording interventions and evaluations daily, encouraging treatment and care and guiding teamwork (21) .
This study also shows that, following the Psychiatric Reform, psychiatric patients are being included and cared for in general hospitals, contributing to overcoming the historically alienated care in psychiatry, as there is a need for these experiences of psychiatric hospitalizations, in Brazilian general hospitals, to be analyzed and disseminated, as they have beneficial effects in the treatment of patients with mental disorders, in contrast to what happens when they are hospitalized in psychiatric hospitals (29) .
The study also confirmed that university hospitals have been the forerunners in developing mental health care in general hospitals in Brazil and are strategic in structuring a treatment and care model which moves away from the previous model, which resulted in excluding individuals with mental disorder from society (29) .
One of the literature reviews, in addition to demonstrating the development of the NP stages in nursing care for children and adolescents with bipolar disorder, emphasized the need for nurses to constantly evaluate these patients, due to occurrence of comorbidities and the fact that this disorder affects different aspects of their life, as well as including family members in the process of developing a care plan for these patients (19) .
Nurses play a fundamental role in planning care, one of the NP stages, as well as involving the family in drawing up care plans, this being a mode of intervention through educational and informative activities about the mental illness of their family member (19,30) , the changes in the mental health care model have a place for family participation in the recovery process of the mentally ill family member (30) .
Still on the topic of developing the care plan, the studies show that when drawn up in participation with the patient, their needs and mental health problems are considered in an individualized and comprehensive way, as they are better drawn up by the nurse, these being the ones who spend the most time with the patient, as well as exchanging information on actions undertaken in the last 24 hours within the nursing team, this helps with planning and guiding nursing team activity (19,21,28) .
Finally, the NP appears in the context of the new model of mental health care, so as to qualify the care delivered.It is also characterized as something that is developed by an inter-disciplinary team, in which applying the NP requires the involvement of nursing in the treatment regime and establishes the nurse's autonomy in reference to the team (14)(15)18) .
A limitation of this review was identifying the nine studies portraying partial use of the NP, with the definition of nursing diagnoses guided by medical diagnoses, restricting the conditions of care if aspects of practice centered on the nurse/patient partnership are considered, something which requires the ability to criticize, listen, understand, share, be honest and skills to facilitate transposing the patient's limits (31) .

Final considerations
The review identified evidence of the applicability of the NP in the context of psychiatric nursing care, which encourages comprehensive, consistent and qualified care delivered systematically and ethically, as appropriate to the new mental health care model.Moreover, it is noteworthy that, following the Psychiatric Reform, the nurse as an agent of treatment no longer delivers custodial care but aims at the psycho-social rehabilitation of the mentally ill individual and their reintegration into society, bringing family members into closer proximity of care for mentally ill relatives.
Likewise, studies have shown that NP, as a scientific methodology of professional nursing work, conveys a position of autonomy on the nurse in relation to the inter-disciplinary team and, when shared through more formal records, results in guiding the care delivered by the professionals, not only those in nursing, encouraging health care team interaction.
Another aspect indicated in the studies is that the NP encourages psychiatric patients Badin M, Garcia APRF, Toledo VP.
to adhere to treatment, as they themselves assisted in constructing it, the NP guides the treatment of these patients and can be developed through the interpersonal and treatment relationship with the nurse.
To conclude, there is bias in applying all stages of the NP in the studies reviewed here, moreover, only a few studies were identified on this topic, which may indicate the need for research institutions and universities to prioritize developing research on implementing and executing the NP in different health care services that provide psychiatric and mental health nursing care in Brazil and in other countries.

Figure 1 -
Figure 1 -A summary of the articles included in the integrative review shows the categorization of the studies included in this review: SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.out.-dez.2015;11(4):243-55 (The Figure1continue in the next page...) (The Figure 1 continue in the next page...) (The Figure 1 continue in the next page...)