Nursing Consultation on Mental Health : integrative Review

It is an integrative review of literature that aimed review scientific productions about nursing consultation on mental health in health services in the period 2001to 2013 in the databases Scientific Electronic Library Online (SciELO) and Latin American and Caribbean Health Sciences ( LILACS). It was found that 60% of the researched articles indicated that nurses have limitations to make the diagnosis of mental health nursing. It was concluded that the nursing consultation and its relationship in the mental health field still incipient. It is suggested that the nursing consultation be systematic and involves topics such as interpersonal relationship, nursing history, physical and mental examinations, diagnosis and planning in nursing.


Introduction
The World Health Organization (WHO) defines mental health as a welfare state in which the individual realizes his/her actions, possibly facing the difficulties of life and working productively being capable of contributing to their community (1) .From this perspective, mental health is part of people's general health and directly affects their quality of life.
As knowledge and subjectivity field, mental health includes a spectrum that involves human suffering and mental disorders.According to the Ministry of Health, 3% of the Brazilian population have severe and persistent mental disorders; more than 6% of the population have severe psychiatric disorders arising from the use of alcohol and other drugs; and 12% of the population needs some assistance in ongoing or possible mental health (2) .
From every arrangement that involves the field of mental health, in addition to the theoretical field and attention to the human subjectivity, required to statistics, mental health is also a right.After 12 years of social struggle, in 2001 Law 10,216 was enacted, supporting the Brazilian Psychiatric Reform and providing changes in the model of care in mental health.The indicative of inclusion and possible contact with the family and the community replaced isolation and exclusion of people with mental disorders.It is assumed to guarantee the population access to mental health services in territorial basis and respect for freedom and autonomy (2) .
Bolsoni EB, Heusy IPM, Silva ZF, Rodrigues J, Peres GM, Morais R While recognizing that various experiences contribute to the formulation of public policies, deinstitutionalization has been the fundamental basis to guide an ethical project, technical in expanding access to mental health care and improving the quality of life of people with mental disorders hospitalized for long periods of time.From the Psychiatric Reform, and currently with Ordinance 3088 of 2011, care made exclusively in psychiatric hospitals shall be carried out in the care network.There are several points in the latter, which is the main path to Primary Care.Thus, the construction of the transition begins from one care model centered in psychiatric hospital for a community care model based on the territorial attention and care to people with mental disorder, aiming their reintegration into family and community (3) .
With the nursing consultation being one of the ways of that monitoring of care, this study aims to contribute to the expansion of knowledge about the realization of nursing consultation in mental health, and as part of the Singular Therapeutic Project, among others.
Nursing consultation in health is a powerful tool for nurses to care for the person and have more historical and relational benefits to the person in distress.Nursing consultation on mental health is one of the care assistance that brings recognition to the professional, knowledge sharing and gives autonomy to the person or family (4) .
However, on the one hand, during the process of teaching and learning, in undergraduate course of nursing at the Federal University of Santa Catarina (UFSC), the authors of the article realized the lack of nursing consultation on mental health in services when performing their internships.In the search for a better understanding of this fact, some nurses reported difficulties in working conditions, high demand to develop their work process and training limitations, disinterest and detachment regarding theoretical and methodological frameworks that integrate nursing consultation and mental health.
On the other hand, the work of nurses in the mental health field has grown considerably in Brazil, because in addition to developing activities in traditional areas of care such as the psychiatric hospital, they can also act as professionals in Health Centers, Outpatient Care and new psychosocial care devices, indicating that the mental health consultation is a prerogative to be performed in the nursing work process in various care settings (5) .Studies on the nursing consultation on mental health in health services is important because all health demand is also mental health, thus, nurses should be aware and prepared to develop the nursing consultation on mental health in any situations of the health process, disease and care.
Nursing consultation to the person with a health care demand, or mental disorder, or psychological distress, covers the determinants and conditions for quality of life, such as feeding, housing, basic sanitation, environment, labor, income, education, transportation, leisure and access to essential goods and services.With the proposal to deepen the understanding of nursing consultation on mental health in health services, the following guiding question is: in Brazil, how is the nursing consultation on mental health approach in scientific publications?
The purpose of this article is to review the scientific publications that describe nursing consultation on mental health in Brazil.

Method
This is an integrative review of the literature regarding nursing consultation on mental health, from access to scientific publications on the subject.Integrative review is a method of literature research by which one seeks to deduce generalizations about the delimitation of the subject and from the main results of the studies.Integrative review supports research to discuss hypotheses, suggestions for new theoretical issues and identification of necessary research (6) .
To choose and to combine the keywords we had the contribution of a librarian who accompanied the study: care, assistance, consultation, nursing, mental health and psychiatry.Scientific studies have been researched on the basis Scientific Electronic Library Online (SciELO) and Latin American and Caribbean Health Sciences (LILACS).The combinations with the keywords were: LILACS: ("Nursing consultation") AND ("mental health") = 14; ("nursing assistance" OR "consultation") AND ("nursing") AND ("mental health") = 190; ("nursing care" or "nursing assistance" OR "consultation") AND ("nursing") AND ("mental health") = 213; ("care" or "assistance" OR "consultation") AND ("nursing") AND ("mental health") = 637; SciELO ("care" or "assistance" OR "consultation") AND ("nursing") AND ("mental health") = 40.These combinations have been built and tested in the course of September and October 2013.
Inclusion criteria were: complete scientific articles indexed in national journals published in Portuguese and Spanish, from 2001 to 2013, which addressed nursing consultation on mental health in health services.This time frame is justified because the publications are more fruitful from the year of SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.Oct.-Dec.2016;12(4):249-59 studies that did not contemplate the scope of this study.
The method that guided the integrative review followed the steps outlined in Figure 1 (6) : sanction of law 10.216 (7) ; research that contribute to the decision-making for the deepening of the study object.Because of the framework adopted we could add studies of different theoretical and methodological nature such as literature review, reflection studies and experience reports.Exclusion criteria associated Source: Adapted from Ganong (6) Figure 1 -Method used in the construction of integrative review Data collection was performed using a preliminarily table, alluding to the following topics: title of the article, authors' names, titles of the authors, publication year, journal, objective of the research, methodology, main results, relevant discussions, the main findings on the remarks and recommendations.Data collection occurred from September to October 2013.Thematic analysis (8) was used to examine the data from scientific publications.Articles that comprised this study are identified by the abbreviation (A) from 1 to 10.

Selection of the research question
Search criteria: inclusion criteria, descriptors, database.
Search summaries and articles: objectives, methods, results, final remarks.

Results
In the first survey 677 articles were found, of which, 637 were 40 from LILACS and 40 from SciELO.In search of some titles, some studies were excluded and with the application of the inclusion/exclusion criteria and reading the abstracts, 25 articles were selected, 19 from LILACS and 6 from SciELO.After careful reading, 10 articles were chosen (Figure 2 according to the scope of this study).

Title Authors Objective Method Results
A1 (9) Nursing consultation in mental health sustained in the theory of interpersonal relationships: experience reports Canabrava DS, Vilela JC, Brusamarelo T, Roehrs H, Maftum MA.
Report an experience of nursing consultation based on the theories of interpersonal relationships on mental health.
Identification of problems that require immediate attention and implementation of nursing prescriptions.A2 (10) Nursing attention to patients with depressive disorder: a reflection Candido MCFS, Furegato ARF.

Disseminate knowledge on care to people with depressive
disorders.
Reflection study.
The importance of also observing in patients with depressive disorder physiological, cognitive, emotional and behavioral responses.
A3 (11) Care in mental health: a system for teaching nursing  As for titles, six articles cite mental health, two of them cite nursing consultation and only one cites nursing consultation on mental health.Thirty-eight authors wrote such articles, of which 33 nurses, four nursing students and one academic of computer science, equivalent to almost four authors per article.The production, as the publication years, was more assiduous from 2005 to 2012.Among the journals, there was no predominance; each article was published in different journals.Of the 10 articles, six were published in nursing journals.All studies showed overall objectives, reflecting clarity and consistency in their description, following the introductions and issues of the studies.According to the objectives, seven articles cite nursing actions, two cite nursing consultation, one cites nursing history and one cites systematization of nursing assistance.
Of the described methods, two studies used qualitative and quantitative methodology, two experience reports, a qualitative approach, a literature review, a case, a descriptive, exploratory study, a discourse analysis, and an integrative review.
Of the seven articles that carried out the research in study scenarios, we obtained two in psychiatric hospitals, two in primary care, two in outpatient care and one in the mental health service.It is shown, thus, that the nursing consultation on mental health in primary care occurs in the same proportion as in the other levels of complexity.The number of scientific publications on the nursing consultation on mental health in primary care is still incipient.
As for theories used in articles as methodological theoretical framework, one study indicates theories of interpersonal relationships, one study indicates a theory of basic human needs and reference terminologies CIPE (International Classification for Nursing Practice), NIC (Nursing Interventions Classification) and NOC (Nursing Outcomes Classification) and an article presented as theoretical support the historical and dialectical materialism.The others studies do not clarify or do not use theories to support data analysis.

Discussion
The practice of nursing consultation on mental health in health services According to A2, A3 and A6, Systematization of Nursing Assistance (SAE) is recommended to provide nursing care, being important to the decision making process according to the needs of the patient (10)(11)14) .
In Brazil, nursing has been using most popular words as: NANDA diagnoses (North American Nursing Diagnosis Association), the Classification of Nursing Interventions (NIC), the Classification of Nursing Outcomes (NOC), International Classification for Nursing Practice (CIPE) and International Classification of Nursing Practice in Community Health (CIPESC), the latter is a CIPE adaptation in Brazil.These words, in addition to allowing the register, as the nursing process, provide the same meaning for professionals from different regions, having its importance for the Nursing development, as they serve as tools to realize global knowledge.In addition, if the vocabulary used in practice is structured, standardized and classified, there is a better understanding of professionals as well as the monitoring of the quality of nursing care provided to patients, increasing the production of scientific studies (19) .
The systematization of psychiatric nursing assistance has been a useful and important tool in trying to build a more effective practice in the Brazilian psychiatric nursing in relation to psychosocial rehabilitation.Nursing consultation, by the priority attendance of the basic human needs, seeks attention to self-care, thus, it is necessary to effectively associate theory with practice so that understanding and implementation occur in the nursing process in mental health (20) .
In the systematization of nursing assistance, there is an organization of professional work on the method, personnel and tools that enable the operation of the nursing process.This is based on the assistance to the person in distress and guides the nurse for nursing process application, providing safety to the patient, quality of provided assistance and greater autonomy for nursing professionals (21) .
The COFEN 358/2009 resolution describes that the nursing process should be performed in all public and private environments, organized into five interrelated, interdependent and recurring steps, they are: nursing history, nursing diagnosis, nursing planning, implementation and nursing assessment (22) .As to A9, nursing care, when performed according to systematization, contributes to the recovery of the patient, promoting the psychological, physical and social well-being (17) .
Nursing History is a standard procedure and should be performed in the nursing consultation when searching the patient data.It is the first step of the scientific method, as from it, performing the nursing diagnosis, treatment plan, implementation and assessment, evolution and nursing prognosis are possible (23) .
According to A1, from the therapeutic actions that improve mental health care are: observation, listening and perception of nonverbal communication (9) .The latter qualifies human relationship, allows an understanding and greater awareness of the feelings presented by the person, and not only the meaning of words expressed, as in non-verbal communication one also exposes emotions (24) .Merhy (2002) proposed health technologies, which are forms of care, which are valid for all areas thinking of humanization.Such technologies are divided into light, light and hard and hard.Light technology is part of the relationship between the person receiving care and the professional.Light and hard technology mean technical knowledge and expertise, considering that hard technology is focused on equipment and technical procedures.A care technology complements the other; however, the light technology should drive all the nurse's work, considering that the bond and relationship depends on the dialogue between professional and the person looking for care (25) .Thus, A2 and A4 address that during nursing consultation the physiological, cognitive, emotional and behavioral responses should be noted, conducting clinical historical research, personal habits and risk factors.Still, request and assessment of additional exams, information on pathology and use of medication, encouragement for adherence to treatment, guidelines, registration information in the medical record (10,12) .However, in A6, considering the SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.Oct.-Dec.2016;12(4):249-59 sociocultural background of the person with mental disorder is essential (14) .
Therefore, in addition to the interpersonal relationship that should be established in the nursing consultation, physical and mental exam should be conducted (A6) through these, being possible to establish nursing diagnoses.Thus, the nursing consultation is based on a tripod, namely: bond, mental and physical evaluation.After these procedures, diagnosis nursing and therapy planning should be performed and, if necessary discussion with the team (14) .
Regarding the mental state assessment, during nursing consultation the nurse should assess topics as: patient's appearance (smell, health status, presence of deformities, facial expression, signs of anxiety, and extreme emotional expressions (sadness or exaggerated joy). in addition to sleep, which may be in excess or insomniac, psychomotor skills including walking, hyper or hypoactivity, tremors due to somatization or effects of medications, (in)voluntary attitude and movements; characteristics of thought, speech, among others (26) .
A3, A6 and A7 bring theories that are used in nursing practice as Basic Human Needs by Wanda de Aguiar Horta and Self Care by Dorothea Elizabeth Orem.In Horta theory, basic human needs are common to all human beings; however, what varies between individuals are the ways to satisfy or meet their needs.In Orem theory, nursing should act according to the individual needs of patients, in order to maintain life and promote health, prevent diseases and their consequences (11,(14)(15) .The assistance occurs according to the needs and preferences of patients dependently on the nurse's perceptions.
The nursing process based on Basic Human Needs, proposed by Wanda Horta, comprises a set of systematic and interrelated steps to completely assist the human being (27) .
The implementation of the nursing consultation on mental health goes through a maturation process in which it is necessary that such actions are applied as interpersonal relationship, nonverbal communication, mental examination, nursing systematization, process and nursing theories.Such knowledge should be enhanced and directed to the best performance in the practice of mental health according to its peculiarity.

Limits and challenges of nursing consultation on mental health
According to A2, A3, A4, A5, A9 and A10, there are limitations of professional training on the ability to identify signs and symptoms of mental disorders, recognition of actions that are from mental health, incorporation of philosophy and instrumental knowledge of psychiatric reform, even considering the assistance centered on the doctor, in drug treatment and especially in the hospital setting (10)(11)(12)(13)(17)(18) . Therefoe, six of ten studies indicate technical and paradigmatic difficulties of the nurse's role in mental health.A5 and A10 score as one of the barriers to the realization of nursing consultation in mental health the lack of continuing education and training in the specific area of knowledge (13,18) .According to A4, nurses reported having greater difficulty to perform assistance and health promotion towards people diagnosed with depression, due to the absence of qualification in the specific area (12) .It is noted that the training processes should be structured from the problematization of the work process, aiming at the transformation of professional practices and the work organization, in view of the health needs of the population (20) .
In the field of mental health, the challenge of continuing education is to consolidate the psychiatric reform.This should articulate specific professional knowledge with the network of knowledge and practices involved in the health system.Nursing education requires interdisciplinary teaching programs that enable more integrated analyzes of health issues (20) .
In addition, articles A5 and A6 cited nonimplementation of the systematization of nursing and care model as difficult to care and realization of nursing consultation in mental health (13,14) .To perform the Nursing Consultation, it is necessary that the institution's nursing service has a pattern of clearly defined structure, set out in the care model, which allows to capture the individual and collective face of individuals and families assisted (28) .
However, this standard structure by means of instruments to guide the nursing consultation on mental health was not found in this literature search.A5 highlights the importance of nursing to build an instrumental knowledge in the mental health area that exceeds a discourse plan and manifest itself in practice.
Bolsoni EB, Heusy IPM, Silva ZF, Rodrigues J, Peres GM, Morais R A2 states that nurses in activities in primary care are not prepared to give due attention to mental disorder patients, despite having average theoretical knowledge in the revised study (10) .It is necessary to sensitize the professional of the assistance (service) and teaching (education) on the implementation of specific actions in the nursing care towards the individual with mental disorders at all levels of complexity.
According to A1 it is essential that new studies are conducted in order to contribute to the effective implementation of the nursing consultation, both in mental health and in other nursing practice areas (9) .A10 highlights the need to expand the research focused to the topic presented, contributing to the strengthening of psychosocial practices in extrahospital institutions (18) .
In view of the psychiatric reform, which provided changes targeted to the user's inclusion in the community and in the family environment, it is necessary to overcome existing limitations and challenges in professional practice, in the academic training and the search for theoretical support to strengthen the science of nursing on mental health.This will strengthen the nursing discipline as a profession and will contribute to safe care and resolving health system.

Final remarks
The literature integrative review showed that it is still incipient the number of productions that deal with nursing consultation on mental health, being addressed general actions developed by nursing in this area, showing the need for studies on the subject and practice inclusion in health services in Brazil.
It is noteworthy that the changes in the Brazilian health system, which have been taking place in line with law 10.216/2001, should be pari passu driven and monitored in nursing, since it is expected that the psychosocial care model is operated by nurses.
Nursing consultation on health services working with mental disorders should be systematized.Therefore, through literature review a nursing consultation model is suggested, which can be adapted according to the needs of each service.In nursing consultation interpersonal relationship, empathy, respect, and guaranteed autonomy should be transversal over the other procedures.Nursing history should be required, that is, the anamnesis (name, age, gender, education, blood type, main complaint, aspects of life history, disease history, lifestyle habits, etc).
Physical examination can evaluate hydration, mucous, attachments (nail and hair), cardiac assessment, blood pressure, pulmonary evaluation, temperature, vital signs, among others.During the nursing history and physical examination mental examination is possible, which assesses mental functions: awareness, attention, sensory perception, orientation, memory, mood, thought and language.From the collection of such data, the diagnosis in nursing and their interventions is carried out.
Limits and challenges to implementation of the nursing consultation found in the review can be overcome through continuing education, academic education with approach in mental health practice, because there were no reports in the articles on vocational training with limitations, lack of training and continuing education.The move towards the nursing consultation on mental health in health services is due to the teaching and professional interest, the choice of theoretical and methodological frameworks, the appropriate use of Nursing Process and assessment indicators that allow change in symptoms and quality of life of patients and families in the mental health field.
In this context, the study provides professionals from different areas of health activities, especially nurses, contributions on the nursing consultation on mental health as their professional practice and the challenges to be overcome, so that care is provided with quality and autonomy.