The Psychiatric Nursing / Mental Health Education : advances , limitations and challenges 1

This study aimed to examine the Psychiatric Nursing/Mental Health Education in public nursing courses in the State of São Paulo, Brazil, and investigate and analyze the educational practice of professors responsible for the disciplines in the area. Interviews were conducted with twelve professors, whose verification took place through thematic analysis. This is a qualitative research. Results show that the professors are, mostly, unaware of the Pedagogical Political Project of the undergraduate courses in which they are inserted, the teaching method is predominantly traditional with desire for changes to use active methods, the teaching content has a primarily biological focus and the devaluation of the profession of professor is also present. Although we can notice a desire for advances by these professionals, we see little investment in their educational training.


Introduction
The Psychiatric Nursing/Mental Health Education has been studied by several researchers in Brazil.Most of the investigations have sought to portray the daily life of the psychiatric nursing education in the search to improve the professional practice.However, new proposals of curricular changes -Law of Guidelines and Bases of National Education (LDB/96) and the National Curriculum Guidelines of the Undergraduate Nursing Course (DCNENF/2001) -have established Souza MCBM.
the national curriculum guidelines for undergraduate nursing courses, requiring other perspectives on education (1)(2) .
Our study is justified by its proposal to investigate the Psychiatric Nursing/Mental Health Education from the aforementioned legislation and guidelines and to highlight how the professor is inserted in the teaching/ learning process in this context of change.
Today, in any area, the training of professionals with a profile that is appropriate to social needs implies providing them with the ability of working in teams, communicating and having agility in the face of new situations.These characteristics become necessary for the training of professionals of the future and are not consistent with the teaching model, according to the traditional educational design, in which the teaching is based on a type of curriculum marked by passivity, submissiveness, lack of participation and critical attitude of the student.
In this logic, universities are invited to revise their teaching methods and implement challenges inspired by the adoption of methodologies that encourage the development of critical spirit and the capacity of reflection to encourage the active participation of students in the construction of knowledge.There are several authors in the area of education that collaborate to this reflection (3)(4) .
The Psychiatric Nursing/Mental Health Education, in addition to following the laws governing education in Brazil, also follow certain principles of the Brazilian psychiatric reform, mainly seeking to insert students in open spaces of attention for persons with mental disorder, and not keeping them exclusively in the hospital context (5)(6) .Currently, the outlook is that the assistance to persons with mental disorder presents a more humanistic and social nature, with a view to the construction of citizenship.The shifting of the look from the disease to the subject is one of the issues that have been punctuated by experts in the area of mental health over several years (5)(6)(7) , among others.
It is important to know how the teaching in the area of Mental Health has been addressing these changes in its educational practice.How the construction of curricula has contributed to meeting the mental health policies?What educational trend prevails in teaching?What are the subjects addressed?How the educational training of professors happens?These questions lead us to search for the understanding on how education occurs in the area of Psychiatric Nursing and Mental Health today.

Objectives
The aim of our study is to analyze how the Psychiatric Nursing and Mental Health Education occurs in public undergraduate courses in the State of São Paulo, Brazil, and investigate and analyze the educational practice of professors of the disciplines in the area, involving the content addressed, the teaching methods used and the training practices of the professors involved.

Methodology
This is an exploratory, descriptive study of qualitative nature that is justified by the fact that it enables the researcher to observe and work with the meanings, motives, aspirations, attitudes, values and beliefs of the object being investigated (8) .The research was carried out with professors who teach disciplines in psychiatric nursing and mental health in undergraduate nursing courses.The data were collected in 2009 and 2010.During the period of data collection, thirteen public schools were operating in São Paulo, being them two federal, six state and five municipal (9) .Only one of the schools did not participate in this study because the professor contacted did not respond to the invitation in a timely manner.
The data were collected through semi-structured interviews, following a script with comprehensive questions related to the profile of the professor and other questions on the knowledge that these professors have on, for example, the structure of the course, the pedagogical political project and the content addressed.For the diagnosis of the data, we carried out a Thematic Analysis (8) .
Regarding the ethical procedures, the project was approved by the Research Ethics Committee of EERP/USP (Protocol No. 0995/2009).After approval, we contacted the Coordinator of each course and requested a list of the names of the professors responsible for the mental health disciplines.The choice of professors happened by drawing lots, and the professor drawn received an invitation via email to participate in the research, being one professional from each school.The participants were informed about the purpose of the study and signed the Informed Consent.To preserve the anonymity, the professors have been identified by fictitious names.

Professors participating in this study
The group researched is composed of twelve professors, aged 30 to 59 years, being seven of them female and five male.Regarding their training, seven had doctoral degrees, three master's degrees, one specialization in the area of psychiatric nursing and one specialization in occupational health nursing.The training of professors has its emphasis on doctoral degrees, which can be justified by the demands of the current guidelines of public universities, which have, as their premise, the hiring of professors who have at least the title of doctor.
In relation to how long they have been teaching, half of the professors have been teaching from three to thirteen years and the other half from fourteen to thirty-five years.The longer teaching time may involve greater experience, contrasting with the entry of newly trained professionals at the universities who demonstrate little experience, both in assistance practice and in teaching.
The employment contract of these professors covers the categories of: hourly professor ( 1 The interviews were analyzed in the light of the literature review.During the process of analysis, the following thematic categories emerged: The professor inserted in the undergraduate nursing course; The role of the professor in the psychiatric nursing and mental health education; and, Building oneself as a professor.In the presentation of the results, we show, implicitly or explicitly, the different conceptions of world, man, learning, knowledge, society and culture of the participating professionals.These different conceptions imply choices, both educational and theoretical approaches, which subsidize the mental health education.

The professor inserted in the undergraduate nursing course
In this category, we worked the issues related to the conditions of the courses in which the professors are inserted, regarding the construction of the Pedagogical Political Project, which is understood as a construction that is reflected on the pedagogical axes and axes related to the vision on health, student profile and guidelines of the project.
The Pedagogical Political Project (PPP) is a challenge for undergraduate courses as, through it, new ways and new guidelines can be shown to schools.There are several paths for the construction of the PPP, which must be marked by different and interdependent moments: the situational act, which describes the reality and develops the educational action; option by the theoretical framework to be followed; what concepts are needed to transform reality; and, operational, that is, how to perform the action (10) .
From the LDB/96 and DCNENF/2001, the guidelines for the preparation of PPPs are disseminated in all higher education institutions.To meet this legal requirement, the schools begin the discussion and building of their PPPs.
It is worth mentioning that it is explicit in the interviews that the professors have not always participated in the construction of the pedagogical project: However, the collective participation in the construction of the project is described as one of the general parameters of the DCNENF; thus, some of the schools, to respond to the guidelines, involved their professors in the process of construction, even if they are not yet sure about the purpose of the PPP: Actually, we constructed it when we were required because of the issue of ..

. I helped construct it, but, in general, I know what is expected of the nurse, but if you ask in detail I couldn't answer (Athena).
The construction, implementation and realization of a pedagogical project, is not an easy or quick task; on the contrary, it takes time and understanding for the need for change and, above all, willingness to break with old practices based on pedagogical efforts (10).
In relation to the professional profile desired for students, the DCNENF emphasizes the training of a generalist professional, attentive to the humanistic, critical and reflective issues (2) .Beyond the context of the educational reform, it is also necessary to consider the Health Reform Movement, culminating in the consolidation of the Brazilian Health System -SUS Souza MCBM.
-, in 1988, driving the country to a new health care model that requires the training of professionals able to recognize the required range of expertise, aiming at meeting the social needs (11) .
The Nursing Courses investigated in this study, in order to meet the DCENF, have initiated changes in their curricula and propose, in their PPPs, the formation of a generalist professional: (...) It is aimed at the formation of the generalist nurse who can act on the hospital network, but above all, on the collective health (Dionysus).
The generalist nurse, with a critical view of society (...) is basing our project (Athena).
In relation to the guidelines and/or guiding bases governing the pedagogical projects of the courses investigated, there are aspects that are related to the vision of health/health care and to the educational axes of the course, set out in the curricular structure.
Some of the participants mention the guidelines that are more significant to them or those more focused on each course in particular, although all the mentioned ones are described in DCNENF: ... There's axis, the axis of Primary Health Care, there's another axis on Skills, the framework of skills, there's also an axis, let me see... on Interdisciplinarity (Aphrodite).

Principles of the SUS, every guideline is based on them, the idea is to train professionals to work in the SUS (Hercules).
In relation to the educational axes guiding the project, according to reports of the professors, the options considered the current requirements for the undergraduate nursing education and the demands arising from the health work: The main guideline might be teaching using active methodologies.We work with the idea of the competence of the student, the work by competence through active methodologies; our entire practice, our entire project, it seeks to enable the student to have contact with the practice and with the skills of the future professional from the first year (Hercules).
The active methodologies, based on the criticalreflexive educational concept, enable the effective participation of the individuals involved in the teaching learning process (11) .
The role of the professor in the psychiatric nursing and mental health education Currently, higher education institutions, responsible for training health care workers, have been encouraged to revise their educational practices in an attempt to get closer with the social reality.Therefore, we can perceive a greater search for progressive educational approaches for teaching and learning, which allow the formation of critical, reflective individuals, with ethical, political and technical skills, empowering them to intervene in complex contexts (12) .
On the other hand, in the teaching based on traditional pedagogy, the methods are based on oral exposure of the subject, and the student's attitude is receptive, without any dialog with the professor during the lesson (3) .The teaching/learning process is often restricted to the reproduction of knowledge.The professor "gives" the contents and the student retains and repeats them, without question, in a passive attitude, becoming the spectator, without the necessary reflection and criticism.
In one of the interviews, the professor points out as limiting factor in the teaching/learning process, in addition to the traditional teaching method, the curricular structure with disciplines and compartmentalized, fragmented and not articulated content: We still have the traditional method, that traditional method with ... discipline ... one discipline and then the contents; they are well divided, each one has its class (Aphrodite).
The fragmentation of knowledge in specialized fields has led universities to be subdivided by departments and, consequently, the courses are formatted with curricular structures composed of separated disciplines (13) .
In some statements, it is possible to grasp the intention and desire of professors in using active methodologies, although they encounter the limits imposed by the university system: (...) in this way, we wanted to carry out a teaching more focused on practice with active, innovative methodologies, but at the time we were faced with the structure of the university, very focused on disciplines (Hera).
The use of active methodologies, or any other way of teaching, demands the educational training of professors.However, the need for such training is often not felt by university professors, as they believe that their training, specific for the knowledge area, is enough.
For the most part, the higher education institutions analyzed in this study are traditional institutions, in which, historically, hierarchical relationships are established, both within the central coordination and in the structures of education, influenced by power relations marked by the past.
The program content, pointed most often by the participants of this research, is highlighted.We can see that some of the content covered by the professors is related to psychopathology and the health-mental SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.July.-Sept.2016;12(3):139-46 disease process, still with a biological focus, centered on the disease: And ... about disorders, about knowing more about the patient, knowing the disease, because Psychiatry emphasizes this a lot, it is something very present, the care, the assistance and especially ... the disorder (Aphrodite).
(...) psychopathology, we take only the three large groups.
Other content selected and considered as relevant to the area of mental health, by the professors, are interpersonal relationship and communication, which are taken as basic instruments for care: The first discipline, which is only theoretical, has no laboratory and internship, so this is where they learn the tools of psychiatric nursing care, the basic instruments, communication, interpersonal relationship... (Apolo).
In relation to the content on Mental Health Policies, we highlight that, with the transformations that have been taking place in Brazil, and with a closer look to extramural care in open services, professors have rethought the content of their disciplines and the practical scenarios for the development of activities together with students.Until the '90s, the nursing action was carried out in the administrative spaces of the psychiatric hospital, based on the biological model.With the Health Reform in the last decades of the 20th century and the consolidation of the SUS and the Psychiatric Reform, some changes have occurred, such as the reorientation of the care model in mental health (6,14) .

Building oneself as a professor
Historically, the area of psychiatric nursing and mental health has been devalued in the field of professional practice for reasons such as: no professional recognition, low pay and lack of training of professionals who work in this area (15) .
In this study, the reasons for the devaluation pointed out by the professors can also be see in educational institutions, as noted below: (...) it is also a challenge, because within the university itself, the professors themselves ... it's not a valued, recognized area.I can say it's a challenge.... (Artemis).Some professors refer to the demands of the university and the difficulties to meet all of them: The technical division of the organization of the educational work emphasizes a depoliticizing approach of the practice and changes the role of professors.The school has more bureaucratic and administrative burdens to the detriment of activities of political educational nature (16) .
The exercise of teaching is always a process, movement, with new places, new information, new feelings and new interactions (16) .In this sense, some professors express satisfaction in being a professor:

I love being a professor; I think being in Mental Health
Nursing is perfect for me because I love this discipline (...) (Alceste).
(...) it's an area that I have identified with since graduation and as a professor I also had as an objective to teach in the area (mental health) (Apolo).
In the testimony, we can see the idea that being a professor is always associated with the area of psychiatric/mental health nursing, and, at no point, the professors refer to the educational role to this end.
Being a professor goes beyond being a good professional.Specific skills are required, other than those relating to the professional practice.The teaching training needs to be related to the principles that guide the educational practice (16) .
Currently, in public universities, research productivity has been emphasized, what meets the market laws, scientific rationale and technical efficiency, driving professors to individualized work and dichotomizing the theory of practice, learning education, assessment education, content of medium, and, consequently, inhibiting the ways to establish relationships of analysis of the practice itself, with production of knowledge far from reality, thus preparing individuals who have difficulty with a contextualized reading of the world (10) .
The professors interviewed show what they think about the priority investment in research: Currently, in the entrance and promotion examinations in universities, in general, research productivity is highly valued.In the departments, research activities and publications are also prioritized, sometimes giving a lower value to the activities linked to education.It is a risk that the university has, because we can find excellent researchers who are not good professors (18) .Souza MCBM.
Professors, generally, do not mention the need for educational training for teaching: The proposal for the first two years is active methodologies, right?This is the proposal, but we know that it's actually hard to change the minds of professors, not all have training; this is a big challenge (Perseus).
"The practice of the profession and its domain do not occur through a direct transfer of divine wisdom"; we cannot expect that the research professor, by joining the university, is prepared to teach.Investment in educational training is a necessity (18) .

Final Remarks
This study allowed us to observe the advances, limitations and challenges faced in the process of construction of the pedagogical projects of the courses, in the educational training of professors and in their activities in the field of psychiatric nursing and mental health.
In general, many professors are unaware of the pedagogic project of the courses; sometimes, they are inserted only in order to respond to the legislation concerning the collective construction.A barrier we found concerns the tendency to prioritize content centered on psychopathology/signs and symptoms of the disease, with less focus on attitudinal and procedural content.Despite some modifications that express the approach to content related to metal health policies, the core of the disciplines still resides in psychopathology.
In relation to the training of the professors, we can see that universities invest very little in this process.The idea that 'a person who knows how to do also knows how to teach' is still present.In public examinations for the hiring of professors, the amount of scientific publications is prioritized; a lower value is assigned to the educational training of professors.A major challenge that emerges from this research is the understanding that the educational training of professors inserted in universities has been something mistakenly presumed, which requires intervention.
), professor with 20-hour work week (1) and exclusive dedication with 40-hour work week (10).Most have contract of Exclusive Dedication, what meets the standards of the public universities that favor the performance of activities of teaching, research and extension.

(
...) Mental Health Policy, the whole historical part ... Psychiatric Reform, until we reach the new model today.The network, the new services, the clinic (...) (Hera).

(
...) but with the number of professors and the demand of the university itself we can't do what we ought to do, it would be interesting if we could... (Perseu).

(
...) sometimes I feel, like, we let a little aside the role of professor, especially in the undergraduate level, because of the demands that the University imposes on us (Perseus).