The menTal healTh of nursing sTudenTs: an inTegraTive review of liTeraTure

Study of integrative review type in order to examine the occurrence of scientific research on the mental health of undergraduate students in Nursing in Brazil in the last 21 years. 54 articles were included that from the content analysis were categorized into five thematic categories related to: quality of life, feelings during their academic formation, teacherstudent relationship, student care and the consumption of alcohol and other drugs by the nursing student. The results portray the convergence of Brazilian publications that point critical moments experienced by students during the course, indicating the importance of initiatives to support them in their difficulties coping with a view to strengthening their mental health.


Introduction
The focus of nursing is focused on patient care and during graduation makes the student-patient relationship is guided often by intense emotional stressors (1) .
The National Curriculum Guidelines (DCN) for undergraduate teaching in Nursing guide that the nursing education enables the development of skills to "take care of their own physical and mental health and seek their welfare as a citizen and as a nurse" (2) .
We must consider that usually the nursing student is under pressure to mature quickly by forces of circumstances, because he perceives that in the process of care it is need to use skills that not always have to deal with situations of suffering inherent in health care (3 -4) .
The mental health of college student should be revealed at the academic environment, since most of them is in a peculiar period of the evolutionary process, moving from adolescence to adulthood by itself, surrounded by doubts and uncertainties (5)(6) .
Some stressors factors are commonly present in the life of the university interfering with his mental health: increased responsibility, anxiety and competitiveness, academic tasks and financial and social difficulties (6) , and the separation of friends and of a safe circle of family and relationships (5) .
These circumstances may trigger existential crises situations responsible for the maturation and strengthening of identity, or generate mismatch until the onset of diseases (5,7) .
The process of nursing education, even when loaded with anxiogenic situations, has not offered strategies that strengthen the emotional equipment of the academic, so it is essential to invest in studies that address such issues (6.8) .
In this perspective the present study was designed to analyze the occurrence of scientific research about the mental health of undergraduate students in Nursing in Brazil in the last 21 years.

Methodology
An integrative review study type which consists of extensive literature review with standards of methodological rigor.This type of study gathers and summarizes research findings about a delimited topic or issue in a systematic and orderly way, so that the reader can identify the characteristics of the studies included in the review (9) .
The process of building an integrative review provides six distinct stages, which were carefully followed for the preparation of this article: the identification of the theme and selection of the research question; establishing criteria for inclusion and exclusion of studies; categorization of studies, evaluation of the studies included, interpretation of results and presentation of the review (9) .
The chosen articles were published in Brazil in the area of nursing knowledge in the period from January 1990 to December 2011, which corresponds to ten years before and ten years after the publication of Resolution No. 3CNE/CES in 2001, which established the DCN (2) .
Indexed journals were included in the database, with regular and periodic publication of national circulation.The search was conducted in the catalog of scientific journals available on the Virtual Health Library (VHL) via the link "search by DeCS / MeSH descriptors".
The following descriptors were used as criteria for selecting the sample: "nursing students" and "mental health."The articles were selected after previous reading of the titles available in the indexes of periodicals, which was the first form of inclusion, followed by an analysis of the summaries.Those who indicated in the content the subject "mental health of nursing students" were compiled for full reading proving the presence of the given subject.The publications depicting the mental health of secondary students in nursing were not captured.Thus, 53 articles that met the inclusion criteria for this study were selected.After, it was performed a qualitative analysis according to the technique of content analysis (10) of paired form, and related information to the journal and the article were organized through the formation of a database.
After raising the central points of the articles, the categorization was performed, which were treated separately in order to better exploit their content.Then, finally, the evaluation, interpretation of results and summary of evidence were proceeded.

Thematic categories of the articles
The articles were grouped into five thematic categories: Quality of life -an overview of student life, Reacher-student relationship and the Mental Health of students; Feelings experienced during their academic formation, Care with the student and his formation and The nursing student and alcohol and other drugs consumption.
Although the analysis of the content of some publications allow frame them in more than one category, it was decided to include in only one group whose theme constitute the major portion of the content present in the article.

Quality of life: an overview of student life
In this category were included articles that depict the factors that affect the quality of student life.
There is a subjective, complex and multidimensional character in quality of life term and can be considered as a degree of personal, professional, social and family satisfaction (11) .Despite the conceptual difficulties, it was possible to realize the interest of many authors on the need and importance of evaluating the quality of life of nursing students (11)(12) .
Although the presentation of the topic quality of life in the publications has been shown after the year 2000, in the 80's there was already interest in the topic, especially more recently.
All publications included in this category are unique and related to quantitative investigations.Their results show unanimity on the importance of an integral vision of the nursing student, and the measurement of the quality of student life as a way to know him in fact (12) .
There is a trend in articles to examine the student's care to himself, reflecting on his quality of life, using as justification the need to be physically and psychologically healthy to be able to provide care to another with quality.
Important information found in the articles that compose this category was related to the variation in quality of life during the years of graduation.The quality of life of nursing students found to be decreased in the second year, at which initiation occurs in practical activities of the profession (13) .The nursing students need special attention regarding the factors related to quality of life, especially women in physical and psychological dimensions (12) , important aspect considering that most nursing students are female.There have been reports about the dissatisfaction of academics in relation to sleep and rest, sexual life, little or no opportunity for leisure and the presence of negative feelings (11) .

Teacher-student relationship and the mental health of students
In this category, represented in Figure 2, the articles portray aspects depicting the relationship between the educator and the student and their implications on the mental health of students.The totality of these investigations is unique and quantitative.
The subjects of these investigations were mostly of the second year.The studies focused on reviews of the teacher-student relationship especially during the insertion of this in the practical activities of profession.Understand the meaning and consequences of the use of a traineeship diary by female nursing student.
Understand the meaning of the first practical experiences of female nursing student and its relationship with the teacher.
Know the experience of undergraduate student from the first physical examination, his feelings, concerns and perception about the role of the nursing teacher.
Analyze the stress experienced by female nursing students in their practical experience and their relationship with the teacher.It is noteworthy that in most other articles of the other categories the teacher-student relationship was also cited or studied as an important factor of promotion or disruption of mental health of nursing students.
The teacher usually accompanies the student in academic daily and therefore can identify and advise on aspects of their mental health in order to not impair the formation and professional career.His value stands out in the student's life considering the personal professional performance (12) .
The relationship with the teacher is appointed as a decisive factor in the teaching-learning process, which can contribute to the student to assert itself as a person and can develop as a student.
The sudden entry of students into unfamiliar situations can trigger tensions and anxieties and effect in a negative way on learning, so it is crucial that the teacher be aware of such possibility and have attitudes of understanding for the student (14) .It is expected to value the dialogue, exchange and interpersonal relationship for the teacher-student communication becomes the basis of the teaching process.The educators thus instruct and encourage the student to make judgments, observations and realize relations (15) .
The teacher can use resources that reinforce the potential of students and is the most responsible for guiding them in the conduct of relationships with patients and healthcare team through dialogue (14) .

Feelings experienced during their academic formation
The articles in this thematic category provide information about various kinds of feelings that students experience during their undergraduate (Figure 3).
It is old the interest of nursing authors for research that enter in students' feelings, showing itself very current.In this category the qualitative studies (50.0%) have prevailed, followed by quantitative (37.5%) studies and the existence of three case/experience reports (12.5%).The articles related in Figure 3 have different objectives, among which stand out the study and analysis of anxiety in teaching certain subjects, the emotional involvement of the nursing student with the patient and their reflections on his future life as a professional, the identification of the difficulties of students, feelings experienced, indicative characteristics of stress, depression and the generator process of existential crisis, and also reports of experiences of participating students of differentiated teaching strategies, as well as their perceptions and feelings related to their formation as a person/professional.

Reference of the article
Generating pressures of stress are experienced at different moments in the life of each, phenomenon that is no different in the academic trajectory when students experience feelings of fear, frustration, stress, anguish and anxiety that can trigger pathological disorders if the adaptation does not occur.Although stress situations are present in the entire undergraduate course, those periods that relate to the first clinical trials stand out (6) .
If on one hand the initial phase of the course has been identified as a period of threats and challenges, the concluding period is also considered as a generator of stress due to anxiety related to labor market and professional responsibilities (1) .
The nursing student can develop problems resulting from stress due to the complexity of the course and dealing with human limitations (6) .A universe of reactions can happen, creating anxiety with regard to the technical procedures and relationship with the patient and teacher, beyond the inevitable clash on the difference between theory and practice when the student comes into contact with reality (14) .Some authors have shown special interest in studying the presence of anxiety and stress in nursing students (1,4,6,15) .Anxiety interferes with the student-patient relationship and tends to increase as practice gets closer.These studies point out that before this knowledge it is possible to program help resources that assist students, especially for those with high levels of anxiety.
A number of symptoms of physiological scope and psycho-emotional character may be present due to exposure to stressful situations reflecting in the quality of students' mental health, making them more angry, anxious, with low self-esteem and unstimulated (6) .It is common to find the typical symptoms of stress include negative feelings, despair, anxiety and depression, dissatisfaction with sleep and sex life, and little or no opportunity for leisure activity and remuneration insufficient to meet the needs (16) .
Knowing that such feelings imply in a negative way in the development of academic activities, in so far as the teacher listen and identify the difficulties of the students he will be more efficient to help them to find ways to cope with and adapt to their experiences of practice (15,17).
By emphasizing that nursing is a stressful profession and since from the formation period there are indicative signs of stress in academic, the publications evaluate the importance of studying the subject besides implementing measures which address the mental health of students by the educational institutions.

Care with the student and his formation
The works that constitute this category present as a central theme the resources that the educational institutions together educators have used to offer support for the  nursing student during undergraduation and reflections about the guidelines of the formation of this student.
Figure 4 lists the items and their respective authors that deal with the care with the student and his formation.
The contents of these publications presented intersection points and information that were complementary among the articles, allowing to perform a extensive analysis about the concern of the teachers regarding the student's education.
Examine the key concepts of the psychodrama method and the possibilities of using this in the education of nurses.
Evaluate the influence of the discipline Psychiatric Nursing on the student.Reflect on the experience of nursing students related to their first contacts with the occupation.Most authors started from the observation of their practice as teachers.Realized that the teaching-learning process has been presented with gaps and flaws, often by the contradiction between theory and practice and also by the highest value that has been given to technical formation.It emphasized the need to promote in the teaching environment the idea of not separating the personal from professional reflecting the subjectivity of the student in order to consider it as a complete being in the perspective of integral human (8) .
The articles included in this category also indicate the stimulus to self-consciousness of the student during his formation considering the importance of lead him to perceive himself as a person, a condition that will help him to see the patient as a human condition and not just as an illness (8) .
The self-analysis along with the exploration of feelings appears among the essential qualities for those who want to be able to assist the other (7) .In the case of nurses, these characteristics are indispensable for performing the role of caregiver.
Teaching strategies different from conventional that enable the development of the student were highly recommended and and defended in the articles selected, especially the sociodrama, psychodrama, experience workshops and moments of sensitization during introductory periods of nursing undergraduate course.These techniques are shown to be effective in the development of professional identity of the student and also to assist in solving the various eventualities that arise during the education of the students.
Teachers realize that beyond the problems that arise in the natural course of life there are still those who are connected to the area of nursing.The profession is presented as charged with potentially generating events of existential crises.
In this scenario, it arises the need to undergraduate courses in nursing to develop methods of guidance and training to prevent emotional disorders in students such as discussion groups to promote the exchange of experiences and sharing difficult situations that arise in various stages of professional education of nurse (1.4) .
It is observable that the number of Brazilian Public Universities concerned with the issue of mental health of college student has grown and several programs have been implemented (5) .
Psychological support to the graduate student was also mentioned as a strategy to help in meeting his needs and the needs of the patients."As the one who will provide care, nursing student also needs to 'be cared' and maintain his physical and mental health at appropriate levels" (6) .

The nursing student and consumption of alcohol and other drugs
The concern regarding the consumption of alcohol and other drugs by nursing students stood out among the selected articles in the literature search, 10 studies have been found (Figure 5).
The research indicate that nurse are more susceptible to addiction to psychoactive substances due to increased access and possibility of self-administration (16) .Most of them have predisposition to alcohol consumption, especially in the initial five periods of the course and female students.The female predominance is related to the specificity of the nursing course which traditionally attracts more women than men.The use of tranquilizers and amphetamines with anorectic effects, besides being larger in the female students, also has higher early and diversification in the type of drug used (16) .
Scholars on the subject understand that ignorance about the use and abuse of drugs and lack of reflection on the topic in academic area may reflect in the posture and attitudes of academics in providing care to the patient by enabling developing prejudices and stereotypes towards alcohol consumers and drug users (17) .
In 2010 were launched the results of the National Survey on Use of Alcohol, Tobacco and Other Drugs among University Students from 27 Brazilian capitals that brings a picture of consumption of alcohol, tobacco and other drugs for more than 18,000 students.The study reveals disturbing data to show that this phenomenon is more frequent than in the general population, because almost half of Brazilian university has already made use of some illegal substance and 80% of respondents who said they were under 18 said they had consumed some type of alcoholic beverage (18) .
Anxiety and fear of university entrance or situations such as separation from family, new bonds of friendship, participation at parties with alcohol use may be risk factors predisposing to the use of alcoholic substances, either by peer pressure or by sense of independence (19) .The papers also depict that the main reasons for the frequent use of psychoactive substances are breaking the routine, to enjoy the effects of substances and decreased anxiety or stress.
The deeper understanding of this phenomenon is important, therefore, for the development of prevention and preparation of specific policies aimed at nursing students.

Final considerations
The analysis of scientific production concerning the mental health of undergraduate student in Nursing allowed in addition to identifying the various nuances that this topic has been targeted by the nursing brazilian researchers in the last 21 years, to identify the most common factors and occasions that maintains a direct relation with the theme.
Among the critical moments are highlighted the input of the student in the academic area, when he finds himself in an environment that is unfamiliar; the beginning of practical activities, putting him in contact with complex issues of the health system, with his own insecurity and unpleasant aspects of the natural course of life, such as sickness and death; at the conclusion of the course when the student usually finds himself concerned with the labor market and the demands of profession.
Given the various possibilities of academic exposure to various factors throughout the course, making him vulnerable to the development of existential crises, it is undeniable the importance of initiatives to support him coping his difficulties.
The result of the review of the literature portrayed a converging panorama of several Brazilian publications that focused somehow the mental health of the nursing students, allowing further identify authors who investigate more the matter.When addressing an emerging theme in the context of health, such as consumption of alcohol and other drugs advances in this emphasis so necessary to understand the possible relationship between people's mental health and the use of alcohol and other drugs in academic area.
The teacher's role and relationship with the student have unique importance in the thematic thrust in this study, considered as a structuring factor in mental health of nursing students.
A limitation of this study was the variety of terms used by the authors as if they were descriptors, making difficult the search in the database.As new articles are published in compliance to the criteria of the MeSH, this tool will become an increasingly important benchmark for scientific research.Although the vast majority of national journals maintain this requirement for the publication, there are still studies, especially the older ones, in which researchers disregard the terminology recommended by VHL descriptors in their works.It is important to use MeSH as a criterion for identifying the keywords that characterize the scientific production.
Finally, it is considered that the studies included in this review are fundamental subsidies to constitute strategies and services dedicated to the care of mental health and quality of life of nursing students, to warn about the use of alcohol and other drugs in this population, and steer discussions about the teacher-student relationship and its influence on the teaching-learning process, equally important to the mental health of future nurses.

Figure 1 -
Figure 1 -Scientific production with the theme "Quality of life: an overview of student life"

Figure 2 -
Figure 2 -Scientific Production of the category "Teacher-student relationship and the mental health of students"

Figure 3 -
Figure 3 -Scientific production with the theme "Feelings experienced during the academic formation"

Figure 4 -
Figure 4 -Scientific production about "Care with the student and his formation"

Figure 5 -
Figure 5 -List of articles in category: "The nursing student and consumption of alcohol and other drugs"