versão impressa ISSN 0124-0064
Rev. salud pública vol.12 no.5 Bogotá Out. 2010
1 Departamento de Enfermagem Psiquiátrica e Ciências Humanas, Escola de Enfermagem de Ribeirão Preto. USP, Brasil. firstname.lastname@example.org, email@example.com, firstname.lastname@example.org,email@example.com, firstname.lastname@example.org
2 Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto. USP, Brasil. email@example.com
Objective Describing profiles for professional psychiatric service categories in Ribeirão Preto.
Method This was an exploratory study of 8 services (3 hospitals and 5 extra-hospital facilities). Data was collected using questionnaires and semi-structured interviews with professionals who worked for all these services.
Results 74 % of the professionals working for the eight services investigated took part in the study. Doctors and nurses predominated in the hospitals and multidisciplinary teams in extra-hospital facilities. Ages ranged from 24 to 68, females predominating (73 %). 127 (88 %) of the 144 subjects in this study had received specific education after graduating in their respective areas but only 48.5 % had studied mental health. Doctors (42/44) and nurses (36/42) predominated in the teams; 121 (83 %) earned over R$ 1,000 per month as their salary.
Discussion The teams mainly consisted of doctors and nurses, although it was considered that other professionals were important in constituting such teams. One of the main problems hampering reform in the psychiatric field is how services are provided for the population. No country has been able to make the necessary reforms for overcoming all the barriers. The service network studied met the minimum prerequisites for providing psychiatric care for the community.
Key Words: Mental health service, nursing, health personnel, psychiatry, epidemiology (source: MeSH, NLM).
Objetivo Describir el perfil de las diferentes categorías profesionales en los servicios psiquiátricos en Ribeirão Preto.
Método Estudio exploratorio realizado en 8 servicios (tres hospitales y cinco extrahospitalarios). La recolección de información se realizó por medio de cuestionarios y entrevistas semi-estructuradas a los profesionales en todos los servicios.
Resultados Participó el 74 % de los profesionales que trabajaban en los ocho servicios estudiados. Médicos y enfermeras predominaron en los equipos multidisciplinarios de los servicios hospitalarios y extra-hospitalarios. Las edades variaron entre 24 y 68 años, con predominio del sexo femenino (73 %). De los 144 sujetos estudiados, 127 (88 %) tuvieron educación posgraduada en sus áreas específicas y sólo 48,5 % se especializaron en salud mental. En los equipos predominaron los médicos (42/44) y enfermeros (36/42); 121 (83 %) recibieron salarios mensuales superiores a R$ 1 000.
Discusión Aunque en los equipos predominaron los médicos y enfermeros, ellos consideraron que los otros profesionales son importantes en la conformación de los equipos terapéuticos. Uno de los principales aspectos en la implementación de las reformas en la asistencia psiquiátrica es la provisión de los servicios para atender la población. Ningún país ha logrado implementar de manera efectiva las reformas necesarias para superar todas las barreras. La red de servicios estudiada aplica los requisitos mínimos para la asistencia psiquiátrica con enfoque comunitario.
Palabras Clave: Servicios de salud mental, enfermería, personal de salud, recursos humanos, psiquiatría, epidemiología (fuente: DeCS, BIREME).
Objetivo Descrever o perfil das diferentes categorias profissionais dos serviços psiquiátricos em Ribeirão Preto.
Método Pesquisa exploratória, realizada em 8 serviços (3 hospitalares e 5 extra-hospitalares). A coleta dos dados ocorreu por meio de questionários e entrevistas semi-estruturadas junto aos profissionais em todos os serviços.
Resultados Dos profissionais que trabalhavam nos oito serviços investigados 74 % participaram. Nos serviços hospitalares e extra-hospitalares com atuação de equipes multidisciplinares, houve maioria de médicos e enfermeiros. As idades variaram entre 24 e 68 anos, com predomínio do sexo feminino (73 %). Dos 144 sujeitos deste estudo, 127 (88 %) fizeram formação, após obtenção da graduação em suas respectivas áreas, apenas 48,5 % com especialidade em saúde mental. Há predomínio de médicos (42/44) e enfermeiros (36/42) nas equipes; 121 (83 %) concentram ganhos salariais mensais acima de 1 000 reais.
Discussão As equipes são formadas predominantemente por médicos e enfermeiros, embora se considere que os outros profissionais sejam importantes na constituição das equipes terapêuticas. Um dos principais problemas na implantação de reformas na assistência psiquiátrica é a provisão de serviços para atender a população. Nenhum país conseguiu ainda efetivar as reformas necessárias para superar todas as barreiras. A rede de serviços pesquisada atende aos requisitos mínimos para a assistência psiquiátrica na visão comunitária.
Palavras-chave: Serviços de saúde mental, enfermagem, pessoal da saude, recursos humanos, psiquiatria, epidemiologia (fonte: DeCS, BIREME).
Since the Caracas Declaration was published (1990), the goal of restructuring psychiatric care in the Americas has been to encourage community-based care, using the whole decentralised healthcare network with intensive participation by the citizens who use the services, strongly appealing to the effectiveness of the work performed by healthcare professionals Such transformation is reflected in service organisation and professionals education (1-5).
It was thought to be the time to evaluate such results. The investigation was aimed at identifying the care panorama involving many population groups and different services so that decisions may be constantly adjusted and respond to current challenges (6-13).
This study presents the teams working in the Ribeirão Preto mental care network, identifying the profile of professionals working in these care teams as part of the psychiatric service.
Study type and place This was a descriptive pilot study of the 8 services (3 hospitals and 5 non-hospital facilities) providing mental health services in a city in Brazil.
Psychiatric services offering full-time hospitalization included:
-Hospital das Clinicas (Ribeirão Preto Medicine Faculty/USP (HCAB) inpatient service, having 23 beds in two units aiming at partial remission of symptoms in up to 10 days (14);
-Hospital das Clínicas Teaching Hospital Emergency Unit (UEHC, Ribeirão Preto Medicine Faculty/USP) having six beds for hospitalizations lasting up to 72 hours (9); and
-Hospital Santa Teresa (HST) which works in small specific units having 60 beds for acute cases for short periods. There are intermediate re-socialisation units for chronic situations (15,16).
Other psychiatric care services
-Teaching Hospital Day Hospital (School of Medicine -HDHC, Ribeirão Preto Faculty of Medicine/USP (), providing different types of intensive care therapy during this period of monitoring and after discharge (6,17);
-Psychosocial Care Centre (CAPS II), aimed at controlling symptoms and promoting psychosocial recovery, reinsertion and rehabilitation (9);
-Regional Mental Care Outpatient Clinic (ASM) providing analysis, diagnosis, treatment, care and rehabilitation of mental disorders and community reinsertion (9);
-Psychosocial Care Centre for Alcohol and Drugs II (CAPSad) where a multidisciplinary team provides care for users of all ages (18); and
-Mental Health Care Centre (NSM), an outpatient clinic service specializing in clinical psychology and psychiatry for people aged 18 or older (11).
Population and sample The 193 university-level professionals working in the eight mental health services in Ribeirão Preto were invited to participate in the study; 144 (74.6 %) agreed to become involved in the sample.
Research instruments A questionnaire was prepared which was based on the original project proposed by the PAHO Collaborating Centre, adapted to the Brazilian context (19).
It is a semi-structured questionnaire, divided into two parts:
Multiple-choice questions about identification and sociodemographic information (educational background, salary, working hours) and the type of work done by the professionals in each team (identification of professional practice, opinions about management in the units and teams).
Open-ended questions about mental healthcare policies in the Brazilian governments three levels (city, state and federal) and their repercussions on the services, the structure of the teams, their opinion about each category regarding mental healthcare education for professional purposes.
Ethical procedures The project was approved by the HCRP Review Board (file #13282/2005), and the data was collected with the services authorization. The volunteers signed a letter of consent.
Data collection After receiving information about the study, the subjects filled out the first two parts of the questionnaire while in the presence of the researcher. They answered the open-ended questions verbally.
Analysis procedure The results of "contextualisation of services and hospital and extra-hospital teams" are considered here; other results will be published separately.
One hundred and forty-four (74 %) of the 193 professionals working in the eight psychiatric care services in Ribeirão Preto city made up the sample; subjects were recruited from all areas: doctors (44 out of 66), nurses (42 out of 52), psychologists (23/28), social workers (16/23), occupational therapists (10/12) and another 9, including physical educators (2/3), pharmacists (3), biochemists (1/2), dieticians (2/3) and a dentist (1). Each professions participation record is shown in Table 1.
It should be noted that doctors, nurses and psychologists were the most numerous professionals in the mental care teams and in this study, representing 30 %, 29 % and 16 % of the studied population, respectively. Most professionals came within the doctor category; there were 66 subjects, and 44 agreed to take part in the study. The highest number of participating professionals came from Hospital Santa Teresa (HST), accounting for 42,2 % of the sample.
Characterizing the professionals
Females were predominant among professionals in all service providers who took part in the study, namely the ASM (100 %), CAPS II, UEHC and HCAB (80 %), CAPS ad (76 %) and HST (72 %).
The data was configured by professionals aged 30 to 39 (33 %) and 40 to 49 (33 %). Although the staff covered all productive ages, the HST had a predominance of older employees. There was a higher concentration of doctors aged 29 or younger (61 %), compared to the other professional categories.
Nurses occupied second place regarding professional skills in the teams, in almost all service units. There were 26 % nurses in the general distribution and 29 % among those who took part in the study. A higher concentration was observed in the 30-39 age range.
Psychologists represent 14.5 % of the total and 16 % of study subjects, having a higher concentration in the 40-49 age range (30 %); 61 % were aged 50 years or older. Social workers represented 12 % of the subjects.
Time since graduation and career time spent in mental care
Professionals who had graduated 10 to 19 years beforehand (the present survey) predominated in all services. Career time spent in mental care had nearly homogenous distribution in the 8 services (33 %).
Specialization. 127 (88 %) had taken courses after graduating in their respective areas, especially doctors (43/44); 46 % had taken specialized mental health care courses.
Specialized human resources predominated in CAPS II and CAPSad (100 %). Also, all CAPS II staff had taken specialization courses, but only half of them had focused on mental care; there was a similar structure at CAPSad. However, Mental Care Centre personnel were all specialists in the area. Attendance on other specialization courses was low in all professional categories.
Years spent working at the same institution. Some professionals had been working for a few months in the service whilst others had been working for over 15 years. Professionals having had a 5-to-9-year career and one lasting 15 years or over predominated at HST, UEHC and NSM.
Hours spent weekly in a particular service. No professionals were working fewer than 20 hours in Hospital Santa Teresa or Hospital das Clinicas where 30 weekly hours or more were the norm.
Doctors worked less than 30 hours a week; on the other hand, nurses worked 20 hours or more (81 %), the psychologists (69 %) and social workers (87 %) work for 30 hours or more. In the open services the predominant weekly working shifts have between 20 and 29 hours, observed in Table 3.
It was observed that only 31 % of the professionals did not have another job/ occupation; 72 % of the professionals who had been working at their current institution for four years or less held another job.
Salary range. 121 (83 %) of the 144 professionals in the mental care teams in Ribeirão Preto earned salaries of between 1,000 and 3,000 reais.
The nurses and doctors had the best salaries when observing the professionals salary range distribution. It was also observed that the best salaries were being earned at HC, HST and CAPS II.
Implanting psychiatric reform is an ongoing, complex process, both in the theoretical-conceptual and healthcare providing, legal, political and socio-cultural fields (20). According to the World Health Organization, one of the main problems with implanting reforms in psychiatric care is the provision of services for the sick population, chronic cases, new cases and promoting mental care (1).
World Health Organisation data states that there is an average of 4.15 psychiatrists, 12.9 psychiatric nurses, 7.35 psychologists and 11.58 social workers for every 100,000 inhabitants; their activities are mostly concentrated in large urban centre. As such, it is necessary to acknowledge and value their professional practices so that they can feel valuable, as well as improving new human resources qualifications and education (21).
However, some countries have areas where there are no psychiatrists or psychiatric nurses or where existing ones are too few to meet current demands. Although teams were still in a precarious state regarding the multi-professional aspect, the WHO predicted (2002) that having one doctor and one nurse in teams was the least that could be expected.
Unequal composition in professionals distribution in service teams was observed, as well as little coordination amongst them. It is worth noting that both the Mental Care Centre and the Outpatient clinic (characterized as open services) did not have professional composition as recommended by the Ministry of Health regarding mental care team formation (5). The presence of a doctor was predominant, in addition to the absence of other professionals. The Centre had the most incomplete team regarding other services predominantly having doctors; it is a city-based service involving Medicine School and Nursing School participation as both are USP departments.
However, CAPSad had a full multi-professional team, the same as CAPS II and the Day Hospital, which also had full teams.
The Day-hospital forms part of a teaching hospital, resulting in differentiated dynamics in providing service for users. This service receives patients who are primarily of interest for scientific studies (i.e. medical research). The same occurs in Hospital das Clínicas inpatient unit. Since this is an integral inpatient service, there is a concentration of doctors and nurses, in addition to psychologists, social workers and occupational therapists. The Emergency Unit also focuses on clinical aspects, having a predominance of doctors and nurses.
Hospital Santa Tereza has 88 professionals having university-level education, thereby maintaining normal hospital structure regarding human resources composition, doctors, nurses and psychologists seeing to acute, clinical and senior patient units. The number of clinical doctors and radiologists in this institution, in addition to psychiatrists, should be noted. This structure was built up over time as it is a macrohospital. Since this is an inpatient institution (chronic patients being hospitalized and having inpatients living in the hospital), then there is also a concern for psychosocial rehabilitation, thereby justifying the presence of social workers and other professionals such as nutritionists or dentists.
The emphasis on work in multi-professional teams coincides with the appearance of mental care practice outside classic, hospital-based models providing services for patients having emotional problems (5,6). The important issue being posed is, "How has each professional category contributed towards therapeutic care for mental patients in both hospitals and open healthcare network services?"
There were differences amongst weekly working hours for the services investigated here. The predominant weekly working shift spanned 30 hours or more in hospitals; in other services, such as ASM, CAPS II, CAPSad and NSM, the predominant weekly shift tended to span 20 to 29 working hours.
Inpatient hospital services had longer weekly working hours. When mental patients were discharged, they returned to open clinical services for monitoring and social reinsertion. However, if open services were to replace inpatient services, should not community network services be equivalent? However, fewer professionals, fewer services and shorter working hours were observed in this study.
The time elapsed since professionals graduation in the mental healthcare network in Ribeirão Preto had compatible variations in two situations: 1) doctors and nurses being the professionals having the highest hourly loads in healthcare institutions due to the characterization of their work with mental patients and 2) older inpatient services were seen to employ older professionals, having had longer careers.
Most professionals had taken other courses after graduating in their respective areas, specializations predominating among nurses and doctors; however, fewer than half of the professionals were specialists in mental care. The services having the highest number of specialized professionals were CAPS II and CAPSad, although half of them were not specialized in mental care; however, NSM professionals were all specialists in the area.
The study participants mentioned not having had the necessary support for developing mental care, thereby revealing that their search for professional improvement was a consequence of personal interest for gaining a qualification by means of courses or by reading about the topic.
The lack of support and encouragement for professional improvement may have led to the persistence of a viewpoint still chained to the asylum-based aspects of care. A study that investigated the CAPS in Rio de Janeiro observed aspects of these services daily routine deemed "blatant," exposing the inner workings of professionals contributing towards keeping asylums alive. They look only at the disease, despite institutional structure and policies being focused on reintegrating mental patients into society (22).
Psychiatric reform increasingly demands that professionals have specialized education and practices while low salaries and precarious working conditions often discourage the very people in question (23). Several remote places in Brazil have difficulties in hiring professionals because they usually study and live in large urban centre.
This study was aimed at presenting a panorama regarding the composition of the teams making up the eight mental care services in Ribeirão Preto (hospital and community services) which had 193 university-level employees at the time of this study. Differences were observed in the teams make-up, education and the professionals specializations, hourly load and salaries
Acknowledgements: This project was funded by CAPES/PRODOC #0126/05-5.
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