A total 203 nursing consultations were recorded. However, considering the eligibility criteria, only 49 consultations were included in the present study, distributed in municipality A (30.6%), municipality B (12.2%), municipality C (2.0%) and municipality D (55.1%). These consultations were carried out by 21 nurses and involved 49 users.
Regarding the users' profile, it was observed an average age of 41 years (±15.9), 85.7% (n=42) of whom were female, 64.5% (n=31) declared themselves mixed race and 44.9% (n=22) completed high school. Furthermore, 91.6% (n=44) were residents of urban areas, 53.0% (n=26) did not work or were unemployed, 61.2% (n=30) declared that they did not have partners and 83.6% (n=08) did not have children.
Concerning complaints reported by users during the researchers' approach, 95.9% showed three or more nonspecific symptoms and the most common difficult to sleep (63.2%). Moreover, 26.5% reported having a diagnosis of anxiety and/or depression and 4.1% reported abuse drugs and/or alcohol.
Among the nurses (n=21) who participated in the study, 20 completed the personal characteristics questionnaire. Of these, mostly female (75.0%), self-declared to be mixed race (60.0%), work in units with the Family Health Team (65.0%) and with the multidisciplinary team (80.0%), additionally, the majority mention having an exclusive room for care (65.0%). A total of 9 nurses reported having more than ten years in PHC (45.0%). They reported receiving more than seven minimum wages (60.0%) and having another job outside the APS (35.0%).
In addition, all of them have some postgraduate degree (100%), such as specialization in PHC (35.0%), specialization in Family and Community Health, Public Health or Public Health (45.0%), professional master's degree (5.0%), academic master's degree (5.0%), specialization in MH or Psychiatry (10.0%) and in another area (70.0%).
In relation to courses taken by nurses in the last year, 10.0% of them responded that they had taken some type of course in Mental Health area and 30.0% in Nursing Process (NP). Majority of nurses responded that they had some difficulty in carrying out the nursing consultation (70.0%) and did not have standardized instruments for carrying out the nursing consultation (60.0%), despite reporting that there are Nursing Protocols (60.0%).
Regarding the time spent in nursing consultations in MH, it observed a median of 20 minutes (24), with a high percentage of interruptions (≅59.2%) due to some demand related to the search for a nurse or other reasons. The satisfaction reported by users with the service was, on average, 9 out of 10.
In general, it was assessed that there are gaps regarding to execution of the nursing process steps and accurate recording. Nursing practice in mental health consultations at PHC, based on nursing process steps, is described in Table 1.
Table 1. Description of compliance with the NP steps in a MH consultation at PHC. Brazil, 2023
After analyzing the NP steps, aspects related to communication were evaluated. The nurse greeted and/or identified the user in 83.6% (n= 41) of consultations, introduced himself in 18.3% (n=9), paid attention to the user's comfort or privacy in 59.1% (n=29), started the consultation with open questions in 48.9% (n=24), alternated the use of open and closed questions throughout the consultation in 40.8% (n=20), maintained eye contact during interaction with the user in 65.3 % (n=32) and offered enough time for the user to express themselves, without interrupting them in 67.3% (n=33).
Furthermore, they adapted their speech, avoiding the use of scientific language in 85.7% (n=42), avoiding criticism or value judgments in relation to the user in 86.6% (n=41), avoiding non-verbal communication that denotes disinterest or disapproval in 65.3% (n=32), repeated the user's message validating their understanding and information in 38.7% (n=19), verified the user's understanding by encouraging the clarification of doubts in 40.8% (n=20). Closing the consultation formally indicated by looking or greeting in 61.2% (n=30) and summarized the information and prioritized the demand in 32.7% (n=19).
However, there is still little active listening, paying attention to the user's verbal and non-verbal manifestations, as evaluated in 26.5% (n=13), the user's involvement in planning actions discussing therapeutic options in 16.3% (n=8) and in the summary of the query in 10.2% (n=5).
In no consultation, feedback was requested on the user's understanding of what was discussed in the meeting, and encouragement to verbalize feelings, expectations and/or concerns was verified in 18.3% (n=9).
The nursing records it was present in 87.7% (n=43) of the consultations. It was identified that in the nursing history step, the records were partial, with the presence of subjective data in 51.1% (n=22) and objective data in 76.7% (n=33). It is noteworthy, as observed in the videos, that only 44.1% (n=19) of the medical records included a record of the physical examination and the psychological examination was not recorded by the nurses.
Regarding nursing diagnoses step, these were absent in 51.1% (n=22) of the medical records analysed. When present, only 20.9% (n=9) were related to the history and 18.6% (n=8) partially responded. The mainly registration format was through International Classification of Primary Care (ICPC) (100%), so that 86% (n=37) were showed in the ICPC relationship with the recorded history.
The planning step documentation evaluated the goals and expected results and were present only 6.9% (n=3) medical recorded. When considering the goals and results described in medical recorded in relation to the nursing diagnosis reported, the connection is identified in only 2.3% (n=1).
Regarding nursing prescriptions, in most records (69.7%), it was partially present. It is important to highlight that only in 9.3% of consultations was a nursing prescription related to the goals and results described in the medical record made.
It was observed that the implementation stage is rarely recorded. Only in 2.3% (n=1) of the records described this item. In the evaluation stage, the review of the plan/evolution was present in the record in 13.9% (n=6) of the records.
Figure 2 illustrates the compliance with Nursing Process steps (videos) according to nursing record and duration (in minutes) of consultation. In the Graph A, a relationship observed between compliance with the NP in the videos (execution of the consultation) with the performance of the NP in the medical record (consultation record). The Graph B, show an increasing correlation between the consultation time and compliance with the steps of the nursing process.
Figure 2. Compliance with Nursing Process steps (videos) according to nursing record and duration (in minutes) of consultation. Brazil, 2023.
In additional, it was observed that the increasing correlation between the consultation time and compliance with the steps of the nursing process that remained even after including the number of symptoms, graph A (Figure 3). Furthermore, nurses who took nursing process courses in the last year presented consultations with greater compliance with the nursing process and a longer average time, Graph B (Figure 3).
Figure 3. Relationship between NP compliance, symptoms and consultation time. Brazil, 2023
For qualitative investigation of ANP competencies, seven consultations were selected that obtained a score of greater than or equal to 50% of compliance with the stages of the nursing process (Table 2) including communication aspects.
Table 2. Compliance with nursing steps according to analysis of medical records and videos. Brazil, 2023
The best consultations were carried out by three nurses from the municipality D. Two of them mentioned having an exclusive room for care and having experience in the PHC for more than ten years. All reported receiving more than seven minimum wages and only 1 had another job outside the APS. In addition, everyone has one or more postgraduate degrees, such as specialization in PHC (n=1), specialization in Family and Community Health, Public Health or Public Health (n=3), academic master's degree (n=1), and in another area (n=2). Furthermore, these nurses took at least one course in the last year in Nursing Process and one of them, additionally, took a course in MH. However, despite presenting the best performance among all those analyzed, most of them responded that they had some difficulty in carrying out the nursing consultation (n=2).
The seven users seen in consultations with greater compliance with the basic elements of the nursing process are female and live in urban areas. Regarding MH complaints, all users reported having a diagnosis of anxiety and/or depression. One of the users mentioned another unspecified MH diagnosis and reported the use of psychotropic medication. The distribution of symptoms related to MH was: five mentioned difficulty sleeping, nervousness, discouragement, weakness, and dizziness; four reported crying/sadness, ringing in the ears and multiple pain; three mentioned feeling short of breath, feeling chest pain and feeling unwell; and only two reported palpitations.
Investigating the care management skills proposed for the ANP(21), nursing consultations in MH in PHC, with better performance, present some skills, however, still in a partial form. Among the categories, the frequency of the dimensions of care focus (39.68%), assessment and diagnosis (38.78%) and care provision (47.62%) stands out. (Table 4).
Nursing prescriptions shared and agreed between nurse and user are an expected aspect of both PHC nurses and APN competencies, but are still rarely present in MH consultations. However, in the best performing consultations, the coordination of MH care, one of the attributes of PHC, is found in the scenes.
Scene: 2507-04-MDS-SP
The nurse listened to the user, reviewing the demands presented and their assessment with her, proposing to agree on care strategies. Interacted through gestures and eye contact, with a direct posture towards the user.
Discourse: E25: “And would you agree to start treating your sadness? I'll tell you what I learned from our consultation. I understand that you have anxiety, that you have this suffering, and this anxiety makes you unable to sleep, makes the pain more intense. And when we don't sleep, we have pain, we get irritated, because no one can live with so much pain and so much sleep deprivation, I understand you, especially not having anyone to talk to, I understand that all of this becomes a cycle that goes It's getting harder to support yourself, isn't it? (user nods yes). So would you agree to treat this sadness you feel? (user nods yes). OK! This is important. And I will say that the treatment can have several phases, several pillars that we talk about and medication is the last pillar. Not that he will start last, but it is one of the pillars and we like to talk about other pillars first, for example, we strengthen the support network, improve the quality of life, quality of sleep. You only live with you and your daughter, is that it, just the two of you?” U34: “Yeah.” E25: “And are you unemployed at the moment?” U34: “Yeah, it’s only been three months, I’m insured [unemployment insurance].” E25: “Three months. Oh, it’s safe!” U34: “But I’m going to start, people are already finding jobs for me.” E25: “Ah, it’s about to start, has it been cocked?” U34: “At the company I worked for, the supervisor is already calling me.” E25: “And how do you feel about that?” U34: “I'm happy, because it's money and just leaving the house is good.” E25: “That’s right.” U34: “Yes, I worked, I had my problems, but I tried not to show it, because we have to work and we don't need to show our things”. E25: “Ahem, yes! There are things at work that don’t have to be opened, right?” U34: “I worked on the street, I worked with supervisors, you know? Going to the building looking for them, they had a lot of fun, enjoying themselves, chatting. I felt fine, but after the company closed, I stayed at home these days.” E25: “Ah, did you leave because it closed?” U34: “she closed”. E25: “Okay! But it's good that you have a goal in front of you, right, a perspective for the future, which is to go back to work, because that makes you excited. Even because the financial aspect affects our issues a lot, right?” U34: “It affects, but what can you do, right?”
Aspects of communication and clinical communication skills, investigated together with the NP, were present in the nurses, however, the therapeutic relationship, expected in the exchanges of dialogue, knowledge and understanding between nurse and user were achieved only in a few consultations, if highlighting how the best performers.
Scene: 2807-04-DCB-SPThe nurse provided guidance on the user's physical health after carrying out data collection and assessment. Furthermore, she returned to MH interacting through direct visual contact with the user and through gestures.
Discourse: E29: “And so this part of anxiety, this feeling of anxiety, we need to talk to the doctor, okay? Relate what you told me to what you are feeling, which is this anguish, tearful from time to time, and let's see if she prescribes any medication. You know that we have NASF [Multiprofessional Team] here, okay? If we are unable to help you with this part, we will look for the NASF to provide this matrix support and support you in a more complete way, okay?”
U45: “Uhm.”
E29: “But I believe that by talking to her [doctor], explaining everything we talked about today, her [doctor] prescribing the medication, you will improve.”
U45: “I’ll be fine.”
E29: “But then we will decide together with you to see if this is the best treatment for you, okay?” U45: “Okay.” E29: “But I'm going to leave it separately here so we can discuss this situation.”
Considering the stage of the history in the NP and the competencies for assessment and diagnosis dimensions, the integration of results suggests that aspects, such as the stage of the history in the NP and characteristics expected in ANP competencies, at the time of assessment, are common challenges.
Scene: 2207-05-TSA-SPThe nurse begins to assess the user, mentioning the procedure she would perform (blood pressure measurement). They are sitting side by side; the user shows signs of restlessness (fidgeting hands and legs) and spontaneously asks the nurse a question. From the doubt presented (about the heart), the nurse begins to investigate the symptom through questions that guide her to perform clinical reasoning and search for the cause.
Discourse: E25: “I’m going to check your blood pressure (…)
U33: “Is it normal to feel a lot of pain in your heart?”
E25: “Heart pain? What is this pain in your heart like, explain to me.”
U33: “It’s a twinge.”
E25: “Is it always or what frequency?”
U33: “I feel it about three times.”
E25: “A week, three times a week?”
U33: “Yes, and at night.”
E25: “Do you feel anything else besides this heartburn, any pain, back pain?” U33: “Yes, I already had the pain here (points to the heart).”
E25: “But when you feel the pain in your back, do you feel the stinging at night?”
U33: “The back pain is every day and the pain is sometimes, I think it’s strange.” E25: “Do you have any anguish? Affliction? Anxiety?" U33: “I have anxiety.” E25: “And when you have that pang, do you realize if you are anxious at that moment?” U33: “If I focus too much on that thought, I feel a lot of anxiety and a lot of pain.” E25: “That’s where the pain comes, right? It's a truly anguished heart. Because look, until now, you haven’t presented any health issues, your follow-ups are very good.” U33: “My blood pressure? I have doubts about my blood pressure.” E25: “Let's take a look at her, you can lean back, relax. Your pressure is great, it's 90x60 mmhg”
Nursing record: BEG, LOTE, flushed, hydrated, eupneic in room air.
Gestational age: date of last menstrual period 31 6/7; gestational age: USG 31 2/7; Uterine Height 27 CM; BCF 136 BPM
Position: cephalic; MF+; Edema: no edema; Using ferrous sulfate + calcium; Food: eat only 2 meals a day; Did not collect exams from the 2nd quarter; Did not perform a rapid test;
Measurements
Weight: 50.9 kg | Blood pressure: 90/50 mmHg.
DE1: ineffective control of the therapeutic regimen, referring to failure to collect tests in a timely manner; attitude towards impaired nutritional status
DE2: impaired comfort.
Thus, the nursing consultation in MH in PHC is still fragile, as is the presence of the care management skills proposed for the ANP in PHC.