Rev. Enferm. UFSM - REUFSM
Santa Maria, RS, v. 11, e49, p. 1-22, 2021
DOI: 10.5902/2179769253339
ISSN 2179-7692
Submission: 08/24/2020 Acceptance: 11/10/2020 Publication: 06/22/2021
Original Article
Nurses' contributions to matrix support in mental health in primary health care*
Contribuições do enfermeiro para o apoio matricial em saúde mental na atenção básica
Aportes del profesional de Enfermería al apoyo matricial en salud mental en la atención básica
Guilherme Emanuel Weiss PinheiroI
Luciane Prado KantorskiII
I Nurse, PhD in Nursing, Professor of Basic, Technical and Technological Education at the Polytechnic College of the Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil. E-mail: enfermeiro.guipinheiro@gmail.com Orcid: http://orcid.org/0000-0003-0069-7023
II Nurse, PhD in Nursing, Full Professor of the Nursing College of Nursing of the Federal University of Pelotas, Pelotas, Rio Grande do Sul, Brazil. E-mail: kantorski@uol.com.br Orcid: http://orcid.org/0000-0001-9726-3162
* Extracted from the thesis entitled “Evaluation of matrix support experiences in mental health in a health region in Rio Grande do Sul”, Post-Graduate Program in Nursing, Federal University of Pelotas, 2020.
Abstract: Objective: to identify the nurses' contributions in the context of matrix support in mental health in primary health care. Method: a qualitative research study, based on the Fourth Generation Assessment, carried out with workers from matrix support centers and reference teams of a municipality in southern Brazil. 84 observation hours of, 15 interviews and two groups of data validation were carried out between December 2018 and February 2019. The analysis was performed using the constant comparative method. Results: nurses contribute with matrix support as they act in the inclusion of the nuclei with the teams, in the exercise of management, leadership and shared care, and in the mediation of the mental health actions in the territory. Conclusion: nurses' leadership is decisive, since by concentrating managerial and assistance functions, they collaborate in the construction of care alternatives for people with mental distress in primary health care.
Descriptors: Nursing; Mental health; Primary health care; Health management; Comprehensive health care
Resumo: Objetivo: identificar as contribuições do enfermeiro no contexto do apoio matricial em saúde mental na atenção básica. Método: pesquisa qualitativa, com base na Avaliação de Quarta Geração, realizada com trabalhadores dos núcleos de apoio matricial e das equipes de referência de um município do sul do Brasil. Foram realizadas 84 horas de observação, 15 entrevistas e dois grupos de validação dos dados, entre dezembro de 2018 e fevereiro de 2019. A análise ocorreu pelo método comparativo constante. Resultados: o enfermeiro contribui com o apoio matricial à medida que atua na inclusão dos núcleos junto às equipes, no exercício do gerenciamento e da liderança, do cuidado compartilhado e na mediação das ações de saúde mental no território. Conclusão: a liderança do enfermeiro é decisiva, pois ao concentrar funções de gerenciamento e assistência, colabora na construção de alternativas de cuidado às pessoas em sofrimento mental na atenção básica.
Descritores: Enfermagem; Saúde mental; Atenção primária à saúde; Gestão em saúde; Assistência integral à saúde
Resumen: Objetivo: identificar los aportes del profesional de Enfermería en el contexto del apoyo matricial en salud mental en la atención básica. Método: investigación cualitativa, basada en la Evaluación de Cuarta Generación, realizada con trabajadores de los centros de apoyo matricial y de los equipos de referencia de un municipio del sur de Brasil. Se realizaron 84 horas de observación, 15 entrevistas y dos grupos de validación de los dados, entre diciembre de 2018 y febrero de 2019. El análisis se realizó por medio del método comparativo constante. Resultados: el profesional de Enfermería contribuye al apoyo matricial en la medida en que se desempeña en la inclusión de los centros junto a los equipos, en el ejercicio de la gestión y del liderazgo, de la atención compartid, y en la mediación de las acciones de salud mental en el territorio. Conclusión: el liderazgo del profesional de Enfermería es decisivo, puesto que, al concentrar funciones de gestión y asistencia, colabora en la construcción de alternativas de atención a las personas con padecimientos mentales en la atención básica.
Descriptores: Enfermería; Salud mental; Atención primaria de salud; Gestión en salud; Atención integral de salud
Introduction
The World Health Organization estimates that, in 2020, there are more than 27.9 million Nursing workers in the world. They correspond to the largest number of professionals in the health sector, representing approximately 59% of the staff contingent.1 Therefore, such professionals are responsible for the sustainability of different universal systems, for example in Brazil, the United Kingdom, Canada, and Denmark, among other countries.
Brazilian Nursing has approximately 1.8 million workers, constituting a category that adds more than half of the workforce in the health sector.2-3 When looking at the reality of the Unified Health System (Sistema Único de Saúde, SUS), it is possible to notice a similar situation: a population of approximately 886,309 professionals, being 259,434 nurses, 451,200 nursing technicians and 175,675 nursing assistants, representing more than 50% of the SUS workforce.3
The Nursing professional is one of the key elements in sustaining the health systems, since it is the profession that substantially adds the care practice.4 Care is considered as an attitude of committed, harmonious and protective relationship from different realities: social, personal and environmental. The act of caring means accompanying, “being with”, assuming responsibility, giving attention, good treatment, effort, welcoming and respect.5
The nurse has been decisive in the current health context, due to the skills developed and improved by the profession, given the need to consider – in the care process – social determinants, inequalities, population aging,4 and development of chronic conditions, in addition to other peculiarities. Among the chronic conditions, mental distress stands out. An international study points out that shared care, that is, articulated between general practitioners and specialists, tends to improve the clinical outcomes in assisting people with depression and suggests that this approach improves care management in the context of chronic conditions.6
When observing the complexity of the issue of mental distress and the need to articulate care strategies in primary health care, it is necessary to reflect on the nurse's actions in this context, which needs to be developed, qualified and transformed. In the reality of the Family Health Strategy (FHS), the nurse assumes several functions, such as: direct assistance to the population, through welcoming and Nursing consultations, for example; service management; program coordination; elaboration of reports; and provision of information systems. It should be noted that many of these duties are shared with the other workers in the team.7-8
In this perspective, the importance of interdisciplinary and inter-professional work is highlighted, as no professional category is capable of centralizing comprehensive care, requiring articulation with the other fields of knowledge. Thus, there is a need for actions in mental health in the context of primary health care to be developed with the aid of matrix support, which is a strategy that supports workers, people in mental distress, their families and communities in care, and in health promotion and rehabilitation.9
Matrix support seeks the integration of specialist professionals – also known as supporters – with general practitioners and members of the reference teams, through interdisciplinary practices that help to expand the clinic, care quality and the resoluteness of the services.10 In addition to the integration of the professionals, matrix support also adds elements of shared care, such as educational support, specialized care, regulation, co-management, multi-professional care, systematic communication, structured care and organizational support.6,11
In the Brazilian context, matrix support has transformed health work methodologies, including elements such as dialog, accountability, and collective decision in the actions and relationships of and between reference and matrix support teams. This promoted the expansion of communication among workers who, when conducting cases together, experience aspects of shared care in the territory.12
In this light, matrix support is understood as a way of providing health care in a shared manner, with the objective of offering comprehensive and resolute care, through interdisciplinary and collaborative work.13 In this scenario, the nurse is an articulator of these actions and, often, responsible for the management of services and care.
However, in the literature there is a gap in relation to the nurse's work with matrix support. As an example, an integrative review demonstrates that most studies investigate matrix support from interdisciplinary work and not from Nursing or any specific professional field.14 Reinforcing this idea, the systematic literature review indicates that, currently, there is limited evidence on mental health interventions carried out by nurses in primary health care, although it points out that mental health Nursing actions performed in primary health care contribute to significantly reduce the symptoms of depression and anxiety.15
Given the above, this study had the following research question: What are the nurses' contributions in the context of matrix support in primary health care? And as its objective: to identify the nurses' contributions in the context of matrix support in mental health in primary health care.
Method
This is a study with a qualitative approach, from the perspective of the Fourth Generation Assessment,16 developed in a research on the evaluation of matrix support experiences. The COREQ (Consolidated Criteria for Reporting Qualitative Research) directive was used to guide the writing of this article.
The theoretical and methodological framework of this research is based on the Fourth Generation Assessment, which concerns an alternative to traditional evaluations, given its constructivist and responsive nature. Furthermore, it is characterized by being used to designate a different way of focusing on the evaluation process. Thus, the interest groups and the organizational focus are defined, seeking critical consensus among these groups in relation to the study object, through the hermeneutic-dialectic process. The parameters and limits of the assessment are determined by the interactive and negotiation process, involving interest groups, which determine the raising of questions for the collection of information.16
The term “constructivist” designates the methodology used, that is, the way of conducting the assessment, an alternative to the positivist paradigm, which, in its turn, is based on measurement and quantification. The perspective at issue in question is considered to be responsive as it answers questions after gathering information, taking into account the view of the stakeholders.16
This study took place in two stages, the first of which was called “Characterization of the Primary Health Care Support Centers – Mental Health (Núcleos de Apoio à Atenção Básica, NAABs)” in a health region of Rio Grande do Sul (RS). It was carried out online, via electronic forms (Google Forms®) sent to the professionals of the referred centers, as a way to establish an approximation with the field for evaluative research. The referred form also consists of a characterization questionnaire which aimed to understand the work and structure of each center, for example: team composition; hourly workload; insertion of mental health actions in the territory; reviewing the referral practice; alternatives for health promotion; and composition of the Health Care Network.
The stage in question was held in December 2018, in a health region of the state of RS, composed of eleven municipalities, of which only three maintained a NAAB. After this stage, the data produced, originating from the characterization questionnaire, were analyzed considering the criteria contained in the legislation creating the center.17 At the end of the analysis, a municipality (belonging to the health region selected for the research), which met the criteria of the regulation, such as team composition, workload, work coinciding with the hours of primary health care teams, insertion of mental health actions in the logic of the territory, review of the referrals practice, and health promotion actions,, was chosen to take part in the next stage of the study.
The second stage, the “Fourth Generation Assessment”, took place from the approach of the main researcher, through visits to the municipal health secretariat of the municipality chosen in the previous stage, between the January and February 2019. Among the characteristics of the selected municipality, it can be highlighted that it is small, located in southern Brazil, and with an estimated population of 12,561 inhabitants,18 whose health network was made up of own and affiliated services. With regard to primary health care, the municipality maintained four urban and mixed (urban and rural) FHS teams and one rural FHS team. In addition, it had two matrix support centers, the NAAB and the Family Health Support Center (Núcleo de Apoio à Saúde da Família, NASF), two health academy centers and a therapeutic workshop, which includes Physical Education and Music professionals, who carry out activities in partnership with primary health care and other devices in the territory.
Data collection took place through the Dialectic Hermeneutic Circle, which consisted of an empirical data collection methodology. To this end, the researchers intentionally selected an initial respondent, being an individual who occupied a strategic position in relation to the object of the assessment. Subsequently, the other workers were indicated by the individuals who took part in the interviews to compose the aforementioned circle.16
Semi-structured interviews were conducted with the workers, presenting questions focused on aspects related to the work of matrix support, for example: how it was developed, characteristics, difficulties, practicalities, and evaluation of the participants, among other aspects. The interviews took place in rooms, individually and privately, in the health units of the municipality, with a mean duration of 27 minutes, were audio-recorded, transcribed in full, and later analyzed. The participants were personally approached by the researchers, and the interview was scheduled, as indicated. During the interviews, open-ended questions were asked.
Fifteen workers took part in the study, namely: seven members of the matrix support centers, NAAB and NASF; and eight members of the FHS teams of the municipality. The participants were: nurses, nursing technicians, community health agents, physician, occupational therapist, artisan, psychologist, therapeutic companion, physiotherapist, nutritionist and speech therapist. It should be noted that there was no refusal to take part by the nominees. Regarding the characteristics of the workers interviewed, it is recorded that: 13 are female and two are male; nine were between 27 and 39 years old and six between 40 and 56 years old; in relation to the time of experience in the profession, two worked for less than two years, seven between 2 and 10 years and six between 11 and 32 years. The selection criteria used were as follows: being a worker from the municipality's reference team or support center, and having been indicated in the Dialectic Hermeneutic Circle.
In addition, participant observation was performed, constituting itself as a study technique of social interaction that facilitates the observation of the individuals' actions, composed through the report of those who take part in the interaction; thus, participant observation occurred in the context of social interaction.19 This observation is called prior ethnography,16 and was carried out in the daily life of primary health care services in the municipality, following-up the daily lives of the workers, in home visits, individual and group visits, meetings and activities, making up a total of 84 hours, between January and February 2019; such observations were recorded in field diary notes.
At the end of the observations and the semi-structured interviews, negotiation took place through the validation and negotiation groups, carried out with the workers, with a total duration of three hours between both groups, on February 27th, 2019, in the meeting room of the municipal health secretariat. Two groups were organized, one with the matrix support workers and the other with the reference teams, with the main results of the fieldwork being presented, systematizing consensus and dissent, looking for possible alternatives, together with the participants.
Data analysis proceeded in parallel with the data collection process, based on the Constant Comparative Method, which is divided into two stages: identification of information units, and construction of thematic nuclei or categorization. The first consists in identifying the sentences or statements extracted from the empirical material, recorded by the researcher. The second, on the other hand, concerns the search for provisional categories, approximated by the similarity in the content, so that after the validation and negotiation group, it constitutes the definitive categories or thematic nuclei.16
It is to be noted that the research was submitted for approval to the Committee of Ethics in Research with human beings, obtaining it under Opinion No. 3,038,987 on November 26th,2018, with Certificate of Presentation for Ethical Appreciation number: 02237118.2.0000.5316. The research was conducted in accordance with the ethical standards required by the national legislation of the Ministry of Health (Resolution No. 466/2012; Resolution No. 510/2016; and Resolution No. 580/2018). The participants signed the Free and Informed Consent Form in two copies, one remaining with the participant and the other with the researcher.
Codes were used to preserve the participants' identity. For that, the workers in the matrix support centers were identified with the letter A followed by the interview number (A1-A7), while the members of the FHS teams with the letter E followed by the interview number (E1-E8). The excerpts from the field diary emerging from the participant observation are indicated by DC, followed by the number of the diary (DC1-DC16) and the validation group by GVN, indicating the participant (GNV-E1 to GNV-E8 or GNV-A1 to GNV-A8).
The research activities were conducted by the authors of this article, who have been trained in the field of Nursing, in addition to having experience in qualitative studies and in service evaluation. The observations were made only by the main researcher, who has expertise in the area. The participants' knowledge about the researchers is associated with interactions with professionals from educational institutions, researchers in the health area – in which the research in question was a doctoral research in the Nursing field. The interviews and observations were completed according to the data saturation criterion.
Results
In the reality studied, matrix support is made up of the NAAB and NASF centers, which offer assistance and didactic-pedagogical support13 for four FHS units in the municipality selected for this study, and the matrix workers are organized in pairs to accompany them. The pairs are formed by a member of each group, who are responsible for monitoring the teams. Thus, they take part in meetings both within the scope of the health units and of municipal management, in which they discuss situations and demands highlighted in support, either planning, activities or contribution to Permanent Education in Health. It is important to point out that, through these actions, they form a link between assistance and management, and vice versa.
The results presented in this study focus on the view of health workers about the nurses' contributions to matrix support and mental health care in primary care. In the data collection period, the teams participating in the research were complete, from the point of view of professional composition. The statements below present the nurses who facilitate the entry of matrix support with the health teams:
When you get to have a relationship, to show your work to a nurse, she ends up using you whenever she needs and that has happened in my work. At the moment, I'm finding more difficulties in the team [referred to a reference team]. I notice that this bond between me and the team and, mainly, with the nurse is not happening. In other places it has always happened, they used me as if I were a part of the team, they trusted me, they trusted knowing that I was going to deal with the situation. (A6)
The gateway to the FHS is always Nursing, and we realize this very much, because depending on who is in charge, things happen more. The nurse takes on the responsibility herself and talks to the team and it happens. (A7)
Matrix support workers recognize the nurse's work and the particularities of each person in leading the team. Thus, they evaluate, in a certain way, the performance of this professional and make comparisons.
Today I'm working in a team that's very good, the nurse is very nice, she has a way of talking, everything flows, she has a way of taking things very well, so things go well, but I've already worked in other teams that were not like that, that did not have this union. (A2)
The nurses' leadership with the teams is remarkable and considered a differential, since they act to conduct work in primary health care with a view to qualifying care. The above is evidenced in the statement below:
The nurse is prominent and has a leadership posture towards the team, the people being assisted and the management, performs the necessary demands, problematizes matters with wisdom, and reflects, making self-criticism in relation to the work. (DC11)
Another aspect to be highlighted concerns the opening of the teams in relation to matrix support, with nurses being fundamental in this process. These, in turn, consider and treat matrix support as a priority, especially with complex or mental health cases, and in the organizational issues of the unit:
Nursing prioritizes quite a lot the issue of matrix support, especially with those patients who have difficulty in adhering to treatment, complex cases and almost always in mental health. (A3)
Nurse requests support from NAAB and NASF in building the schedule of activities and to plan something with the rural communities. (DC11)
There are also difficulties experienced by the professionals to work with mental health issues. They point out the frequency of cases that arrive at the units, the difficulties of referrals and care they face:
It's just what's showing up for us, it's just what's coming, and more than one case in the day, be it acute, chronic psychosis, alcoholism, drugs, whatever [...]. Ah! There's no responsibility, there's no one you can refer to, it's a difficult area to work, because the family member is much shaken. (GVN – E1)
I was very surprised by the number of mental health cases here in the municipality, be it a disorder or substance dependence, there are many, almost half of the population uses controlled medication. So, you have to take care, because these patients are in the unit every day and we have to take care. (GVN – E3)
In view of the difficulties faced, the workers point out some strategies to be built as an alternative to overcome the problems. Permanent Education in Health is one of the strategies that nurses, as team members, identify to face difficulties, knowledge gaps and the optimization of work in primary health care.
You know, the primary health care team, in short, you have to be always building knowledge, you have to be more prepared for that. I think that, suddenly, investing in permanent education in this area is very important here for the municipality. (GVN – E3)
Other strategies are highlighted by the nurses, among them the construction of bonds and the recognition of the reality of the territory in order to, from that, develop actions of comprehensive care and assertive decision-making in the development of the work, leading the team in order to qualify assistance. The involvement of this professional in this process is highlighted below:
The nurse is involved with the work and the team, in addition to having a good bond with the population [...]. The nurse knew the users by name, knew where they came from [whether they came from distant locations or not]. The nurse is a person who has good knowledge of the reality of his territory, facilitating people's access to the service. In addition to that, they have good leadership in relation to the team, as professionals turn to them in times of doubt. (DC10)
The results presented show the importance of nurses in the articulation with matrix support. This occurs by prioritizing the Nursing professional with: teamwork, their bond with the people assisted and their involvement with the territory, strengthening mental health care in the community.
Discussion
The study participants point out that, when recognizing matrix support, the nurse shares many achievements and, when the team has this understanding, work flows. In this context, the testimonies of the interviewees highlight the presence of the professional in question as an important figure, who adds, making their work activities occur jointly.
The fact that nurses believe in the role of matrix support and collaborate in the entire process can be associated with the concentration of managerial functions in their daily work in primary health care. Corroborating this, a study on the perception of their identity shows that their practice is associated with coordination and has value due to this attribution in the FHS team, recognized by the other members of the team.7
In this sense, the nurses assume the responsibility for themselves, including the members of the matrix support team, who feel part of the team, feeling connected to the others. This inclusion contributes positively to matrix support, since the referred professional recognizes the importance of the occurrence of interventions carried out jointly in the field of health. Thus, the relationships among the workers is strengthened, facilitating the entry of support centers along with the reference teams, which makes work proceed in a collaborative way and in an inter-professional perspective.20 If this does not happen, matrix support finds it difficult to connect with the supported teams, which, consequently, can compromise the performance in primary health care.
In the FHS, the nurse performs different functions, together with the other professionals, and needs to work in an interdisciplinary manner, assuming responsibility with the team and the people assisted, building collaborative and shared care in the territory. Thus, it is important that mental health actions and practices be developed in primary health care, articulating care with all workers, mediated by the figure of the nurse.9
Thus, it is necessary to highlight the leadership exercised by nurses in primary health care, which comprises the managerial dimension of the Nursing work, being considered as a critical and priority element in the health work.21 It needs to be exercised with wisdom and science, because the professional in question absorbs managerial and assistance functions.
A study carried out with nurses from the Brazilian Southeast region shows that the complexity of primary health care requires that they be qualified to perform the functions at this care level. Emphasis is also placed on some issues that hinder the development of leadership, such as lack of integration between the teams, demobilization of health work, and overlap of managerial and assistance actions.21
In the studied reality, it was possible to visualize the magnitude of the nurse's work in the context of primary health care, observing the managerial and leadership issues of the teams. It was noted that some teams were articulated with matrix support, using the tool and accessing the workers to strengthen the work done in FHS. These are actions made possible by the nurse who facilitates this process, through the exercise of leadership and team management. Through the data presented, it was observed that the nurse is a leader that adds, problematizing situations, making necessary demands and, also, practicing self-criticism, that is, recognizing the limitations and difficulties found for the work done in primary health care.
It is necessary for nurses to responsibly assume the integration with the matrix support teams, since they seek, from that point, specialized aid and support for decision-making, especially in complex and difficult to solve cases. As an example, people in psychological distress with difficulty adhering to the therapeutic proposal, or in a situation of social vulnerability, or even without support from the family and social network, among other possibilities. It was noticed that the aspects related to mental health are generally shared with matrix support. Thus, shared care is a widespread strategy in the context of care for chronic conditions, based on the integration of different knowledge. It can also be understood as integrated and collaborative care, which inserts different disciplines in the same discussion environment.6
Another understanding regarding the search for matrix support for mental health cases can be related to the teams' “lack of preparation” to work with this reality. This is due to the fact that mental distress is often seen in a way that is dissociated from other chronic conditions, requiring such emphasis:
Chronic conditions, therefore, go far beyond chronic diseases [...], as they involve persistent infectious diseases [...], conditions linked to motherhood and the perinatal period [...]; conditions linked to the maintenance of health through life cycles [...]; long-term mental disorders; continuous physical and structural disabilities [...]; metabolic diseases; oral diseases; health conditions characterized as disorders (illnesses) where there is suffering, but not diseases that fall within the biomedical standards.22:27
Thus, it is possible to note that, although mental distress is presented as a chronic condition, there are difficulties in recognizing it as such, especially in primary health care, where the biomedical model still imposes fragmented work processes, becoming a barrier for comprehensive care be made possible. It is worth noting the recognition by workers, especially nurses in primary health care, of their responsibilities in relation to the care of people with diabetes, hypertension, pregnant women, mothers and children, but with certain difficulty in recognizing mental distress like these conditions.9
From this, there is a need for support so that the workers absorb the demands of mental health and act with this view in the care provided in the territory. In this way, the nurse welcomes the support and realizes the need for articulation so that the most complex issues are assisted with matrix support. This articulation is favored by the managerial actions of the nurse, who understands the need to have specialized professionals and an external perspective to work on some complex demands, especially those of mental health.
In this sense, a study conducted with support workers and nurses and focused on matrix support actions in primary health care identified aspects of mental health care in the territory. In addition, it pointed out the need for planning, integration and strengthening of the actions carried out by the teams, so that assistance is qualified, people's autonomy is preserved, workers are prepared and share care in an inter-professional and interdisciplinary manner.23
Another study conducted with nurses from the FHS and specialized mental health care in southeastern Brazil indicated that matrix support is intended to be “a path of hope”, in which the actors place the best expectations in relation to the assistance to people in mental distress. It also signaled that matrix support is a powerful tool in the health care network, especially in caring for people in mental distress, as workers add security to their daily activities, and the support is indispensable and essential for assistance to be provided with quality and resoluteness in primary health care.10
The managers – participants of a study, which analyzed the strategies, challenges and possibilities of the articulation between mental health and primary health care – sustained that matrix support requires a dialogical relationship between the actors involved, based on an inter-professional logic and a collaborative practice, seeking comprehensive care.20 In this way, understanding matrix support from dialog and the contribution of different backgrounds makes primary health care capable of betting on the mental health care actions in the territory. Furthermore, it is worth highlighting the existing diversity in these spaces and the possibility of caring in freedom, valuing autonomy, freedom, citizenship and human rights – basic principles of psychosocial care.
Currently, it is not understood that mental health specialists are exclusively responsible for the care of people in mental distress, as all the professionals who work in primary health care are co-responsible for the psychosocial rehabilitation process. Thus, what facilitates performance in this context is the articulation of the multi-professional team, through which case resoluteness becomes viable, since the workers share the same objective.24
The participants in this study highlighted difficulties in meeting mental health situations, recognizing it as a difficult area to be worked on, observing a growing demand in the health units and lack of specialized service for referral. However, they recognized the importance of mental health care, through the mobilization of actions along with matrix support and carrying out different interventions in the territory.
Reinforcing what the participants in the present study experienced, a survey conducted with FHS teams in northeastern Brazil investigated perceptions regarding mental health actions in primary health care, highlighting the importance of working with a focus on mental health. However, it recognized as a difficulty the great demand for care, in addition to the insecurity of most workers in enabling mental health actions in primary health care.25
Generally, small municipalities do not have specialized mental health services, and primary health care is responsible for these cases, with support from matrix support and the collaboration of other services in the network. Thus, an analysis of the organization of the psychosocial care network, from the Brazilian health regions, detected the existence of care gaps in the field of mental health, and there are municipalities that rely only on primary health care devices and have no other point of the psychosocial care network. This issue is of concern in terms of expansion, regionalization and the movement to internalize psychosocial care, being characterized as an important limitation of the universal mental health coverage in the country.26
Thus, matrix support acts in the logic of overcoming referrals, seeking to develop an expanded and comprehensive view of mental health care. In addition to understanding the dialogical basis of management, in the construction of collective health work, prioritizing care for the person and their family. Matrixing seeks to promote discussion and enable possible ways of working from the perspective of psychosocial care and of care in the territory, as well as respecting the different dimensions of the person in mental distress, their family and the community.27
To strengthen the principles of the Psychiatric Reform and the assumptions of psychosocial care, matrix support is considered to be a powerful tool for Permanent Education in Health, which has in its bases innovative pedagogical references that act in the construction of integrative and democratic practices, such as: meaningful learning; learning to learn process; and problematization; among others. It consists of a proposal, based on active teaching and learning methodologies, which places the daily services and professional training under constant analysis, through the involvement of the subjects in the transformation of the reality where they work.28
Thus, the nurse has a role in articulating, stimulating and executing Permanent Education in Health actions since, through significant educational practices, the social actors are empowered and transform their work.7 In addition, the professional in question privileges the perspective, reflection and intervention on the reality and daily practices of the health services.8 In this way, the Nursing professional acts in the logic of empowering the workers for care in the territory, transforming views on mental health and elaborating participatory and collaborative strategies.23-24
When recognizing that care for people with mental distress in primary health care needs to occur in a qualified manner, the need for training the workers is discussed so that qualified assistance is viable. Following this bias, it is imperative that the process of Permanent Education in Health proceeds in a concrete and constant way, with a view to comprehensive care for people and their families, based on welcoming and therapeutic listening.25 Thus, matrix support can collaborate with the didactic-pedagogical dimension, which is made possible by the construction of educational processes, seeking to qualify the service and mental health care.13
Contributing to this discussion, a study with FHS workers emphasized the need for investments in the training of nurses in the mental health field. These professionals feel insecure in conducting cases of this nature, in structuring actions and strategies to care for people in psychological distress. With a view to transforming this reality and with the aim of qualifying assistance, Permanent Education in Health needs to be prioritized, breaking with the paradigm experienced and seeking to consolidate the psychosocial care model.10 In addition, the occurrence of educational processes, in the day-to-day services, strengthens the care actions, qualifying health work and generating new perspectives of performance in the professional routine.28
Another study on the work of nurses in primary health care reveals that the insertion of FHS teams has been promoting different modes of care production in the territory. This is due to the fact that, at this care level, light technologies are highlighted and are associated with the construction of bonds, in the field of social relationships, in qualified listening and in welcoming.8 From this, the importance of the nurse and the entire health team to approach the reality of the territory in which they are inserted is noticed, to know the people and their needs, and to produce with them actions to improve access and build autonomy in the community.
When looking at mental health care, it is necessary to understand the types of care technologies, be they light, light-hard and hard. Light technologies are those of the relationships, bonding, autonomization, welcoming, management of work processes; light-hard technologies consist in the well-structured knowledge that operate in health work as a medical clinic; and hard technologies are those related to technological equipment, norms, routines, and organizational structures.29
Light technologies are highlighted as emblematic and fundamental in mental health care, as they involve the field of relationships that produce health and build autonomy with people. Thus, the bond articulates with the satisfaction of the person being monitored, as they feel valued, with trust in the professional, and satisfied with the service they get. These relationships, which are established between the health professional and the assisted person, demonstrate the relevance that inter-subjective relationships maintain in health care and work.30 It is emphasized that knowing the territory, the people and the realities, as well as understanding them in their context, are fundamental for the construction of comprehensive care.
This article presents characteristics of a qualitative research study, such as singularity, since it carried out in only one health region, which portrays a specific reality in a municipality of RS. As a limitation, it can be noted that this research was developed in a single location, presenting data from a specific reality. However, the observations, interviews, validation and negotiation groups and discussions can serve as indicators for reflections in this scenario in new studies in other specificities, as well as other contexts, in order to expand the research field. With this, the relevance of matrix support and Nursing is highlighted as an enhancer of these actions, in the sense of offering elements to problematize and discuss mental health in primary health care.
Conclusion
This study provided an opportunity to identify the nurses' contributions in the context of matrix support in mental health in primary health care. Such contributions can occur through the inclusion of matrix support with the work of the teams, through the management of the service and the leadership that contribute to articulation, through shared care and through the mediation of the mental health actions in the territory.
Nursing is a profession that concentrates the attribution of care and, with that, co-responsibility for the people it follows-up. In the context studied, it was noticed how nurses perform this function, with the support of matrix support, inserting the nuclei in their daily activities, collaborating in the construction of alternatives for people in mental distress, their families and their communities.
In addition, it was observed that the nurses' leadership in primary health care is decisive, as they concentrate managerial and assistance attributions. Thus, they collaborate so that matrix support workers, together with those of the reference teams, elaborate care alternatives in the territory, respecting people's individualities, constructing autonomy and freedom.
In addition to these issues, some weaknesses were seen and pointed out by the workers, such as the increased demands in the mental health field and the difficulties in relation to professional qualification in this area. This clarifies the need for investment in Permanent Education in Health actions, so that workers are empowered to work with mental health issues in primary health care.
This study sought to contribute to primary health care in the sense of offering support for mental health care in the territory, raising the discussion of this theme from the nurses' contributions. This, in turn, facilitates the access of matrix support to the FHS teams, being considered a highlight in the issue of leadership in this context and maintaining openness for collaborative and inter-professional work in primary health care. Thus, the profession in question decisively contributes to the sustainability of the SUS, through its work at different performance levels and spaces. It emphasizes performance in primary health care, and it is possible to observe how important Nursing becomes in the context of mental health care in the territory.
References
1. World Health Organization (WHO). State of the world’s nursing 2020: investing in education, jobs and leadership. Geneva: World Health Organization; 2020 [cited 2020 May 19]. Available from: https://apps.who.int/iris/bitstream/handle/10665/331673/9789240003293-eng.pdf
2. Machado MH. Perfil da enfermagem no Brasil: relatório final. Rio de Janeiro: NERHUS - DAPS - ENSP/Fiocruz; 2017. 748 p.
3. Fundação Oswaldo Cruz (FIOCRUZ), Escola Politécnica de Saúde Joaquim Venâncio (EPSJV). Força motriz do SUS [Internet]. Rio de Janeiro: EPSJV; 2019 [acesso em 2020 maio 19]. Disponível em: http://www.epsjv.fiocruz.br/noticias/reportagem/forca-motriz-do-sus
4. Arcêncio RA. Nursing as the profession of the future and the foundation of universal health systems. Rev Latinoam Enferm. 2018;26:e3063. doi: https://doi.org/10.1590/1518-8345.0000.3063
5. Boff L. Saber cuidar: ética do humano - compaixão pela terra. 20ª ed. Petrópolis: Vozes; 2014.
6. Smith SM, Cousins G, Clyne B, Allwright S, O'Dowd T. Shared care across the interface between primary and specialty care in management of long term conditions. Cochrane Database Syst Rev. 2017;2:CD004910. doi: https://doi.org/10.1002/14651858.CD004910.pub3
7. Assis JT, Santos JF, Pinto LMC, Brito PKH, Ferreira MA, Fernandes MC. Identidade profissional do enfermeiro na percepção da equipe da estratégia saúde da família. Rev Saúde Ciênc [Internet]. 2018 [acesso em 2020 jan 08];7(3):43-58. Disponível em: https://rsc.revistas.ufcg.edu.br/index.php/rsc/article/view/141
8. Galavote HS, Zandonade E, Garcia ACP, Freitas PSS, Seidl H, Contarato PC, et al. The nurse’s work in primary health care. Esc Anna Nery. 2016;20(1):90-8. doi: https://doi.org/10.5935/1414-8145.20160013
9. Nascimento MGG, Nadaleti NP, Vilela SC, Terra FS, Silva SA, Resck ZMR. Nursing work process in the promotion of mental health: reflective analysis. Rev Enferm Cent Oeste Min. 2017;7:e2097. doi: https://doi.org/10.19175/recom.v7i0.2097
10. Almeida DR, Soares JNC, Dias MG, Rocha FC, Andrade Neto GR, Andrade DLB. Care for carriers of mental disorder in primary care: an interdisciplinary and multiprofessional practice. Rev Pesq Cuid Fundam. 2020;12:420-5. doi: https://doi.org/10.9789/2175-5361.rpcfo.v12.8388
11. Saraiva SAL, Zepeda J, Liria AF. Components of matrix support and collaborative mental health care: a narrative review. Ciênc Saúde Colet. 2020;25(2):553-65. doi: https://doi.org/10.1590/1413-81232020252.10092018
12. Castro CP, Campos GWS. Apoio matricial como articulador das relações interprofissionais entre serviços especializados e atenção primária à saúde. Physis (Rio J). 2016;26(2):455-81. doi: https://doi.org/10.1590/S0103-73312016000200007
13. Campos GWS, Domitti AC. Apoio matricial e equipe de referência: uma metodologia para gestão do trabalho interdisciplinar em saúde. Cad Saúde Pública. 2007;23(2):399-407. doi: https://doi.org/10.1590/S0102-311X2007000200016
14. Araujo RCG, Santos RD, Mesquita KSF, Bento TMA, Silva LKB. Apoio matricial na atenção psicossocial com foco na enfermagem. Cad Graduação Ciênc Biol Saúde. [Internet]. 2019 [acesso em 2020 jun 02];5(2):203-14. Disponível em: https://periodicos.set.edu.br/index.php/fitsbiosaude/article/view/6324/3343
15. Halcomb EJ, McInnes S, Patterson C, Moxham L. Nurse-delivered interventions for mental health in primary care: a systematic review of randomized controlled trials. Fam Pract. 2019;36(1):64-71. doi: https://doi.org/10.1093/fampra/cmy101
16. Guba EG, Lincoln YS. Avaliação de quarta geração. Campinas: Ed. UNICAMP; 2011. 320 p.
17. ESTADO DO RIO GRANDE DO SUL. Resolução nº 403/11 – CIB/RS, de 26 de outubro de 2011. Porto Alegre, RS: Secretaria de Saúde, 2011. Disponível em: http://www.saude.rs.gov.br/upload/arquivos/carga20170220/23102058-1340039277-cibr403-11.pdf. Acesso em: 13 jan. 2020.
18. Instituto Brasileiro de Geografia e Estatística (IBGE). IBGE Cidades [Internet]. 2019 [acesso em 2019 jun 28]. Available in: https://cidades.ibge.gov.br/
19. Cardano M. Métodos qualitativos para pesquisa em saúde. J Nurs Health. 2017;7(3):1-5. doi: https://doi.org/10.15210/JONAH.V7I3.12847
20. Souza AC, Amarante PD, Abrahão AL. Inclusion of mental health in primary health care: care strategy in the territory. Rev Bras Enferm. 2019;72(6):1677-82. doi: https://doi.org/10.1590/0034-7167-2018-0806
21. Oliveira C, Santos LC, Andrade J, Domingos TS, Spiri WC. Leadership in the perspective of family health strategy nurses. Rev Gaúcha Enferm. 2020;41:e20190106. doi: https://doi.org/10.1590/1983-1447.2020.20190106
22. Mendes EV. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da estratégia da saúde da família. Brasília (DF): Organização Pan-Americana da Saúde; 2012.
23. Oliveira GC, Schneider JF, Pinho LB, Camatta MW, Nasi C, Guimarães AN, et al. Matrix support in mental health in primary care: the vision of supporters and nurses. Rev Gaúcha Enferm. 2020;41(Spec No):e20190081. doi: https://doi.org/10.1590/1983-1447.2020.20190081
24. Gurgel ALLG, Jorge MSB, Caminha ECCR, Maia Neto JP, Vasconcelos MGF. Mental health care in the family health strategy: the experience of matrix support. Rev Enferm UERJ. 2017;25:e7101. doi: https://doi.org/10.12957/reuerj.2017.7101
25. Silva GR, Reis HFT, Dos-Santos EM, Souza MPA, Azevedo RL. Mental health in primary care: perceptions of the family health care team. Cogitare Enferm. 2016;21(2):1-7. doi: https://doi.org/10.5380/ce.v21i2.43861
26. Macedo JP, Abreu MM, Fontenele MG, Dimenstein M. A regionalização da saúde mental e os novos desafios da Reforma Psiquiátrica brasileira. Saúde Soc [Internet]. 2017 [acesso 2020 jun 01];26(1):155-70. Disponível em: https://www.scielo.br/pdf/sausoc/v26n1/1984-0470-sausoc-26-01-00155.pdf
27. Lima MC, Gonçalves TR. Apoio matricial como estratégia de ordenação do cuidado em saúde mental. Trab Educ Saúde. 2020;18(1):1-21. doi: https://doi.org/10.1590/1981-7746-sol00232
28. Gigante RL, Campos GWS. Política de formação e educação permanente em saúde no brasil: bases legais e referências teóricas. Trab Educ Saúde. 2016;14(3):747-63. doi: https://doi.org/10.1590/1981-7746-sip00124
29. Merhy EE. Saúde: a cartografia do trabalho vivo. 4ª ed. São Paulo: Hucitec; 2014.
30. Jorge MSB, Diniz AM, Lima LL, Penha JC. Matrix support, individual therapeutic project and production in mental health care. Texto Contexto Enferm. 2015;24(1):112-20. doi: https://doi.org/10.1590/0104-07072015002430013
Scientific Editor in Chief: Cristiane Cardoso de Paula
Associated Editor: Daiana Foggiato de Siqueira
Funding/Acknowledgment: This paper was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001
Corresponding author
Guilherme Emanuel Weiss Pinheiro
E-mail: enfermeiro.guipinheiro@gmail.com
Address: Avenida Roraima, 1000, Colégio Politécnico da UFSM, Prédio 70, Bloco G, Sala 321A. Santa Maria – RS, Brasil.
Zip Code: 97105-900
Authorship Contributions
1 – Guilherme Emanuel Weiss Pinheiro
Conception or design of the study/research, data analysis and/or interpretation, final review with critical and intellectual participation in the manuscript.
2 – Luciane Prado Kantorski
Conception or design of the study/research, data analysis and/or interpretation, final review with critical and intellectual participation in the manuscript.
How to cite this article
Pinheiro GEW, Kantorski LP. Nurses' contributions to matrix support in mental health in primary health care. Rev. Enferm. UFSM. 2021 [Accessed on: Year Month Day]; vol.11 e49: 1-22. DOI: https://doi.org/10.5902/2179769253339