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The PET-Networks as transformer of practices of a Psychosocial Care Center.

Introduction

In recent years, many countries have been attentive to the challenges that the current changes in society have posed to the health services. This fact has generated a process of reflection on the education of the professionals that work and/or will work in these services (1,2).

Brazil's Ministry of Health has been adopting, for some time, strategies to connect courses in the area of health with the daily routine of Sistema Unico de Saude (SUS--Brazil's National Healthcare System). It is a process to contextualize teaching, and it aims to educate professionals to act according to the population's health needs, strengthening the country's public policies and the National Healthcare System (3).

One of these strategies is the Programa de Educacao pelo Trabalho para a Saude (PET-Saude--Program of Education through Work for the Area of Health). This program is one of the instruments that aim to join different actors from diverse professions, offering internships and experiences contextualized in the SUS, and having the SUS as support and scenario of practice. Such internships and experiences are targeted at the population's health needs (4).

PET-Saude has the purpose of generating deterritorializations, that is, destabilizing what is deeply rooted in health education processes (5), with parameters being provided by the SUS. In addition, it aims at the adoption of teaching-learning strategies grounded on the problematization of and critical inclusion in the reality, with the purpose of extracting elements from it that will provide meaning and direction to learning. It presupposes the interlocution between scientific knowledge and popular knowledge by means of the multiprofessional experience, in order to reach interprofessional education (6).

It is a program created with the aim of inducing changes in the perspective of a new health education process, guided by Brazil's National Curriculum Guidelines. It stimulates the suspension of the tendentious movement of educating isolated and independent professionals, by means of their transit in a collaborative working practice integrated into the public health services (7,8). Thus, at the same time that it induces education contextualized in the professional practice, it also enables a process to restructure the form in which healthcare has been provided.

In this context, PET-Redes de Atencao a Saude (PET-Healthcare Networks) was created, with the same perspective of PET-Saude with regard to students' education and health professionals' development. However, it also promotes interventions in diverse assistance units in order to investigate the population's context and needs, and these interventions become sources of production, knowledge and research in teaching institutions (9).

Furthermore, PET-Redes de Atencao a Saude has the differential of enabling students' inclusion in the Redes de Atencao a Saude (RAS--Healthcare Networks), which consist of a process that organizes health actions and services of different technological densities, integrated by means of technical, logistic and management support systems, guaranteeing comprehensive care. Their implementation promotes greater efficacy in health production and an efficient management of the healthcare system, enhancing the effective functioning of the SUS (10).

Among the several RAS that were created with the objective explained above, there is the Rede de Atencao Psicossociai(RAPS--Psychosocial Care Network), which aims to comply with the mental health policy in force, progressively reducing the number of psychiatric beds and creating services to replace hospitalization, such as the Centros de Atencao Psicossocial (CAPS--Psychosocial Care Centers). These services are strategic elements in the constitution of the RAPS, as they are the main articulators of this network and enable interlocutions with the other assistance units that compose it (11).

As articulators of the RAPS, the CAPS must be located in a space of public interaction and must revive the potentialities of community resources (family, school, work, church, associations, etc.), offering amplified healthcare, and becoming the main entrance door to the return of individuals in psychological suffering to social life (12). They are classified into CAPS I, II, III, CAPS-alcohol and drugs, and CAPS-children, depending on the mode of functioning, number of professionals in the composition of the work team and the registered population (11).

The presupposition is that these professionals configure a multiprofessional team, aiming at interdisciplinary care, which is one of the essential principles to the effective occurrence of the resocialization process of the individual in psychological suffering and to the provision of healthcare in a comprehensive way. However, the professionals have not been prepared for teamwork due to the process of uniprofessional education, centered on the disease and not on the individual, in which education is disconnected from practice. This produces weaknesses in the assistance provided, difficulties in professional integration, and insecurity when providing care for the user (6,8,13).

In light of this, the PET-Redes de Atencao Psicossocial(PET-RAPS--PET-Psychosocial Care Networks) was developed in the CAPS II of a municipality located in the State of Mato Grosso (in the central-western region of Brazil), as the potentializer of an assistance unit of the psychosocial network. It aims to qualify assistance, enhance the development of health professionals, and provide students with contextualized education, including them in the health service and enabling experiences and the development of critical-reflective thought about their academic practice.

We decided to conduct this study viewing the PET as a program that gives importance to the qualification of assistance and induces teaching carried out through practice. Its relevance lies in the fact that it gives visibility to the potentialities of the PET device and to the difficulties faced by professionals in the development of mental healthcare. Thus, this study aimed to analyze the contributions of PET-Redes to the activities developed by the professionals of a Psychosocial Care Center.

Methodology

This is a descriptive and exploratory study with a qualitative approach. It was conducted at a CAPS II of a municipality located in the state of Mato Grosso (in the central-western region of Brazil).

We decided to develop this type of study due to the nature of the object and of the theme of the investigation, which is the PET-RAPS and its development among the workers of a CAPS. This type of design searches for the meanings, values, motives and attitudes involving the theme, and enables to understand the processes, phenomena and relations that cannot be translated into variables (14).

The service was chosen because it is linked to the PET-RAPS, developing extension and research activities with users, families and professionals.

The CAPS II where the study was conducted is a psychosocial care service that was inaugurated on December 2, 2002. It is a reference center for the entire municipality because it is the only CAPS that is specific for mental disorders. Its employees are psychologists, doctors, nurses, nursing technicians, social workers, physical educators, crafts instructors, one administrative technician, one cook, and one security guard. The activities proposed in this service are groups, therapeutic workshops, conviviality groups, attention to situations of crises, and monitoring of users in psychological suffering. The PET-RAPS was included in the CAPS for two years, with the objective of integrating the service into the teaching and the community.

Overall, 8 professionals with the CAPS II agreed to participate in this study. All the employees who had been working in the service for, at least, 3 months, were invited to participate in the study, and this period was established taking into account the beginning of the PET-RAPS' activities in the CAPS. Workers who were on holidays and/or sick/maternity leave during data collection were excluded from the study.

We requested authorization to conduct this study from the Municipal Health Department. Subsequently, the project was submitted to the Research Ethics Committee of Hospital Universitario Julio Muller (HUJM--Julio Muller University Hospital) of Universidade Federal de Mato Crosso (Federal University of Mato Grosso). Data collection began only after the project had been approved (Protocol no. 683, 338).

Data were collected by means of semi-structured interviews, which were performed from January 17 to January 22, 2014. The central aspect of the interviews' guiding instrument was the obtention of information about the contributions of the PET-RAPS to the professionals' knowledge, to the care practice, and to users and families. The interviews approached the activities the students developed together with the multiprofessional team, the recognition of the difference produced by the students' inclusion in the service, and the bonds that were established.

Thematic analysis was employed as the data analysis technique. It is divided into three stages: 1) pre-analysis and free-floating reading of the transcriptions of the interviews, which was obtained through the careful reading of the collected material; 2) identification of the text's nuclei of understanding, and 3) identification of the themes that, subsequently, originated the categories. Finally, the data were treated and the findings were interpreted and related to the scientific productions analogous to the theme (14).

The interviews were recorded only after the interviewee's permission, upon the signature of a consent document, in conformity with Resolution no. 466/2012. They were transcribed in full and, subsequently, analyzed. With the objective of preserving participant anonymity, they were identified as E1, E2, E3 up to E8 in their speech fragments.

Results and Discussion

Based on the 8 interviews that were performed, it was possible to identify some contributions of the PET-RAPS. They composed two categories: 1) Inclusion of family members as a comprehensive care strategy in the CAPS: contributions from the PET-RAPS; 2) The PET-Redes as a promoter of improvements in care by means of professional development and education targeted at the SUS.

Inclusion of family members as a comprehensive care strategy in the CAPS: contributions from the PET-RAPS

The inclusion of students in the reality of the CAPS revealed the low participation of families in the care provided for individuals in psychological suffering. The students invested in strategies that enabled and stimulated the families' participation in the care provided for their members, as shown by some reports.

Now we're able to bring more families into the CAPS (E3).

Before, we didn't know how to do it. Today, when the patient's relative arrives here, we try to receive them well (E5).

The family has a large influence on the user's life and including it in the assistance is one of the challenges of the work developed at the CAPS. A study carried out in a city located in the Northeast of Brazil has shown that one of the difficulties that exist in providing care for the individual in psychological suffering is obtaining the family's collaboration in this process (15).

However, this role must not be played just by the family. It is relevant to point to the need of establishing co-accountability among health workers, user, services and family (16,17) in order to enhance users' capacity to face the problems that emerge in their daily routine, with the aim of reintegrating them into society, which consequently reduces the deleterious effects caused by psychological suffering (16).

In view of this context and by means of the partnership established between the CAPS professionals and the PET-RAPS students, the therapeutic group was created, with the families' participation and with the objective of involving them in the planning of the care provided for their relatives in psychological suffering. However, this group was also configured as a space for supporting the families, which is shown by the reports.

Today, the families come to the service more frequently to obtain information on the treatment [...] The family group was created, and there were some interventions in the users' individual therapeutic project that involved the families (E1).

Now it's possible to perceive when they (families) are also exhausted [...] and need support (E7).

When a member of the family displays some kind of suffering, either physical or psychological, the entire family context is affected, a fact that occurs because the family is a constituent of the subject's life. Thus, the experiences caused by any type of psychological suffering start to influence the relatives' life, too (18).

One of the roles of the family regarding the care provided for its member in psychological suffering consists of helping him to establish bonds and reconstruct values and expectations. When the family is included in the planning of care at the CAPS, it is incorporated into the users' therapeutic project (11), and this enables to provide care for the family itself, too (18). Thus, care is not directed only at the person in psychological suffering, but also at his social nucleus. This can have a great influence on the recovery process of the CAPS user.

It is believed that the CAPS is responsible for providing guidance and receiving the family, in order to establish a care relationship also with these subjects, listening to their sensations and tackling not only the issues connected with the user of the health service, but also those related to their caregivers (17-19). Many of them report the feeling of loss of their habitual routine and of the practice of social activities because of the care required by the individual in psychological suffering (20).

This proposition is analogous to the principles of the SUS, mainly integrality, which consists of healthcare centered on viewing the subject in an integral way, that is, viewing the subject as an individual who is included in a physical space and in a psychosocial and political context--not just the carrier of a "disease" or of signs and symptoms. Therefore, we assume that not only individuals in psychological suffering should be approached in this way, but all the Brazilian citizens who, in some way or other, use the SUS.

The PET-Redes as a promoter of improvements in care by means of professional development and education targeted at the SUS

In addition to enabling the amplification of healthcare, the PET-RAPS has enabled the professionals of this CAPS to improve their practices in view of the weaknesses that emerged and were experienced in the assistance provided on a daily basis. Therefore, the students' presence in the health service enhanced the professionals' development concerning the provision of mental healthcare.

It is possible to observe, through the reports, that the students' action triggered changes, contributing to professional development and enabling the review of the dichotomy between theory and practice. Thus, they started to be seen as critical partners of the health service.

And with other people coming here, they have another view [...] outsiders bring a new view [...] They end up helping us to reflect [...] we've been recycling and studying a lot because the students ask questions [...] they (students) stimulate us (E3).

They (students) help us with the theory and we help them (students) showing our practice [...] it's an exchange, you know? (E2).

Because these are things that we learn in the university ... in qualification courses, but then, in the daily routine, you end up not giving much importance to them. Then the PET helps us to revisit [...] because we end up forgetting things (E7).

The student, in the daily routine of the health services, acts as a Continuing Health Education device, that is, he triggers a learning process based on the context and experiences offered by the health work, aiming at collective analysis and reflection (21).

The point of departure is the unpredictability that exists in the daily routine of the health services, which is hard to be solved by means of isolated educational initiatives that follow a pre-determined and formal logic. The process of providing healthcare is based on the interaction that happens when the professional meets demands that are plural (when they refer to health territories), but are also singular (when they refer to individual care) and extremely complex to be solved by means of courses or workshops (22).

These students who generated transformations were encouraged, through the articulation with their teachers and preceptors/health professionals, and based on a need pointed by the team, to request the guarantee of fortnightly meetings with the CAPS workers. The aim was the establishment of a formal moment in which the professionals can revisit their reflections, discuss them, and share them in the team, making a critical analysis of their own practice and of the work process in the CAPS. Some reports mention these contributions:

(The meeting) ... is being very interesting and very rich, and it has been approaching what we experience during our daily routine ... our difficulties (El).

I believe so ... it worked for me because...I'm an administrative employee, I don't participate in groups with users and I also don't receive them, but it has really improved my approach to the user [...] I'm able to use what we talked about (in the meetings) in my administrative activities (E4).

I've learned how to assist the patient, the meaning of receiving patients [...] everything was informed by them (students) in detail (E5).

Thus, the data showed the students' contribution as catalysts for the development process of the professionals who work in the service that was analyzed in the study. It is important to remember that the majority of these professionals had a traditional, banking education, decontextualized from the reality of the SUS.

The teaching that is currently offered in undergraduate courses in the area of health and the present form of the curricular structures of the majority of these courses are insufficient to provide the contextualized knowledge--mainly the practical knowledge--that is necessary for professional exercise (8,23). With this type of education, which does not problematize and is not capable of placing the subject as the protagonist of the construction of his own knowledge, he may not search for new knowledge in the future, being content only with his initial education.

Some studies have shown the inconsistent education of nurses and doctors with regard to mental health. This fact increases the difficulty in effectively implementing the principles of the Psychiatric Reform in the daily routine of the services, as this also depends on the extent to which students have appropriated this knowledge (24,25).

The PET-RAPS experience sheds light on this project's potential for enabling learning based on context, that is, on the reality and needs of the public health services. The students become part of the team, developing their activities, giving opinions and helping to provide care for the unit's users. This is shown by the reports below.

When I was at university, we didn't have the opportunity of visiting healthcare units. We learned everything and afterwards we started working [...] it was very hard because we didn't really know the work (E1).

There are students from many courses in the PET, and each one gives his contribution, in the areas of nutrition, psychology, social work, nursing ... each one brings a contribution [...] and we help them, too (E2).

They (students) have the opportunity of working before they become professionals [...] they are able to see if they really like it or not and we support them, right? (E5).

The students and future professionals are included in the health services early in their trajectory and they are gradually integrated into the work. This allows them to develop diverse activities that provide them with real experiences and amplify their critical view of the care practice, making them experience the concrete reality of the SUS (4). Furthermore, they are responsible for triggering processes that are extremely relevant to the occurrence of exchanges, interaction and communication, awakening the professional to the importance of teamwork (18,26).

The students' presence in the CAPS has enabled to effectively articulate teaching with the municipal health service. This fact has guaranteed the exercise of reciprocity concerning professional development and the education of students in the area of health. It has been verified that both actions have been happening dialogically, that is, at the same time that they have caused the development of the health professionals, they have also provided the contextualized education of the students from the diverse courses involved in the PET-RAPS, making them head towards an emancipatory learning that problematizes reality (23).

Final Remarks

So that the psychosocial care model can replace the psychiatric medical model, the professional must have the opportunity to reflect on the object, instrument and purpose of his working process, providing care for users in psychological suffering within their context and giving them possibilities of social reintegration and autonomy construction.

In this sense, it is verified that the PET-RAPS has amplified the professionals' view in mental healthcare. It has brought the family to participate in and reflect on the users' singular therapeutic project; furthermore, it provides healthcare for the relatives who play the role of caregivers at home.

Another contribution that was identified by means of the activities developed by the PET-RAPS is the opportunity offered to the health professionals of CAPS to reflect on their work. This was enabled by the inclusion of students in the service, which strengthened the integration of teaching into the local health service.

The experiences apprehended by means of the students' contact with the health service have enabled a reciprocal education process that develops in a coherent, contextualized, critical and reflective way, affecting students and health professionals. Therefore, it is important to highlight that the activities developed by the students connected with the PET-RAPS have been favoring the effectiveness of this process.

Thus, this study sheds light on the need for the early inclusion of students in the public health services, in favor of contextualized learning. The current university health courses have the weakness of not focusing properly on the PET-RAPS as a potentializer of the psychosocial care network.

Therefore, we point to the need of further research that is able to portray potentialities and limits of a contextualized and emancipatory education that problematizes reality. We believe that the scientific community is the great promoter of structural changes in academia, which is still strongly linked to traditional teaching-learning strategies.

DOI: 10.1590/1807-57622016.0109

Acknowledgements

To CNPq, process no. 306190/2014-1, and FAPEMAT--Fundacao de Amparo a Pesquisa do Estado de Mato Grosso, public notice no. 004/2015--Doctorate outside the state, for the financial support.

Collaborators

All the authors participated actively in the discussion of the results and in the revision and approval of the final version of the article.

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Translated by Carolina Ventura

Larissa de Almeida Rezio (a)

Daniele Aparecida Fernandes Caetano (b)

Flavio Adriano Borges (c)

Cinira Magali Fortuna (d)

(a) Faculdade de Enfermagem, Universidade Federal do Mato Grosso. Av. Fernando Correa da Costa, no. 2367, Bairro Boa Esperanca. Cuiaba, MT, Brasil. 78060-900. larissarezio@usp.br

(b) Secretaria Municipal de Saude de Campo Verde. Campo Verde, MT, Brasil. daniafc1 8@gmail.com

(c) Programa de Pos-Graduacao em Enfermagem em Saude Publica, Escola de Enfermagem de Ribeirao Preto, Universidade de Sao Paulo (EE/USP). Ribeirao Preto, SP, Brasil. flavioborges@usp.br (d) Departamento Materno-Infantil (e) Saude Publica, EE/USP. Ribeirao Preto, SP, Brasil. fortuna@eerp.usp.br
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Author:Rezio, Larissa de Almeida; Caetano, Daniele Aparecida Fernandes; Borges, Flavio Adriano; Fortuna, Ci
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Date:Jan 1, 2017
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