ENFERMEIROS DE SERVIÇOS DE URGÊNCIA E EMERGÊNCIA PSIQUIÁTRICA: ANÁLISE DE PERFIL PROFISSIONAL E EDUCACIONAL PSYCHIATRIC URGENCY AND EMERGENCY CARE NURSES: AN ANALYSIS OF THEIR PROFESSIONAL AND EDUCATIONAL PROFILE

The present study characterized the professional and educational profile of nurses working at psychiatric urgency and emergency services, identifying its association with clinical practice. A cross-sectional study was carried out with 184 nurses in 17 psychiatric urgency and emergency healthcare services in the state of São Paulo from February to October 2012. A significant association was found between the profile of nurses and clinical practice in psychiatric urgency and emergency care, and the greatest predictors of this association were: male gender (OR=9.05), length of time in the profession longer than 10 years (OR=2.67), and having graduated at public educational institutions (OR=2.14). The prevalence of male nurses in psychiatric urgency and emergency care services suggests the perpetuation of the model based on physical strength. Professional experience and increased workload during undergraduate studies are factors that may lead to a better clinical practice in psychiatric emergency services. DESCRIPTORS: Psychiatric Nursing; Psychiatry; Professional Practice; Nursing Care; Psychiatric Emergency Services. Autor Correspondente: Recebido: 16/02/2017 Talita Dutra Ponce Finalizado: 18/10/2017 Universidade de São Paulo Av. Dr. Enéas de Carvalho Aguiar, 419 05403-000 São Paulo, SP, Brasil E-mail: talitadp@usp.br http://dx.doi.org/10.5380/ce.v22i4.50704 Artigo original 1Enfermeiro. Doutor em Ciências. Docente de Enfermagem da Universidade de São Paulo. São Paulo, SP, Brasil. 2Enfermeira. Doutora em Ciências. Docente de Enfermagem da Universidade de São Paulo. São Paulo, SP, Brasil. 3Enfermeira. Doutoranda em Enfermagem. Universidade de São Paulo. São Paulo, SP, Brasil. 4Discente de Enfermagem. Universidade de São Paulo. São Paulo, SP, Brasil. Cogitare Enferm. (22)4: e50704, 2017 ENFERMEROS DE SERVICIOS DE URGENCIA Y EMERGENCIA PSIQUIÁTRICA: ANÁLISIS DE PERFIL PROFESIONAL Y EDUCACIONAL RESUMEN: El estudio caracterizó el perfil profesional y educacional de enfermeros de urgencia y emergencia psiquiátrica, identificando su asociación con la práctica clínica. Estudio transversal realizado con 184 enfermeros en 17 servicios de atención de urgencias y emergencias psiquiátricas del estado de São Paulo, entre febrero y octubre de 2012. Se evidenció asociación significativa entre el perfil de los enfermeros y la práctica clínica en atención de urgencias y emergencias psiquiátricas, los mayores predictores de esta asociación fueron: sexo masculino (OR=9,05), tiempo desde graduación superior a 10 años (OR=2,67) y ser egresado de instituciones públicas de enseñanza (OR=2,14). Los enfermeros de sexo masculino continúan constituyendo la primera línea de atención en urgencias y emergencias psiquiátricas, sugiriendo la continuidad del modelo basado en la fuerza física. La experiencia profesional y mayor carga horaria durante el curso de grado son factores que pueden constituirse en mejor práctica clínica en emergencias psiquiátricas. DESCRIPTORES: Enfermería Psiquiátrica; Psiquiatría; Práctica Profesional; Atención de Enfermería; Servicios de Urgencia Psiquiátrica. Divane de Vargas1, Janaina Soares2, Talita Dutra Ponce3, Bruna Batista de Oliveira4


INTRODUCTION
The term psychiatric emergency may be defined as an acute behavioral, mental, or mood disorder in patients that may cause harm both to themselves and third parties unless it is treated.It may be considered more serious when it involved an imminent life risk, such as suicide attempts (1) .Psychiatric urgency and emergency situations are common in psychiatry specialized care and general emergency care services, being conditions that demand immediate measures during care in order to prevent severe outcomes (2) .
In the United States, the prevalence of severe mental disorders in the overall population is estimated at 4.2% (3) .In Brazil, high rates of mental disorders (from 20% to 56%) were found in the adult population, especially in specific groups, such as women and workers (4) .
High rates of mental disorders are supposed to lead to high rates of psychiatric urgency and emergency care.Nurses and their teams are often the professionals who have the first contact with patients in these conditions, demanding their immediate intervention along with the multidisciplinary team, in order to prevent further damage to the patients' health and eliminate possible risks to their lives or third parties (5) .
In spite of the importance of providing appropriate care for patients in psychiatric urgency and emergency conditions, studies have shown that nursing teams face communication difficulties, lack of knowledge and experience in the area, in addition to, in the case of nurses, overload of activities (6)(7) .These factors, associated with poor physical infrastructure, lack of human resources (8) , and stigma and prejudice in the face of these conditions (9) , are limitations to providing appropriate nursing care for patients.
There are few studies available in Brazil on this phenomenon (10)(11) .Despite contributing to discussions, they are limited to some regions of the country and intended to build up the profile of workers of urgency and emergency general services and those of psychiatric nature.Therefore, identifying the profile of nurses who work in psychiatric urgency and emergency services is of utmost importance for the psychiatric nursing area.In addition to providing a diagnosis of the situation, it may contribute to the development of education and training strategies, since these aspects impact on nursing care for patients in situation of psychiatric urgency and emergency, which, when provided with safety, immediacy, and quality, is able to establish the acceptance and adherence of patients to the treatment of these conditions (12) .
Considering that the lack of knowledge and experience in the psychiatric nursing area are limiting factors for the practice of nurses in this specialty's urgency and emergency services (6,8) , the objective of the present study was to characterize the sociodemographic, professional, and educational profile of nurses who work in psychiatric urgency and emergency care services, identifying their association with clinical practice.This was a cross-sectional study carried out between February and October 2012 in 17 referenced public services that provide psychiatric urgency and emergency care in the city of São Paulo, which were operating during data collection.
A questionnaire was used for data collection, which contained questions on sociodemographic characteristics (gender, marital status, and age), professional characteristics (workplace, length of time in the profession, work shift, and clinical practice in psychiatric urgency and emergency care -clinical practice was considered as the experience and frequency of care provided in psychiatric urgency and emergency situations in the professional practice of the participants interviewed), and educational characteristics (nature of the institution of graduation, having a lato/stricto sensu graduate degree, graduate degree area, training during undergraduate studies to work in psychiatric urgency and emergency care, and type of training received).
A total of 184 nurses from 17 referenced public healthcare services that provided psychiatric urgency and emergency care in the city of São Paulo at the time of data collection and who affirmatively responded to the initial question "Do you deal with psychiatric urgency and emergency conditions at your workplace?"were included in the sample.Nurses who negatively responded to the initial question (n=53) and those who were on vacation or any kind of leave during data collection were excluded.
In order to enable the representative participation of nurses from the three work shifts and the main regions in the city, the data were collected in the morning, afternoon, and at night, and in referenced services of the southern, central, eastern, western, and northern regions of the city.With the purpose of interfering the least with the professionals' work routine, the data collection instruments were always distributed at the end of each shift, with their return after being filled in within 24 and 48 hours.The participants were asked not to identify themselves in the instruments.
The data were submitted to descriptive analysis, and presented in absolute numbers and percentages, as well as means of the continuous variables.A logistic regression analysis was used to verify the association between the workers' profile and clinical practice in psychiatric urgency and emergency situations.Initially, the data were submitted to the univariate logistic regression, in order to identify the variables that significantly influenced clinical practice, as measures to estimate the odds ratio (OR) with a 95% confidence interval.
All variables that presented values of p≤0.20 (gender, marital status, age, workplace, length of time in the profession, work shift, institution of graduation, institution of the graduate degree, type of graduate degree, graduate degree area, training during undergraduate studies to work in psychiatric emergencies, and type of training received) were introduced step by step in the multiple logistic regression model.In this stage, values of p≤0.05 were considered significant.All analyses were carried out with the use of the Statistical Package for the Social Sciences 22 (SPSS).
The present study was approved by the human research ethics committee of the Municipal Health Secretariat of the city of São Paulo, under protocol no.029/12.

RESULTS
The nurses who work in psychiatric urgency and emergency care were characterized for being women (n=140/76.1%),single (n=78/42.4%),with a mean age of 36.6 years.Regarding professional characteristics, the participants interviewed presented length of time in the profession from six to 10 years (n=61/33.2%),63 (34.2%) reported having a 12-hour working day (fulltime shift), 70 (38%) worked in psychiatric hospitalization units in general hospitals, 61 (33.2%) worked in psychiatric hospitals, and 53 (28.8%) worked in psychiatric urgency and emergency services in general hospitals.All these services provided psychiatric urgency and emergency care in their routine operation.
With regard to educational profile, nurses who had a graduate degree and who graduated in private educational institutions were the majority, totaling 138 (75%) and 126 (68.5%) of the sample, respectively.The most common graduate degree area among nurses was specialization in medical-surgical nursing (n=42/22.8%),followed by psychiatric nursing (n=35/19).Nurses reported having received training in the psychiatric urgency and emergency care area during their undergraduate nursing degree (n=107/58.2%),and this training was provided by means of lectures (n=80/43.5%).
A significant percentage of the nurses invited to participate in the study (n=53/22%) reported not having experience in psychiatric urgency and emergency care.Therefore, according to the suppositions of the present study, they denied having clinical practice in psychiatric urgency and emergency care (Table 1).The variables that presented statistical significance in the univariate analysis were included in the model, as follows: gender, workplace, graduate area, length of time in the profession, and institution of graduation, which were associated with clinical practice, as presented in Table 2.The results of this analysis show that the greatest predictors of this association were: being men (OR=9.05),with length of time in the profession between 11 and 20 years (OR=2.67),and with graduation in public educational institutions (OR=2.14).Still regarding length of time in the profession, the present study found a statistically significant association between length of time in the profession and frequency of care provided in psychiatric urgency and emergency (p=0.04).Nurses with length of time of experience between 21 and 26 years (n=14/80%) reported dealing daily with these conditions.This percentage dropped to n=14/46.7% for those with less than five years of experience.

DISCUSSION
The nurses who work in psychiatric urgency and emergency care services in the city of São Paulo are mostly women, young adults, single, and with length of time in the profession from 11 to 20 years.This result agrees with the profile of Brazilian nurses (13) , which describes that about 90% of the nurses are women and that nursing is one of the ten professions of the healthcare area that contributes to the feminization of the workforce in the health sector in the country.In addition, the fact that most professionals are single may be related to the fact that they are mostly young adults under the age of 39.
Regarding educational characteristics, 68.5% of the professionals interviewed came from private educational institutions, which is a reflection of the undergraduate nursing education supply in the country, in which 87.4% of the institutions are private (14) .Most nurses had a graduate degree in nursing knowledge areas other than those related to psychiatric nursing.This result draws attention, especially because there is deprivation of knowledge in this area, when compared to others, in the curriculum of nurses during their undergraduate degree (15) .Consequently, a graduate degree in the area contributes more effectively to the professionals' preparation to work in this specialty, including in urgency and emergency care (16) .
The fact of nurses not choosing a graduate degree in psychiatry, despite working in referenced psychiatric urgency and emergency services, may be associated with the stigma and prejudice regarding patients with mental disorders, and perhaps, this fact is associated with the lack of specialization courses in psychiatric nursing in some regions of Brazil (16) .The stigma also influences the choice of the graduate area, leading professionals to choose other areas of knowledge other than specialization in psychiatry, even though this is currently an expanding labor market for the nursing area.
The nurses in this study (58.3%) reported having received training in the psychiatric urgency and emergency care area during their undergraduate studies.In spite of criticisms regarding the amount and quality of specific knowledge offered in psychiatric nursing (15), this aspect must be considered positive and was due to changes carried out in the curricula of undergraduate health courses of public and private institutions.These changes are based on the Brazilian II National Mental Health Conference (17) , which pointed out the need for healthcare educational institutions to introduce mental health themes in the curricula, as well as promote the compulsory requirement of academic internships in public and private healthcare nets.
The present study showed that male professionals have nine times more chances of performing clinical practice in psychiatric urgency and emergency care than female professionals.This fact suggests that, although nursing is mostly made up of female professionals, psychiatric urgency and emergency services are, in general, workplaces where there are male nurses, and the prevalence of men in these spaces may be associated with characteristics of the care provided, which demand a greater physical effort for its undertaking (18) .
With regard to this result, the use of physical strength, which is associated with the male gender, seems to be necessary for the care provided to psychiatric patients.However, the exclusive use of strength in psychiatric urgency and emergency care makes room for other questions, because this approach should only be used in physical or mechanical restraint and cases of last resort, after the use of techniques such as verbal approach or chemical restraint (19) , which certainly do not require physical strength, but knowledge and specialized technical training instead.Even in these techniques, in which the use of physical strength is supposed to be a prerogative for its undertaking, there are no impediments so that it is undertaken by female nurses, when they are provided of appropriate preparation (20) .
Nurses with length of time in the profession between 11 and 20 years presented twice more chances of confirming their clinical practice in psychiatric urgency and emergency cases than nurses with less than 10 years of professional experience.This fact may be associated with the lack of experience of nurses with lesser length of service, which may result in difficulties in the identification of psychiatric urgency and emergency conditions.This hypothesis seems to be supported by the results of the present study, which showed that nurses with length of time in the profession longer than 20 years were also those who reported more frequency of daily care of psychiatric urgency and emergency cases, whereas nurses with less than five years in the profession identified daily care with lesser frequency, despite working in the same place as nurses with longer length of professional experience.Therefore, these results may be associated with the lack of skills of nurses with less experience and without appropriate training in the identification of these conditions, despite dealing with them often.
Consistent with this result, it is also worth mentioning the fact that more than 20% of the nurses invited to participate in this study denied having provided care in psychiatric urgency and emergency situations, despite working in referenced care services for these conditions, which implies the possibility that, even when involved in the care of these situations, these nurses do not characterize them as such.
The difficulty in the identification of psychiatric urgency and emergency situations by nurses must be considered, since their non-identification may result in inappropriate care.One of the causes for this phenomenon may be the lack of preparation to recognize these situations, leading nurses to deny this experience even when involved in it.
In this context, it is necessary to think about continuing education strategies for these nurses, because nurses benefit from updates on mental health and psychiatry services (21) , which allows to suggest that these update strategies are focused on nurses with short time of professional experience in psychiatric urgency and emergency care.
The results of the present study showed that nurses graduated in public educational institutions have twice more chances of reporting clinical practice in psychiatric urgency and emergency situations than nurses who graduated in other types of institutions.This fact may be associated with the amount and quality of education that has been developed in public institutions, which, in general, offer a longer course load, including practical training, when compared to private institutions (22) , meeting training requirements with the necessary skills for nurses to work in nursing psychiatric and psychosocial care areas (23) .This may contribute to a higher perception of nurses on psychiatric urgency and emergency situations.
Nurses who work in public services have more clinical practice than those who work in psychiatric urgency and emergency care in psychiatric hospitals and psychiatric units in general hospitals.This is related to the purpose of these spaces, which justifies the greater contact and clinical practical of nurses who work there, thus providing them with greater experience in this care and facilitating the identification of these conditions.The high prevalence of psychiatric urgency and emergency situations in these services may be associated with the insufficiency/inefficiency of the mental healthcare network of the city, where extra-hospital services do not meet the existing demand, which ends up concentrated in emergencies, often needlessly (24) .
Reinforcing the importance of the training in the area to work in psychiatric urgency and emergency services, the present study found a statistically significant association between clinical practice and having a graduate degree in psychiatry, that is, having attended this specialization was a predictor of clinical practice in psychiatric urgency and emergency situations.Consistent with this result, a previous study (25) carried out in an urgency and emergency service showed that the quality of diagnoses of psychiatric nurses was appropriate in 92% of the cases, when compared to those without training in the area.In addition, a greater relevance of the referral carried out by these specialists was observed, reflecting in the improvement of patient satisfaction with the nursing care.Therefore, the present study reinforces the importance of specialized training in mental health and psychiatry for nurses who work in urgency and emergency services of this area.
In spite of the importance of the results brought by the present study and its advances for the knowledge area, it presents limitations, such as the fact that its sample is made up of nurses who, even though belonging to the greatest city in Brazil, certainly does not represent the diversity that can be found in the country.A comparison was not carried out between the knowledge of nurses of urgency and emergency hospitalization services, who are specialists in psychiatric nursing, and nurses without this specialization or who are specialists in other areas of knowledge, which could contribute to verify, with a higher reliability, whether specialized training influences in the preparation of these professionals for the care of psychiatric urgency and emergency situations.
Another factor that may be pointed out as a limitation of this study was the characteristics of the instrument used, which did not enable a greater detailing of the information provided; for example, it was not possible to precisely identify the course load in mental health and psychiatry classes reported by these nurses during their nursing undergraduate studies.

CONCLUSION
The prevalence of male nurses in clinical practice in psychiatric urgency and emergency care suggests the perpetuation of a model of care based on physical strength, in spite of changes in the healthcare setting in recent years and the evolution of nursing technologies for intervention in these situations.
The present study contributed to recognize the profile of nurses who work in psychiatric urgency and emergency services, enabling the mapping of current educational and professional status of this area.It also contributed to recognize the importance of specialized technical training in this area to work in these services, because even though the experience acquired in the work can assure some preparation, a specialization degree seems to be a decisive factor not only for acquiring greater skills, but also for identification and better performance in the care for these conditions.
Questions with regard to undergraduate education strategies in the mental health and psychiatry areas emerged, suggesting the need for further studies addressing this question.The present study also suggests that education strategies and updates in the mental health and psychiatry areas should be carried out in these services, especially targeting nurses at the beginning of their careers or with less professional experience.

Table 1 -
Description of responses regarding clinical practice (experience and frequency of care provided in psychiatric urgency and emergency) of the participants in the study (N=184).São Paulo, São Paulo, Brazil, 2017In the univariate logistic regression, there was no association between clinical practice (experience and frequency of care provided in psychiatric urgency and emergency) and the variables: marital status (p=0.47),age(p=1.19),work shift (p=0.50),graduate degree (p=0.38),type of graduate degree (p=1), training during undergraduate studies to work in psychiatric emergencies (p=0.3), and type of training received to work in psychiatric urgency and emergency care during undergraduate studies (p=0.34).

Table 2 -
Relationship between clinical practice (experience and frequency of care provided in psychiatric urgency and emergency) and the variables that presented statistical significance in the univariate analysis (N=184).São Paulo, São Paulo, Brazil, 2017