Nursing students and their perspective about mental health formation: an integrative review

Objective: to identify, in literature, the perception of students with regard to mental health education in Brazilian nursing graduation. Methodology: this is an integrative review of literature, carried out in the databases Latin American and Caribbean Health Sciences Literature, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Web of Science, in the months of July and August, 2020, using two research strategies and descriptors in Portuguese and English. The study selection was carried out by two reviewers, and systematized using the PRISMA flowchart, with the aid of the Rayyan software, and applying content analysis to extract the themes. Results: the final sample of this review included ten articles, which were categorized and presented in tables. After the studies were analyzed, two thematic axes were found: 1) aspects that favor education in mental health, with three subthemes; and 2) aspects that undermine education in mental health, with six sub-themes. Conclusion: although some factors enable a better education in mental health, such as active methodologies and internships, other aspects undermine it, such as the limited preparation of the professors, the insufficient hour load, and the superficial content. Descriptors: Students, Nursing. Education, Nursing. Mental health. Psychiatric Nursing. RESUMO Objetivo: identificar na literatura a percepção dos estudantes a respeito da formação em saúde mental na graduação em enfermagem no Brasil. Metodologia: trata-se de uma revisão integrativa da literatura, realizada nas bases de dados Literatura Latino-americana e do Caribe em Ciências da Saúde, Cumulative Index to Nursing and Allied Health Literature, Scopus e Web of Science, nos meses de julho e agosto de 2020, através de duas estratégias de busca, utilizando descritores em português e inglês. A seleção de estudos foi por dois revisores e sistematizada a partir do fluxograma PRISMA, com auxílio do software Rayyan, e aplicada análise de conteúdo para extração dos temas. Resultados: a amostra final desta revisão foi de dez artigos, categorizados e apresentados em tabela. Após as análises dos estudos, foram encontrados dois eixos temáticos: 1) aspectos que favorecem a formação em saúde mental, com três subtemas; e 2) aspectos que fragilizam a formação em saúde mental, com seis subtemas. Conclusão: embora alguns fatores permitam melhor formação em saúde mental, como as metodologias ativas e estágios, outros aspectos fragilizam, a exemplo da pouca preparação dos docentes, carga horária insuficiente e conteúdos superficiais. Descritores: Estudantes de enfermagem. Educação em enfermagem. Saúde mental. Enfermagem psiquiátrica. RESUMÉN Objetivo: identificar en la literatura la percepción de los estudiantes sobre la educación en salud mental en la graduación de enfermería en Brasil. Metodología: revisión bibliográfica integradora, realizada en las bases de datos de Literatura Latino-americana e do Caribe em Ciências da Saúde, Cumulative Index to Nursing and Allied Health Literature, Scopus e Web of Science, entre julio y agosto de 2020, a través de dos estrategias de búsqueda, utilizando descriptores en portugués e inglés. La selección de estudios fue realizada por dos revisores y sistematizada mediante el diagrama de flujo PRISMA, con la ayuda del software Rayyan; se aplicó el análisis de contenido para extraer los temas. Resultados: la muestra final resultó en diez artículos, categorizados y presentados en una tabla. Tras el análisis de los estudios, se encontraron dos ejes temáticos: 1) aspectos que favorecen la formación en salud mental, con tres subtemas; y 2) aspectos de fragilidad en la educación en salud mental, con seis subtemas. Conclusión: a pesar de las metodologías activas y las pasantías, aún persisten problemas en la oferta de disciplinas que comprometen la enseñanza, como la falta de preparación de los docentes, la carga de trabajo insuficiente y los contenidos superficiales. Descriptores: Estudiantes de Enfermería. Educación en Enfermería. Salud Mental. Enfermería Psiquiátrica. ISSN: 2238-7234 Silva JVS, et al. Nursing students and their.. 2 English Rev Enferm UFPI. 2021 10:e806. DOI: 1026694/reufpi.v10i1.806 INTRODUCTION The formation of the nursing student must be generalist and humanistic, with the development of critical and reflective thought for professional actions, qualified through scientific and intellectual rigor, based on ethical precepts. This formation must include aspects related to health care, considering the biopsychosociocultural determinants in the making of decisions related to the assistance and to direct and indirect care, in processes of health communication and interpersonal relations, in the leadership of health and nursing teams, in the administration and managing of health sectors and services, and in permanent education. The process of formation in health care, in turn, must aid the student in the development of competences and abilities related to the prevention of health problems, and in the promotion, protection, and recovery of the health of individuals, as well as that of their families and collectives. This must be integrated and present in all cycles and needs of life, which includes the health care of people who are suffering or have mental disorders.


INTRODUCTION
The formation of the nursing student must be generalist and humanistic, with the development of critical and reflective thought for professional actions, qualified through scientific and intellectual rigor, based on ethical precepts. This formation must include aspects related to health care, considering the biopsychosociocultural determinants in the making of decisions related to the assistance and to direct and indirect care, in processes of health communication and interpersonal relations, in the leadership of health and nursing teams, in the administration and managing of health sectors and services, and in permanent education. (1) The process of formation in health care, in turn, must aid the student in the development of competences and abilities related to the prevention of health problems, and in the promotion, protection, and recovery of the health of individuals, as well as that of their families and collectives. This must be integrated and present in all cycles and needs of life, which includes the health care of people who are suffering or have mental disorders. (1)(2) The competences and abilities developed in the process of mental health graduation aim to prepare the student to develop actions and activities related to the nurse, in the many strategic mental health services and in the services that make up the Psychosocial Attention Network (RAPS). This includes the reception and nursing consultation for individuals and families, home visits in the territory, therapeutic workshops and groups, the construction of Singular Therapeutic Projects (PTSs), health education actions, management and administration of sectors and services, among others. (2)(3) This training for the field of mental health in nursing graduation is mandatory, taking place through specific disciplines that are, generally, offered in one or two semesters during the course. Most of them are only theoretical, with little experience in the services, due to the restricted workload for practice. The disciplines have similar characteristics throughout the Brazilian territory. This similarity is related to the their structure and to its organization in the curricular standards for the course, but there are some particularities, considering regional specificities and the context in which the institutions are inserted. (4) Some studies (1)(2)(3)(4) show that the process of mental health education in nursing reflects the need to improve the professional practice of the nurse, with regard to people who are undergoing psychic suffering, especially in specialized services. Considering that the nursing professional is also responsible for therapeutic approaches, these studies show that the nurse needs to be better prepared to carry out this work, instead of just being concerned with clinical aspects.
Mental health teaching in nursing graduation must consider certain elements, such as the structure of the institution, the organization and planning of the discipline, the methodological strategies, contents and themes addressed, the teaching body, the practical fields, among others. All these components of the formation contribute for integral care and for the work in the mental health field. (5) Currently, the learning-teaching process revolves around the student, while the professor has the role of mediator or facilitator of this construction of knowledge for a certain field. The way in which students, who are the focus of teaching and professionalization, perceive the formation in mental health, is different from that of the other people who participate in this process, such as professors, course coordinators, institution managers, or professionals who supervise practice. (3,5) Understanding that the teaching-learning process, today, sees the student as the focus of the construction of their own knowledge, and considering current national curricular directives, which guide the formation of the nurse, it is important to unveil how the students perceive this process and see the methods and resources used for the teaching of mental health.
Considering the above, this review is justified by the need to survey and synthesize the literature on the organization, disciplines, and teaching in the Brazilian territory. It is necessary to understand and reflect on the organization of mental health disciplines in nursing graduation, in such a way that it is possible to visualize new pathways and directions to improve teaching.
As a result, the objective of this work is to identify, in literature, the perception of students with regard to the education in mental health of Brazilian nursing graduation.

METHODOLOGY
This is an integrative literature review, a type of study that aims to synthesize the existing knowledge about a theme or subject from a collection of studies. Its stages are: the elaboration of the guiding question, a survey of literature, data collection, a critical analysis of the studies found, discussion of results, and the final presentation of the integrative review. (6) To formulate the guiding question, the PICo strategy for non-clinical studies was used, in which "P" represents population/phenomenon, "I" represents "intervention/interest" and "Co" represents context/characteristic (6) . The following PICo strategy was used for this review: P -students; I -formation in mental health; Co -graduation in nursing in Brazil. As a result, the following research question was established: what does literature demonstrate about the perception of the students with regard to the education in mental health during nursing graduation in Brazil?
The search in literature took place from July to August 2020,  . Both strategies were used in the database, considering the specificity of each database when the strategy was elaborated and at the moment of the search.
The following inclusion criteria were adopted: studies carried out in Brazil; original articles, available in full; articles in Portuguese, English, or Spanish. The exclusion criteria adopted were: review studies that were not from the last 10 years, due to the changes in health and education policies; articles that did not answer to the research question of this review.
Using these strategies in the databases, 258 studies were found for the initial sample, which were exported for the Rayyan® software, for the selection of the sample. At first, duplicate studies were found and excluded (n=49). After duplicates were excluded, two reviewers read the titles and abstracts of the 209 studies left, independently, making their evaluations and applying the inclusion and exclusion criteria individually. On another stage, the two reviewers indicated the pre-selected articles, including 35 articles which were in accordance with the eligibility criteria for the reading of the entire text. On the third stage, both reviewers read the texts separately and independently, in full (n=35). With the aid of a third reviewer, they determined the final eligibility, leaving only ten articles to make up the final sample of this review. This review was systematized, according to the recommendations of the Preferred Reporting Items for Systematic Reviews and MetaAnalyses -PRISMA® (7) .
The complete process can be seen in the flowchart in Figure 1.  An instrument elaborated by the researchers, for the data collection of the articles, was used. It included year, authors, and title of the study, number of students who participated, method used, Brazilian region where the study was carried out, publication language, and country of publication. To explore and analyze the content of the articles and respond to the guiding question of this review, the content analysis (8) was used as a method to explore and organize data.
The analysis of the level of evidence of the study followed the parameters proposed by Melnyk and Fineout-Overholt (9) , which were determined as follows: I -systematic reviews and meta-analysis of multiple randomized/controlled clinical trials; IIcarrying out at least one randomized/controlled clinical trial; III -carrying out, at least, one noncontrolled/non-randomized trial; IV -cohort studies or control case studies; V -systematic review of descriptive or qualitative studies; VI -descriptive or qualitative studies; VII -reports elaborated by specialists or opinion/experience studies.
This review was systematized, and its results were organized and presented in the form of text and through figures and tables.

RESULTS
All studies analyzed in this review used a qualitative approach and were published in Brazilian journals. Seven of them were in Portuguese and English, while three were only in English. Concerning the geographic distribution of the studies, five were developed in the Southeast of the country, two in the Northeast, one in the North, one in the Midwest, and one in the South. Regarding the year of publication, nine studies were published from 2010 to 2015, and only one from 2016 to 2020. Characteristics such as year, authors, title, type of study, level of evidence, and sample can be seen in Table 1.
Starting with a content analysis, two thematic axes were found: 1) aspects that favor education in mental health; and 2) aspects that undermine education in mental health. In addition to the thematic axes, some subthemes were listed, which emerged during the analysis of the articles and were included in this review. They point at some aspects of the perception of the nursing students about the teaching of mental health. The description of these thematic axes and their subthemes can be seen in Table 2.

DISCUSSION
There are aspects that favor a better education in mental health, from the perspective of nursing students, and it is possible to identify some of them. The first is related to the methods that are used for teaching. The professors use, in the classroom, active teaching-learning methods, and students consider these better strategies to promote the construction of knowledge in the field of mental health, aiding in the assimilation of content. (11,(13)(14)(15)(16) There are many active methods that have been used in the process of teaching-learning mental health. Some of these methods, that appear in the article analysis of this review, include audiovisual resources (11,13,15,16) , textual resources (13,15,16) , seminars (15) , and dramatizations. (11,13) Active teaching learning methods are often used in health teaching because they allow students to take the main role and work more autonomously in the construction of their ow knowledge, using instruments, techniques, and strategies that allow critical thinking, self-evaluation, teamwork, decision making, leadership, among others. (20) The internships, practical activities, and field visits are also strategies that facilitate learning and witnessing the work of the nurse. (10)(11)(12)(13)(14)(15)(16)(17)(18)(19) Many services specialized in mental health are used for the education of the students, as is the case of the Psychosocial Attention Centers (10)(11)(12)(13)15,16) and the Psychiatric Hospitals (12,13,(15)(16)(17)(18) , in addition to primary health care services, as is the case of Primary Health Care Units. (14) Some international studies (2,5,20) showed that the practical teaching and the experiences in the specialized services are strategies that make it easier for the student to truly learn care practices and mental health work.
Internships and practical activities are often used as strategies for nursing formation and in the National Curricular Guidelines of the nursing course (DCN/ENF). (1) Although there are mandatory internships at the end of the course, the nurses can experiment practical moments in the theoretical disciplines, which aim to teach them about the routine, the work of the professional teams in the services, and the exercise of some techniques and professional activities. (3) From this practical experience, the professional competences and abilities of the nurse can be developed (10,(12)(13)(14)(15)(16)(17)(18)(19) . These are pointed out by this revision as another aspect that favors a better formation for mental health work. In the articles analyzed, the competences involved are embracing (10,13,17,19) , nursing consultations (14,18,19) , therapeutic communication (17)(18)(19) , qualified listening (17)(18)(19) , and therapeutic groups (10,(12)(13)(14)(15)(16)19) , such as the work of the nursing professional and in the interdisciplinary team.
Both national (3,22,23) and international (20,21,24) studies showed that the development of skills and competences in nursing, for the work in the field of health, have been the focus of the formation of the students, especially in the elaboration of the themes and activities of the disciplines, both for the development of actions and the specific activities of the nursing professional, and for the development of actions and activities specific to the nursing professional, in addition to those related to interdisciplinary work, which is the main feature of mental health work.
The professors, who are responsible for building theoretical-practical teaching strategies, should favor the preparation of the students for many different practices that will be carried out in the assistance of people with mental disorders, but, for that to happen, these professors must guide and facilitate this process with the student. (3,24) Regarding the aspects that undermine the education in mental health, the studies indicate the inadequate workload of the disciplines (10,(12)(13)(14)(15)17,19) . The disciplines have a very small hour load, and most of them take place within the classroom, with theoretical content. This insufficient hour load of the mental health disciplines limits the contents that are discussed in the classroom, making the themes addressed more superficial, since the time is not enough for them to be explored in-depth. (13)(14)(15) The insufficient workload of the mental health disciplines in the Brazilian nursing graduation has been pointed out by Vargas et al. (4) as something that can compromise the exploration of important themes and content for the education of the nurse. This leads to the finding that mental health disciplines have a low hour load, when compared to the other, being also mostly theoretical and, generally, taking place in a single moment during graduation. Similarly, Bocking et al. (5)  mental health, students have a worse active performance in specialized services for the assistance of people with mental disorders. The mental health discipline seems to be unconnected to the others in the curriculum (12,(14)(15)(16)(17) , which leads to a quite fragmented formation. An international study showed that students hardly ever find a relation between the content addressed in the mental health disciplines and the ones in the curriculum. (21) The structural organization of the mental health discipline, within the nursing curriculum, is an issue that can determine how students perceive their own formation and personal interest for the health care of the person with mental disorders, be it due to the lack of content or to the practice developed throughout their formation. (26) Furthermore, the little experience, the lack of preparation, and the presence of professors without the adequate formation to teach mental health can be considered factors that interfere in the effectiveness of the teaching process. However, these factors are complex, and are related to other issues, such as the lack of interest in the field, the lack of interest in teaching these classes, and the fact that the institution needs to have professors, and often resorts to those who are not experts in the field. Furthermore, the lack of opportunities in the job market and of better positions and salaries, among others, which drive the nurse to choose to work as professors. (26) The amount of practice and internships in the disciplines are considered insufficient by the studies (12,(14)(15)(16)(17)21) , and as a consequence, the students have little opportunity to practice therapeutic activities and develop professional abilities.
Practical mental health activities require structuring the disciplines and dealing with institutional issues, such as adequate work hours, the insufficient number of internship supervisors and professors to monitor the students, who, generally, are divided in smaller groups, thus needing more supervisors. The articulation with the health network, so these students can be received in the field, is also necessary. (3,27) Another issue that interferes in the practices is the mental health network instituted in the cities and regions. (22) Some regions of the country still have little to no specialized mental health services. The lack of structuring of the Psychosocial Health Care Network in the territory makes it more difficult to carry out some mental health practices, which require specific services and have a specific public. (27) It is also important to highlight that society in general stigmatizes the field of mental health and people in psychic suffering. This leads students to remain distant from the field and have little affinity with it, in addition to feeling fear and unsafe, which is also the manifestation of an established prejudice against people with mental disorders. This prejudice always leads to distancing and means that nursing students rarely attempt to become specialists in this field (20)(21)(22) . These findings enable a reflection about the organization of mental health disciplines in the nursing graduation from the perspective of the student, who is the protagonist in the teaching learning process. As a result, it becomes possible to visualize new pathways and directors to improve the teaching of mental health in nursing graduation.
Considering the above, some limitations of this review can be noted, such as the number of studies analyzed. Also, since this population is from parts of the Brazilian territory, it can differ from other countries.

CONCLUSION
This review found that the aspects that favor better mental health care in nursing graduation, from the perspective of students, are the use of active methodologies and practical activities, and of internships in mental health services. Aspects that can undermine the teaching process were also presented, such as: the low hour load of the disciplines; the insufficient number of internships, leading to little contact with the field; the content addressed superficially; and the little preparation and training of the professors.
Other studies are suggested that can present the way in which this process happens in other countries, thus broadening the discussion and the knowledge on the education in mental health, from the perspective of the nursing student.