Alcohol / drugs community mental health services : insertion and practices of nursing professionals

Objective: Verify the inclusion and practice of mid-level staff in nursing at aPsychosocial Care Center alcohol and drugs (CAPS ad) of São Paulo. Methods: A qualitative, exploratory study. Data were collected through semi-structured interviews in a sample of 16 mid-level nursing professionals. The interviews were taped, transcribed and analyzed in the theoretical light of the Brazilian Psychiatric Reform. Results: These professionals effectively take part in the activities of CAPS ad. Extra-functional activities are common practice. As factors that hinder its insertion, there was the little training to work with the users of these services. Conclusion: The mid-level nursing staff has contributed effectively to the consolidation of the Brazilian Psychiatric Reform. Identifying forms of work provides subsidies for a reflection on the possible strategies that aim to improve the professional practice in these scenarios, guiding future educational and training proposals for this profession.


INTRODUCTION
The results of the I and II Household Survey on psychotropic drugs use in Brazil, carried out in 2001 and 2005, respectively, show that the consumption of legal drugs in the country, especially alcohol and tobacco, is higher than that of illegal drugs 1,2 .Among the alcoholics, the addiction rate rose from 11.2% in the I Survey to 12.3% in the II Survey, while the percentage for smokers increased from 9% to 10.1% 1,2 .As regards illegal drugs, the results indicate an increase in the lifetime usage rate in the Brazilian population 1,2 .
In view of the data that demonstrate the increased use and dependence on psychoactive substances, it should be highlighted that, until the 1990's, Brazil had no specific care centers for these clients.In the Brazilian Psychiatric Reform, a new federal policy proposes the structuring of the CAPS -Psychosocial Care Centers, including theCAPS ad, community mental health services that function all over the country and are part of the primary care network for patients with problems deriving from psychoactive substance use and addiction 3 .
Among other aspects, this new policy establishes a minimal team to work with the users, comprising different health professionals, among which mid-level nursing professionals.This gives rise to a new activity area for these professionals, regulated by law 3 .Although mid-level nursing professionals are part of the CAPS ad team, the analysis of scientific production about the conceptions, attitudes, knowledge and practices of nursing technicians and nurses' aides in the field of alcohol and drugs reveals that the theme has aroused little interest among researchers, considering that, although scarce, most studies focus on baccalaureate nurses and nursing students 4 .A study of emergency care nursing professionals at public services observed that, despite the impact of alcohol on the morbidity and mortality of the population, these professionals still receive little or no information and training on matters related to alcohol use, and also relates the lack of knowledge with the factors that make the nurse rank the health problems related to this substance at a lower level on their list of priorities 5 .On the other hand, this study showed these workers' interest in learning matters related to alcohol abuse.Also, research in general prioritizes students and nursing professionals with higher education degrees, omitting mid-level professionals, which in this study showed the need for knowledge on chemical addiction 5 .
A study of baccalaureate nurses working at CAPS ad demonstrates difficulties to get inserted in care at these services, as their practices are more linked with the traditional mental health care model, also indicating a lack of preparation to work in the area, and the limited knowledge on contents related to chemical addiction which favor their insertion in these services 4 .
In view of the data, it is important to undertake studies which, like this one, are aimed at verifying the active area (insertion) and practices of the mid-level nursing team in CAPS ad, considering that, besides permitting the completion of a gap in the literature, of studies that intend to address the work of these professionals in the CAPS ad 4 , the main care scenario for chemical addiction after the approval of the Psychiatric Reform 6 ; by law 3 , the mid-level nursing professionals arepart of the staff at these services, and getting to know these professionals' insertion and practices will permit reflection about the work and effectiveness of these practices in these new mental health care context.

METHOD
An exploratory and qualitative study was undertaken to investigate the activity area and practices of the mid-level nursing team at 9 CAPS ad in the city of São Paulo.The research participants were 16 mid-level nursing professionals, including seven nursing technicians and nine nurse's aides who worked at the CAPS ad at the time of the data collection and who accepted to participate in the study.The sample was closed because of the theoretical saturation of the data, that is, the participation of new subjects was suspended when the data started to reveal a certain degree of redundancy or repetition 7 .The data were collected between October and December 2010.The interviews were held at the institution in a private location, guaranteeing a neutral and calm environment without interruptions.They were recorded and transcribed verbatim and took an average 30 minutes.To preserve the interviewees' identification, they were referred to in the study by the letter I, followed by the number of the interview.The data collection technique used was the semistructured interview, including two guiding questions: "What are your responsibilities here at the CAPS?Describe a typical workday here at the CAPS".To analyze the interviews, the Content Analysis strategy was chosen, which comprises the following steps: 1 -Pre-analysis; 2 -Exploration of the material and 3 -Treatment of the Obtained Results and Interpretation 8 .The data were analyzed according to the theoretical framework of the Psychiatric Reform, comprising four mutually articulated dimensions with feedback: the first dimension relates to the epistemological or theoretical-conceptual field, which represent the production of knowledge, the second is the technical-assistential dimension, which emerges in the care model; the third dimension relates to the legal-political field, which rediscusses and redefines the social and civil relations in terms of citizenship, human and social rights, and the fourth dimension is the sociocultural, which expresses the transformation of the social place of madness 9 .The interviews were intensively read to extract the themes that emerged from the interviewees' discourse and were related to the research objective.
This project received approval from the Ethics Committee for Research involving human being of the São Paulo Municipal Health Secretary under number 149/08.

Sociodemographic characteristics of the subjects
As regards the study subjects, 57.89% worked as nursing technicians, 79% of the sample was female and 50% in the Insertion and practice of nursing in CAPS ad Vargas D, Bittencourt MN, Rocha FM, Silva ACO age range between 31 and 39 years.What the educational background is concerned, 57.89% had studied at private schools.Concerning the length of these professionals' experience, 50% had worked between 1 year and 1 year and 5 months.Regarding the preparation to work with chemical addicts in their education, 52.63% of the interviewees referred they had not received this preparation.

The insertion and practices of the mid-level nursing team at the CAPS ad
Based on the obtained results, the data could be grouped in two analytic categories in the light of the theoretical framework: one related to these professionals' practices at the service, and the second to their insertion in the context of the CAPS ad, whose results are presented next.

Category I -The practices of nursing technicians and nurse's aides at the CAPS ad
The first category groups the different practices of mid-level nursing professionals at the CAPS ad where the data were collected.The analysis of this category originated two subcategories: a) technical practices and specific of the field; c) extra-functional practices.

Technical practices and specific of the field
This subcategory relates to the specific technical practices of technical nursing professionals.The discourse analysis revealed that these professionals execute activities related to their specific knowledge area, such as: administration and orientation regarding medication treatment, wound dressing and verification of vital signs.
"I have the nursing part, such as medication care, sometimes there are patients who need a drip, and who arrives in abstinence (...)" (I.3).

Extra-Functional Practices
Relate to practices that are not directly attributed to the function of nursing technician or nurse's aid.In this category, it was observed that these professionals are more prone to the performance of extra-functional tasks as part of the work dynamics at the service, with a deviation from the recommended activities, such as help with administrative activities.
"I am working a bit outside my function now, (...) Because the two girls from the secretariat are pregnant, so there are job function irregularities, because I stay at the nursing service, do my part and still have to help out at the secretariat" (I.9).
Another report reveals that these professionals, as they are part of a service, perform different activities beyond specific nursing care.
"We do everyone's work, we help at the pharmacy, we help at reception, we help in the kitchen, we help there at the administration room, during the walk, nursing is present in everything (...)" (I.1).

Category II -The insertion of the nursing technicians and nurse's aides at the CAPS ad
This second category refers to the insertion of the nursing technicians and nurse's aides in the context of the CAPS ad.The analysis of this category originated three subcategories: a) Factors that facilitate the insertion of the mid-level nursing professionals at the CAPS AD, b) Factors that hamper the mid-level nursing professionals' insertion at the CAPS AD, c) Spaces for the insertion of mid-level nursing professionals at the CAPS AD.

Factors that facilitate the insertion of mid-level nursing professionals at the CAPS AD
This subcategory is related to the factors that facilitate the insertion of nursing technicians and nurse's aides at the CAPS ADand, among these factors, the professionals refer to the presence of the baccalaureate nurse as a factor that facilitates their learning and their insertion.
"I learned from the nurse in daily work, at that time she was still taking her master's and brought me a lot of content to read about dependence.She read and wanted me to read too and that's how I learned this management, these things with addicts, the groups, the activities.(...)" (I.11).
"We got instruction from the nurse here, she gave us a course right here.And she also gave us some activities, to know how we were going to deal with the situation if the patient got agitated and how our posture would be" (I.14).
Another fact that facilitates these professionals' insertion is the positive relationship and integrality with the other team members.
"I have very good relations, the entire team has a very good relationship, with the technicians as well as with the nurse, with the manager, we get a lot of support, we are really a team" (I.7).
"The entire week we have team meetings, we meet with the technicians, discuss a lot about the cases, and that is very good because the group itself grows (...)" (I.5).

Insertion and practice of nursing in CAPS ad
Vargas D, Bittencourt MN, Rocha FM, Silva ACO

Factors that hamper the insertion of the mid-level nursing professionals at theCAPS AD
In this subcategory, which refers to the factors that hamper the insertion of the nurse's aides and nursing technicians in user care, it was found, among other things, that the physical space was a factor that hampers these professionals' work, interfering in the quality of care.
"Difficulty is space, because there are many patients and no appropriate space for care, (...) the physicians end up attending at the lunchroom (...).There is no room to hold the groups, the workshops, because there are a lot of users.(...)" (I.4).
Another factor that can hamper these professionals' insertion is the team's lack of professional preparation to work with chemical addicts."I was not prepared for this in the program for nurse's aides, we had something, but it was a lecture, superficial.

Spaces for the insertion of mid-level nursing professionals at the CAPS AD
This category is related to the spaces for the insertion of nursing technicians and nurse's aides at the CAPS AD.These professionals report that they participate in workshops and educative groups at the CAPS ad.
"I participate in groups, there's a welcoming group, a family group,a comorbidity group" (I.8).
"We participate in workshops with female and male technicians (nurses, psychologists), excursions and activities like bazaars and garage sales" (I.12).
In addition, they consider that their insertion in orientations and user welcoming contribute to the treatment.

"I think the technicians can contribute a lot with that part of orientation, of self-care for their health, (...) they like it a lot when we give advice" (I.6).
"I think it's very important, not doing just generalcare, but conversation, dialogue, being with them, listening to them too, it's very important and it makes a difference" (I.16).

DISCUSSION
The mid-level health agent is also a subject in transformation, through the historical movement itself.Without this belief, it would be impossible to sustain the premises of the Psychiatric Reform 10 .According to the discourse of the nurse's aides and nursing technicians who participated in the research, it was verified that, besides the nursing care practices, these professionals often perform extra-functional practices, like help with administrative activities.In addition, they demonstrated that they take part in different spaces at the CAPS ad, such as groups and educative workshops.They did mention factors that hamper their insertion, such as the physical space, and the insufficient professional training to work with chemical addicts.
The first subcategory, related to specific biomedical technical practices, demonstrated that the nursing professionals perform activities related to their specific knowledge, such as medication administration.At the same time as we observe these practices based on technical work and on the medicalization of the subject, however, in the second category, the insertion of these subjects in rehabilitation activities is observed.This finding reflects that care delivery to mid-level professionals is still going through a transition process, that is, from a technical model and a relationship of power to a model that attempts to satisfy the users' needs, without remaining limited to technical procedures, but creating rehabilitation and psychotherapeutic intervention actions 11 .According to the epistemological dimension of the psychiatric reform framework, this allows us to observe that, despite the new knowledge produced as a result of the reform, through the rupture in the psychiatric perspective on mental illness, many professionals remain attached to that perspective; therefore, the educational institutions of mid-level nursing professionals and baccalaureate nurses themselves should heed the transformation of this look, which demands a changed conception of the "object" of mental health and the need to deconstruct/reconstruct this new form of working in this new psychosocial paradigm 11 .
On the other hand, according to the subcategory that reveals the extra-functional practices of mid-level professionals, in some cases, although the professionals have the capacity needed to work with CAPS ad users, contributing to the subjects' effective rehabilitation, they continue performing the administrative functions that go beyond their competency area.This matter makes us reflect on the technical-assistential dimensions of the reform framework as, besides the fact that the job function irregularities negatively affect the care delivery of mid-level professionals to service users, they reveal the insufficiency of human resources at the CAPS ad, which can cause difficulties for these workers to perceive their true role in this new care space for users of alcohol and other drugs.
The research participants acknowledge the baccalaureate nurse as a factor that facilitates their insertion in the service because she cooperates towards their permanent education,

Insertion and practice of nursing in CAPS ad
Vargas D, Bittencourt MN, Rocha FM, Silva ACO in accordance with a study 12 that demonstrates that, concerning the training of mid-level nursing professionals to deliver care to drug-addicted patients, this education takes place in practice, in daily work, often mediated by the nurse.In this respect, a study highlights that the nurse plays an important role in the care planning that is executed by nursing technicians and nurse's aides and indicates the baccalaureate nurse as an integrative link that guarantees the care delivery, emphasizing the importance of equipping the mid-level professionals, under the nurse's orientation and supervision, in order to improve the interpersonal relations and gain further technical qualification 13 .This reveals the need for further attention to these professionals' education, who admittedly lack preparation to recognize, forward and assist people with problems related to alcohol and other drugs 4 .Thus, this study showed that the baccalaureate nurse plays an important role in the preparation of mid-level professionals for care delivery to these clients.As the nurses themselves lack knowledge and skills for care, as demonstrated in research 4,14 , they may not be prepared to qualify their team, entailing a care based on models that do not always respond to the user's true needs.
Another facilitating factor that was mentioned was the presence of the multiprofessional team at the CAPS ad, which does not only include several professionals who work individually, but also various professionals who work mutually, due to the dynamics itself of work at a CAPS, which demands an integrated multiprofessional team, facilitating a good inter-relationship among the therapeutic team members.This finding is positive as, according to an earlier study 15 about mental health care, it is not sufficient to simply constitute teams of different professionals if they do not meet to talk about the common activity because, in that case, the actions are simply summed up.Hence, when analyzed through the technical-assistential dimension, the dialogue among the professionals is essential as part of these new devices, considering that, when these professionals dialogue in search of the best treatment for the users, this facilitates the insertion of the mid-level professionals, as the exchange of information and knowledge to guide care gains importance, to the detriment of the ranking of relationships, which contributes little to cope with the demands of the people who receive care.
As regards the factors that hamper the insertion, the inappropriateness of the physical space was mentioned and, often, care is delivered at places that do not serve for this kind of approach.This leads to the discussion of the legal-political dimension, as the error lies in the decree itself, GM 336/02, which defines the structure of the CAPS, as it does not determine the physical space of these Centers, but simply describes the activities that should happen at these places, such as individual and group care; it should not be forgotten, however, that the physical space should hold these activities 16 , and that the chemical addicts, like any other citizen undergoing treatment, is entitled to an appropriate place for this purpose.One study 17 , undertaken in São Paulo to describe, among other factors, the physical structure of 21 CAPS in the City of São Paulo, demonstrated that half of the services was functioning in hired buildings, with inappropriate physical conditions, especially for group care.As a result, care delivery for CAPS users is negatively affected, which can hamper the insertion of different professionals at the CAPS ad, including the nursing team, which is present in most of the activities and spaces.
The interviewees also mention a lack of knowledge about chemical addiction in the technical programs and traineeships.Therefore, a large majority first had contact with chemical addiction in their current job, which indicates the weakness of these professionals' education; a weakness that also affects the treatment of content like interpersonal relationships which, when addressed, is discussed in a fragmented, theoretical manner, without any reflections in the practical field, leading to ignorance about its applicability as a daily work skill 11 .This weakness in these professionals' knowledge is in accordance with the literature, which demonstrates that most mid-level nursing professionals did not have sufficient education in mental health and psychiatry, neither in theory nor in practice 11 .And, as these professionals' mental health education is insufficient, education related to alcohol and other drugs must be weak or inexistent.In this respect, when analyzing the finding in the sociocultural dimension, it is also important to highlight that, as the education is deficient, these professionals acquire social representations based on common sense, which stigmatizes the chemical addicts, negatively influencing these patients' treatment and recovery.
The significant insertion of mid-level nursing professionals was observed in therapeutic groups and educative workshops at the CAPS ad, which is essential as, in accordance with the technical-assistential dimension, this professional will be present in practices that, in the psychiatric reform proposal, are understood as driving forces in the construction of social spaces in which the user can reconquer or conquer his daily life 14 .In other words, in these activities, the professional will truly have contact with a new organization of the work, in which the users' socialization and independence and skills development are promoted, as well as access to latent symbolic contents, still as a leisure activity 18 .In addition, the professionals refer to their activities in welcoming, through dialogue with and listening to the users and orientations; this grants these professionals a new role, different from the performance of pre-established techniques.This means that the organization of work is no longer based on the principles of each professional category's knowledge and specialties, and therefore breaks with the strict hierarchy of being able to/knowing 11 , so that the professionals gain new roles, which will permit the creation of tighter bonds between the user and the health service, enhancing the user's satisfaction with treatment and permitting the reduction of these subjects' abandonment rates.
This study comes with limitations, as only some CAPS ad in the City of São Paulo were involved, making it impossible to Insertion and practice of nursing in CAPS ad Vargas D, Bittencourt MN, Rocha FM, Silva ACO generalize the results.Nevertheless, it advances on nursing research, due to the lack of studies in the Brazilian literature that aimed to investigate mid-level nursing professionals, and specifically to demonstrate their insertions and practices in the substitutive services proposed by the Brazilian Psychiatric Reform, which include the CAPS ad.In addition, this study can trigger strategies to improve these professionals' training in alcohol and other drugs as part of their education and in professional practice, as the lack of training was reported as the factor that most hampers these professionals' work at the CAPS ad.

CONCLUSION
The study was undertaken at substitutive services for care delivery to alcohol and other drugs users, affiliated with the ideas of the psychiatric reform.The results indicated that the nurse's aides and nursing technicians perform nursing care practices and take part in different spaces at the CAPS ad, such as groups and educative workshops.
Based on knowledge about these professionals' practice and insertion form in the CAPS ad in the City of São Paulo, it could be concluded that these professionals, by taking part in a new care model, go through a transition from a model in which they performed controlling, hygienist and punitive functions, with little or no autonomy, to serve as protagonists of the Brazilian Psychiatric Reform, by practicing nursing in a model that presupposes the rupture of former paradigms and consolidates a new form of care, in which the patient is considered a subject instead of a disease.
The results indicate that this transition is still in process at these services though, considering that, at the same time as these professionals refer to their medicalization and back end practices, which remain closely linked to the controlling and hygienist model, they refer to their insertion in rehabilitation activities inside the services; these findings arouse reflections about the importance of improving these professionals' training, as part of their education -through disciplines that discuss mental health from the perspective of the Psychiatric Reform and Psychosocial Rehabilitation, taking into account these professionals' practices and insertion in the CAPS -and also during their practice at these services -through continuing education and lectures involving experts in the area.Thus, these professionals will be able to use the technologies needed for the subject's rehabilitation, permitting the identification of their true role at these services.