Self care theory in pregnant women during chemical detoxification from crack : nursing ’ s contributions Teoría del autocuidado en la desintoxicación química de gestantes usuarias de crack : contribuciones de la enfermería

Objective: To identify the contributions provided by activities that promote self care, developed with pregnant women during chemical detoxification from crack, having Dorothea Orem's Self Care Theory as reference. Methods: A descriptive, exploratory and qualitative study was performed between August and November 2013 with five pregnant women hospitalized at the chemical detoxification unit of a general hospital in the state of Rio Grande do Sul, Southern Brazil. Data were collected before and after the activities, developed during this period, through semi-structured interviews and submitted to content analysis after being approved by the local Research and Ethics Committee (Opinion 072/2010). Results: A total of three categories were identified: from the absence to the need of activities that promote self care; the contributions of these activities to the promotion and acceptance of chemical detoxification and self care; and self care performed by pregnant women after these activities. Conclusion: The activities developed with pregnant women helped to enhance their self care in the reality studied.


INTRODUCTION
Pregnancy is a complex event and an experience filled with intense emotions, characterized as a moment when women experience physical and psychological changes, which can cause different emotional reactions 1 .The association between pregnancy and drug use is a factor that poses risk to maternity.In addition, there has been increasing concern over this phenomenon due to the higher prevalence of psychoactive substance use among pregnant women found in recent decades 2 .
The use of drugs, including crack, during pregnancy can result in miscarriages, prematurity, and a reduction in fetal growth, among other perinatal changes.Moreover, those who are born alive may have developmental disability or other mental and behavioral disorders that will lead to serious consequences to the lives of babies and families 3 .Regarding its teratogenic effect, crack quickly crosses the placental barrier without being metabolized, acting directly on fetal vascularization, which may result in urogenital, cardiovascular and central nervous system malformation 3 .
Drug abuse during the gestational period has a multifactorial etiology, as it is associated with risk factors such as low self-esteem, inadequate support systems, socioeconomic barriers, involvement in abusive relationships and previous history of psychiatric diseases 4 .In this sense, the methodological use of the nursing process is essential to promote self care among individuals seeking health promotion, treatment, recovery, rehabilitation and social reintegration, among which are pregnant women with needs resulting from crack use 5 .
It should be emphasized that the path of development of nursing has been regulated by a wide theoretical structure and that the nursing process is the model through which this structure becomes effective in health care.In the light of Dorothea Orem's Self Care Theory, this process encourages people to actively participate in the therapeutic care, as it emphasizes the importance of clients being committed to self care 6 .
Self care can be understood as the practice of activities that individuals perform for their own benefit, aiming to maintain their life, health and well-being.The purpose is to enable actions to be effective which, by following a model, contribute to human functions and development in a specific and comprehensive way 7 .
In this sense, Orem's Self Care Theory provides structure for the work of nursing, including a wide view of the aspects related to the survey of the specific needs of individuals, in this case, pregnant women undergoing chemical detoxification from crack use.Additionally, this is a methodology that facilitates the planning of nursing care for pregnant women in this situation, encouraging them to actively participate in their rehabilitation, promoting self care, and enabling social reintegration and a healthy life as a result 8 .
By understanding the self care Theory and applying it to pregnant women's chemical detoxification, nurses can develop the dialogical communication, as this theory enables the establishment of relationships of trust that help them to identify causes, make an accurate diagnosis, and discuss solutions that can be best incorporated into each individual's lifestyle 5 .With regard to the way nursing approaches pregnant women, it is well known that low risk prenatal care can be performed by nurses.They can receive these women and conduct the nursing consultation, aiming to know and intervene in problems, situations and diseases and request routine and complementary tests 4 .
The main goal of prenatal and puerperal care is to receive women since the beginning of their pregnancy, thus assuring the birth of a healthy child at the end of this pregnancy and guaranteeing maternal and neonatal well-being 9 .However, when it comes to pregnant women with needs arising from crack use, emphasis should be given not only to the inclusion of educational actions such as dialogical guidance, workshops and playful activities, but also to the importance of the chemical detoxification process in this context.
Some studies have been developed with pregnant women with needs resulting from crack use 2,3 .However, there is a knowledge gap regarding the self care theory when caring for them, thus emphasizing the importance of this study in terms of the construction of knowledge to be added to what is already known about the theme of crack and other drugs.Furthermore, this study is justified by the belief that the development of activities which increase acceptance of treatment and self care among individuals, in this case, pregnant women undergoing chemical detoxification, can promote a healthy life for mothers and babies during and after this treatment, within their context and choices 10 .
Healthy living can be understood as a unique multi--dimensional process that cannot be perceived or defined as something objective, static or as a goal in itself.As a complex phenomenon, whose understanding implies the recognition of the environmental conditions where human beings are included and where they concretely experience their life 11 .
Based on what has been previously described, one may question how the activities that promote self care, based on Dorothea Orem's Theory, contribute to pregnant women's process of chemical detoxification from crack use.In an attempt to answer this question and in view of the possibility of broadening one's view of the process of chemical detoxification from crack use, from the perspective of self care, the present study aimed to identify the contributions of activities that promote self care developed with pregnant women undergoing the process of chemical detoxification from crack use, using Dorothea Orem's Theory as point of reference.

METHODS
A descriptive, exploratory study with a qualitative approach was performed 12 , taking into consideration the contributions of the activities conducted by the project entitled "Playful Care: An Innovative Educational Strategy to Promote Comprehensive Care".
This project had the purpose of developing game-oriented care in health by integrating teaching, research and continuing education, aiming at health promotion and education.It was Self care theory in pregnant women during chemical detoxification Nicolli T, Gehlen MH, Ilha S, Diaz CMG, Machado KFC, Nietsche EA developed by professors and students from the undergraduate nursing course of a higher education institution in a hospitalization unit for chemical detoxification from crack and other drugs in a mid-sized general hospital in the central region of the state of Rio Grande do Sul, Southern Brazil, using Dorothea Orem's Self Care Theory as point of reference.
This study was performed with pregnant women undergoing the process of chemical detoxification from crack use in this hospital's treatment unit for substance dependence.This unit has nearly 24 beds for substance-dependent patients through the Sistema Único de Saúde (SUS -Unified Health System): one bed for children (aged less than ten years), four beds for adolescents (aged less than 14 years accompanied by an adult exclusively and aged between 14 and 18 years), ten beds for adult women (aged more than 19 years) and ten beds for adult men (aged more than 19 years).In this unit, the needs of individuals are met by professionals from the area of health and human sciences.
The following were selected as inclusion criteria: to be pregnant and undergoing the process of chemical detoxification from crack use and to be aged 18 years or more.In contrast, the following were considered as exclusion criteria: pregnant women who were, during the development of this research project, hypersexual, at the risk of showing aggressive, homicidal or suicidal behavior or psychiatric crises, mutilated, with contagious diseases such as tuberculosis or younger than 18 years.Of all six women hospitalized for treatment during the study period, one was younger than 18 years and, therefore, not included.The resulting sample was thus comprised of five pregnant women.
Data were collected before and after the activities that promoted self care were developed by this project between August and November 2013.First of all, there was an individual semi-structured interview including open-ended questions about care and self care performed in the daily routine of the chemical detoxification unit.
Subsequently, educational activities were planned and performed through group discussions, therapeutic workshops using posters, information booklets and playful objects (make up kits, dolls, clothes and colorful accessories) and beauty workshops as a way to promote healthy living.During these activities, pregnant women were given explanations about crack and the importance of care and self care, they had the opportunity to ask questions to nursing professionals and students, in addition to sharing their experiences regarding needs arising from crack use with the group.
After the activities were performed, new visits to the unit were made and interviews with pregnant women were conducted again, aiming to assess the applicability and contribution of these activities to encourage the practice of self care performed by them in their daily routine at the chemical detoxification unit.
The data collected were organized and subsequently analyzed with content analysis 13 , which consists in discovering the cores of meaning comprising communication, whose presence or frequency add meaningful perspectives to the object of study in question.Perception of this theme is associated with a statement about a certain topic, which can be represented by a word, sentence or idea 13 .
In this sense, the development of the analytical process followed three methodological stages.In the first stage, known as pre-analysis, researchers sought to thoroughly read the data, followed by material organization and formulation of hypotheses.Subsequently, the material was analyzed, i.e. raw data were codified.Finally, in the third and last stage, data were interpreted and divided into themes, according to the meanings attributed 13 .
The ethical and legal precepts for human research were taken into consideration, in accordance with the National Health Council Resolution Nº 466/2012 14 .Participants were identified by the first letter of flower's name and the research project was approved by the Research Ethics Committee of the Franciscan University Center.

RESULTS
A total of three categories emerged from the data analysis: from the absence to the need for activities that stimulate self care; the contributions of these activities to the promotion and acceptance of chemical detoxification and self care; and self care performed by pregnant women after these activities were conducted.

From the absence to the need for activities that promote the practice of self care
When seeking to identify how (self) care activities were performed by pregnant women in their daily routine at the chemical detoxification unit, prior to the activities promoting self care, the theory was found not to be used in the routine of this unit.This was because there were no educational practices that contributed to self care and health education about the biological, cognitive, emotional and spiritual needs in the mother-baby bond, as observed in the following reports:

I sleep a lot so time will pass more quickly, I can't wait to get out of this place, few people come with activities, I'd like to get more involved. (O.) I don't perform any type of care here, I just think about leaving this place, giving up this child and smoking crack, I know this is my destiny, to die from crack. (V.)
There is no routine here, I only sleep and ask for my medication to sleep.I really miss my husband, who's in prison.Here, there are not many activities and, when there is, I don't participate, I prefer to keep thinking about things.(D.) In the following reports, the lack of awareness and interest in knowing about the effects of crack during pregnancy can be observed among these women.Additionally, they were unaware of the basic care for their babies to develop in a healthy way.
Self care theory in pregnant women during chemical detoxification Nicolli T, Gehlen MH, Ilha S, Diaz CMG, Machado KFC, Nietsche EA

I don't know much about this, because I didn't want to get pregnant, after all, I don't even know who the father is, I don't like being pregnant and I'm not going to care for this child, I'm putting it up for adoption! (O.) I don't know anything about what crack can do to the baby
who is inside me, I don't want to know or worry about this, after all, this child is not going to be mine, I know the judge will take it from me, so I don't give a damn [...] (D.) The other pregnant women, although unaware of the harm that crack can cause to them and their babies, showed interest and suggested educational activities, as reported below: I think we could learn more about babies, what happens to them, I know crack is not good for them, but I'm not sure how it can harm them exactly.(A.)I know crack is not good for my baby, this is why I want to stop, I want to be treated, I know that if I continued using it, the baby would get sick [...] (V.)I know that I have to take care of myself and that all these hospital people are here to help me and they give me important information about my health every day.It's good to know that there are people who believe in us, who believe in our potential to win this fight, I started thinking a lot about this after I came here, I want to get better.(C.)Moreover, two out of three reports showed that pregnant women are interested in stopping using crack, undergoing the treatment and recovering.Through one of these reports, it could be observed that the woman acknowledges the health professionals working at this unit as people who are there to help her, provide information and see her through the detoxification process.

Contributions of activities to the promotion and acceptance of chemical detoxification and self care
After the activities promoting self care based on Dorothea Orem's Theory were performed, professors and students from the continuing education project, developed in the chemical detoxification unit, conducted interviews with the same questions previously used and found that these activities encouraged pregnant women to live in a healthy way and to protect their babies, promoting self care and acceptance of detoxification:

I thought it was good, I took much advantage of it, because the activities were educational, I learned many things about what can happen to my child and myself, I'm more aware now. (Azalea) I thought the activities were very interesting, because they taught us how we can care for ourselves, I just think there could've been something more specific for pregnant women, like lessons on how to give baths and breastfeed our future babies, so that we already know what to do when they are born. (V.)
It could be inferred that the applicability of the activities proposed to promote self care in the chemical detoxification unit benefited and valued pregnant women, so they can accept the need for this hospitalization time in their lives as the beginning of a constant search for happiness with their children and without crack.
Here I'm certainly heard and cared for, the activities make our days more joyful.From here, I can have a different view of the world out there, only now I realized how easy it is, I just need to try, and now I have my family's and my baby's support, because I'm doing this for him as well.(C.)I like it and I feel encouraged to stop using crack forever, when there are activities about my baby.The nurses have recently shown me all the stages of development of a fetus, from the first to the ninth month, it was touching!(V.) The desire to start a family arose among pregnant women during the detoxification process, mainly after beginning the activities that promoted self care.However, it was difficult for them to concentrate on this type of care, due to the low self-esteem resulting from crack use.

When I got here, I didn't want to do anything, I only thought about running away, until I began to calm down, then I started participating in the activities and talking to people and now it seems that the right things are getting into my head, I want to do everything right to have my baby and my husband back. (A.) There are days when I feel down and I only want to sleep, at times I even ask the nurse to give me something to sleep, but it's complicated because I want to get better to leave this place and have my family, my things and my life, I want to recover and be fine. (V.)
It can be observed that promoting self care helps one to accept the importance of chemical detoxification, especially during pregnancy, which requires nursing and health care provided in a way that values the essence and life history of hospitalized individuals, so they can knowingly choose a healthy life.

Self care performed by pregnant women after the activities that promote self care were conducted
The self care practice participants were encouraged to perform through the routine project activities, during the chemical detoxification process conducted while being hospitalized, helped them to reorganize their daily life without crack, although the desire to use it is still felt:

I usually read a lot to keep my mind busy, I also do a lot of crosswords. (V.)
Self care theory in pregnant women during chemical detoxification Nicolli T, Gehlen MH, Ilha S, Diaz CMG, Machado KFC, Nietsche EA Here, I follow a routine of self care, which was not the case when I was on the streets, where I was always high on drugs and had no idea what I was doing.Here, I wake up, take a shower, watch TV, then I drink tea and hang out with the girls, we talk a lot! (A.) In the following reports, it can be observed that even without being aware of the harm that crack can cause during pregnancy, pregnant women already understand that its use is harmful to health and show an interest in their child and a drug-free life.

I know this is not good, I don't know how to describe the specific effects, I tried to cut down on its use during the pregnancy, but I didn't stop using it [...] (A.) I know that my baby can have a problem in its head and be born all deformed and this is why I'm getting treated, I want my child to be healthy when it's born. (C.) I know that crack is not good for my baby, I want to stop [...] (O.)
Self care promotion during chemical detoxification helped pregnant women to (re)organize their routine, as observed in the following reports: I wake up, make my bed, take a shower and wait for the time to go to the yard.When we come back, I read, watch TV [...] when the academic people come to the unit, we have different activities to do.(V.)I wake up and go straight to the shower, it's my favorite time, because it (the baby) moves a lot.After the shower, I apply a lot of cream to my belly and talk with this little being growing in here, it seems like it can understand me, it kicks, it's lovely!(C.) The reports given by two pregnant women show that the self care performed in the chemical detoxification unit helps them to accept their pregnancy and to form a bond of affection with their baby.

DISCUSSION
Psychoactive substances have been recently spreading, an alarming trend that forces society to face a public health problem 15 .This fact contextualizes a problem that draws the attention of both public and private health institutions, universities and society, in the sense that crack use may increase to dangerously high levels with relevant educational, physical, emotional, political, health and social consequences 16 .
Thus, it is important to apply the theories to the clinical/care practice of health professionals seeking more effective results in both health promotion and prevention of new cases and treatment of existing cases.Dorothea Orem's Self Care Theory is included in this context, which comprises self care, the activity of self care and the therapeutic requirement of self care 7 .
Self care is the practice of educational activities initiated and performed by individuals for their own benefit to maintain their life and well-being.The activity of self care means the ability to be committed to self care.The therapeutic requirements of self care represent the totality of actions, through the use of valid methods and interrelated sets of operations and actions 17 .
In the unit where the activities were performed, Dorothea Orem's Self care Theory was not part of the routine.Pregnant women did not perform activities that stimulated them or there was no routine of activities and, for this reason, they slept as much as possible for time to pass quickly until the day they could leave.Orem's model aims to help individuals to meet their own therapeutic requirements of self care, which has the purpose of enabling them to mature and develop, apart from helping the prevention, control and cure of diseases and harms 17 .
A study conducted in Northwest Rio Grande do Sul, aimed at describing how individuals with needs resulting from drug use perceive such use in their lives, showed that the attitude of change has to come from these individuals themselves, otherwise there will be no change.When those who have needs caused by drug use do not understand the necessity of transforming their attitude, the rehabilitation will not occur, as they will fall back to their old habits 18 .
The pregnant women who participated in this study were unaware of and uninterested in knowing the effects of crack during pregnancy; some also showed a lack of interest in their own baby and they were not aware of basic care for its healthy development.In this sense, dissatisfaction with current and future self care was evident and this should be reversed.However, Orem's Self care Theory presupposes that human beings have their own abilities to promote self care and they can benefit from the care provided by the nursing team when they are incapable of showing self care due to lack of health 17 .
Thus, activities were performed to encourage pregnant women to be interested in living a healthy drug-free life and enable them to choose to accept the chemical detoxification treatment and to feel the need for self care.Orem understands nursing as a humane service that helps people to obtain and recover their abilities and states that physical, psychological, interpersonal and social health aspects are inseparable in an individual.Her definition of an individual refers to human beings that are different from other living beings in terms of their capacity to reflect upon themselves and their environment, to learn and to develop themselves 17 .
Among pregnant women undergoing detoxification from crack use, the activities promoting self care developed in the perspective of Orem's Theory's point of reference, proved to stimulate healthy living, as they helped these women to understand the situation they were experiencing and the importance of Self care theory in pregnant women during chemical detoxification Nicolli T, Gehlen MH, Ilha S, Diaz CMG, Machado KFC, Nietsche EA self care.After the continuing education project actions were conducted in the hospital unit, pregnant women changed their attitude, began to perform self care and, consequently, care for the baby growing in their bodies.
Furthermore, the activities helped the process of reorganization of pregnant women's routine, where they showed better care for themselves and their babies and, as a result, the interest in living a crack-free life, although still feeling the desire to use it.In this context, it should be emphasized that the support and care for substance-dependent pregnant women should not be restricted to clinical-obstetrical actions, but also include health education actions in the routine of comprehensive care and anthropological, social, economic and cultural aspects, which must be known by the professionals caring for these women, while seeking to understand them in the context they live.
Thus, apart from the theoretical-practical knowledge, nurses working in the area of rehabilitation and social reintegration due to crack use must have a humane approach that begins at the moment when individuals arrive at the unit, continues during the chemical detoxification process and extends to the patients who are undergoing a long-term treatment 5 .

CONCLUSION
The present study was considered to be satisfactory, as it was possible to find out the contributions of activities promoting self care developed with pregnant women undergoing chemical detoxification from crack use, using Dorothea Orem's Theory as point of reference.The following aspects stood out in this study: acceptance of hospitalization, routine reorganization, promotion of self care and a drug-free life, reestablishment of the bond with the baby and its protection, and the desire to form a family.In contrast, there were some limitations to this research project, such as the lack of studies on pregnant women who used crack and had Orem's Self care Theory as point of reference.Among the positive aspects that helped this study to be performed, the openness of pregnant women should be emphasized, as they accepted and collaborated with the proposed activities.The point of reference adopted enabled researchers to perceive the potential abilities of these women and the power they have over their actions to consciously transform their health disease status.Orem's Theory was found to be a key strategy to reflect on and discuss health-related situations, leading to greater awareness and the resulting improvement in the way they coped with the reality they experienced.
These factors contributed to the development of this research project, which has characteristics that make it innovative and helpful for (re)thinking the work of nursing/health professionals, emphasizing its relevance regarding the construction of knowledge to be added to the existing studies on crack and other drugs.The activities developed with pregnant women were found to have a potential to promote their self care in the context studied, enabling each woman's potential to be explored and thus showing their qualities that had often been ignored due to crack use.The recovery of self care and family, the reconstruction of values and the possibility of a different life free from drugs were encouraged.
It is believed that the subject approached in this study can have an impact on the opinion of health professionals and society, as it shows the effective contribution of recovering the self care of crack-dependent pregnant women.The data presented here are expected to help the area of nursing/health when dealing with the greater care required by pregnant women using crack, based on points of reference that value the potential of human beings.
It is suggested that Dorothea Orem's Self care Theory should be implemented in the routine work of nursing/health professionals in the reality studied as well as in other health contexts.This subject does not end here and different perspectives can arise by reviewing the data shown in this study.Thus, it is essential that new research projects be performed to further study the contribution of the Self Care Theory to pregnant women undergoing chemical detoxification from crack use.