Conceptions of mid-level nursing professionals facing those with a chemical dependency

Objective: to describe and understand the conceptions of nursing assistants working in Psychosocial Care Centers for alcohol and drugs (CAPS ad), about the patient with addictions. Method: sixteen nursing assistants and technicians from nine of the CAPS ad in São Paulo were interviewed, and data were analyzed using the constant comparative method. Results: performing the functions in the CAPS ad enabled the change in staff’s conception from a stigmatizing and prejudiced view, to the concept of chemical dependence as a disease and those who are chemically dependent as patients with comorbidities and family problems, in need of help and treatment. Conclusion: professional practice in specialized services for alcohol and other drugs enables changes in the staff’s conceptions about chemically dependent individuals, highlighting the need to include the subject of alcohol and drugs in the school curriculum.


INTRODUCTION
According to the First and Second Brazilian National Alcohol and Drugs Survey (BNADS -LENAD I, II), conducted in 2006 and 2012, alcohol consumption among the Brazilian population had significant changes, with regard to the pattern of use.In 2006, 71% of alcohol users reported drinking up to four servings of alcoholic beverages on a single occasion, and 29% reported drinking five or more servings.In 2012, the proportion observed of those who drink five or more servings increased to 39%, increasing both among men and women.These surveys also show alcohol as the most used drug, and shows more people with alcohol abuse and dependence (1)(2) .
The Psychosocial Care Centers for alcohol and drugs (CAPS ad) were created throughout the country, in 2002, to address the health needs of these people with problems related to alcohol and other drugs.They emerged with the advent of the psychiatric reform, comprising a network of primary care for patients with disorders resulting from the use of and dependence on psychoactive substances (3) .
In addition to creating the CAPS, the new policy regulates the minimum team that should compose these centers, among them, the nursing team, which consists of nurses, technicians and nursing assistants (3) .This meant an expansion of the space for integration of these workers in caring for Brazilian people with problems related to alcohol and other drugs.
However, despite the integration of mid-level nursing professionals into the context of care for chemical addicts in the CAPS ad, there is a gap in the national literature on the practices, attitudes and conceptions of these professionals when faced with the individual who is chemically dependent; most studies evaluated these issues among nursing students and nurses (4) .
The lack of studies involving this population deserves attention, especially considering that the nursing staff is the largest contingent of health workers in most of the CAPS ad.Additionally, these professionals can establish bridges in order to promote links between other professionals and patients, and provide a more comprehensive appraisal of their state and evolution (5) .
There is evidence in the literature that, despite the great potential of these nursing staff in identifying and guiding patients on the use and abuse of alcohol, acting in the identification and management of alcohol and alcohol-related problems, and their direct and continuous contact with this population, they remain an underutilized resource in health services (6) .
On the other hand, studies have shown that among health professionals, the mid-level nursing professionals are those who hold the most negative perception of patients with problems related to alcohol (7) , and are those who most agree with the moral etiology of addiction (8) .Nurses show greater prejudice against those with dependence on psychoactive substances when compared to other professionals in these services (8) .
Thus, considering the lack of research on the subject and the preponderant role that these professionals play in specialized services for alcohol and other drugs, this study aimed to describe and understand the conceptions about those with chemical addictions from the standpoint of mid-level nursing professionals working in specialized services for alcohol and other drugs.

METHOD
To describe the perception of the mid-level nursing professionals about those with chemical dependency, and in order to obtain personal and professional experiences of these subjects, we opted for a qualitative approach based on the constant comparative method.This methodological theoretical framework was adopted because it allows an emphasis on "understanding of the phenomenon as it emerges from the data rather than the basis, concepts and theories of the investigator'" (9) , so that the design of the connections between the data need accurate explanations of facts and the social scene in which they occur.
During the work, several measures were undertaken to ensure the rigor of research: data triangulation, regular sessions of discussions among the authors for encoding of the data, comparative use of notes made by the authors during the interviews, and data discussions, considering the scenario and the institutional policies of the CAPS ad.Throughout the process of data analysis, the model that would fit the best interpretation of the data was used.

Study subjects
Semi-structured interviews were conducted with 16 midlevel nursing professionals (nine assistants and seven nursing technicians) who were working in the CAPS ad in São Paulo and agreed to participate in the study.The number of subjects was determined through data saturation, that is, the participation of new subjects was suspended when data began to show some redundancy or repetition (9) .

Data collection
Data collection occurred from October to December of 2010.The interviews lasted approximately 30 minutes, were recorded on videotape with agreement of the subjects, and took place in a reserved location in the CAPS ad which was quiet and noiseless, without interruptions.The statements were fully transcribed, and in order to ensure anonymity, the letter E, followed by the interview number, was used to refer to the participants.The interview was guided by the question: "Who is the chemically dependent individual for you?"At the end of each interview, the participant was asked for any information or comment about his/her experience with the chemically dependent that he/she would like to add.

Data analysis
The data were analyzed using the constant comparative method (9) .During the process, the results of the authors' discussions and the notes taken during each interview were essential components of analysis.Once transcribed, the interviews were coded and compared.After the coding of the concepts of the individuals, the data analysis focused on reconstructing the reality of the mid-level nursing professionals in the CAPS ad, where the common characteristics related to that data were isolated.

Ethical aspects
This project was approved by the Ethics Committee in Research involving Human Beings of the Municipal Health Department of São Paulo.

RESULTS
Regarding the socio-demographic data of the subjects, 57.89% were nursing technicians, 79% were female, and 50% were between 31-39 years of age.With regard to training, 57.89% studied in private schools and, in terms of the length of performance of these professionals, 50% had been working between 12 and 17 months in the profession.Regarding the preparation for work with those with a chemical dependence, 52.63% of respondents did not receive this during their training course as a nursing professional.
Among the mid-level professionals studied from the CAPS ad, the personal meaning attributed to those with a chemical dependence was reflected in two primary concepts that emerged from the data: the chemically dependent individual as a patient in need of assistance and treatment, and the change of the conception with the chemically dependent person, after this study.These concepts and their interrelationships are shown in sequence.

The chemically dependent individual as a patient in need of assistance and treatment
Several professionals referred to the chemically dependent individual as a patient who needs treatment and support from family, friends and professionals for their recovery.The idea that the chemically dependent individual is a sick person prevails in the statement of interviewed professionals, and is fundamental to the work of technicians and nursing assistants in these services, as it enables all of them to recognize the need for specialized care and technical care.

As a patient, he is a sick person; not a person who is different from the others seeking a medical service. (E.13)
The chemically dependent individual is a sick person, a person who has a disease and is looking for a cure.(E.15)

I understand and know he is a sick person, we understand that even he is a patient. (E.2)
In my view this is it, they are patients who need care as well as in any other disease.(E.4)

He is a sick person who needs attention, medication, monitoring. (E.7)
I think that those who work in this area, if they do not understand it as a disease, they have no business working here.(E.12) Someone who needs help, need technicians, needs nursing, need to be reintegrated into society.(E.9) We really need to help because it is difficult, any kind of dependence, addiction, it is very hard to quit, and they need our help, the help of family and even professionals.(E.5)

Family dysfunction
The professionals conceive of the addicted individual as a person who has a family dysfunction, related to conflicts, such as the lack of family support.This causes these patients to use psychoactive substances as a resource to supply their helplessness, and as a way of forgetting the problems in their relationship with family members.The comorbidities Many professionals also understand the chemically dependent individual as a patient who has comorbidities.In the conception of these subjects, psychiatric disorders -among them depression and schizophrenia -are the most common.Despite reporting difficulty in identifying which of the two conditions is the first to occur, most of the subjects mentioned the psychiatric disorder as a triggering factor prior to chemical dependence, which reinforces the need for specialized treatment by trained professionals for such assistance.
I believe that no one is chemically dependent for nothing.They always have a previous condition that triggers something in the middle.Most patients that we have are schizophrenic, persecutory; there's always something.(E.8)

Depression occurs in every chemically dependent person because with depression the person is just looking for a way of escape in the drug world, is usually what happens. (E.10)
Changing the conception after working with chemically dependent Working with the chemically dependent emerged as a determinant of change of staff conception in relation to these subjects, making outweighed the prejudices and the fear of contact with the patient.This is because in contact with the chemically dependent, the staff began to realize the "other side", the person behind the addiction, which allows a new "look" and therefore a more human care, devoid of moral judgment and fear.
We have a bit of prejudice.Now, after I started working here, my vision changed completely.The first time we work so directly, we learn to see the other side, not only that side that we imagine it to be, we learn to see the reality of the person.(E.1) Rev Bras Enferm.2015 nov-dez;68(6):755-60.

Before, I was kind of scared of substance abusers. It's funny, but with alcoholics, for example, I had great difficulty. I did not have much patience and I was prejudiced. and today alcoholics are those to whom I relate better. My view is different from what I used to have before going into the CAPS ad. (E.16)
Today I have another look in relation to the chemically dependent.Before, for me, everyone did drugs because they wanted it and it was kind of, "I do not care about life".(E.3)

DISCUSSION
The results of this study demonstrated that the mid-level nursing professionals reported having changed their view on chemically dependent individuals after practicing the profession in the CAPS ad, changing their prejudiced concept based on common beliefs, to seeing the chemical dependence as a disease, and the substance abusers as patients in need of the help of nursing technicians, family, friends and treatment.They also started to consider them as people with comorbidities, and serious problems within the family environment that are often precursors of drug abuse.
Considering chemical addiction as an illness is something new, occurring only beginning in the second half of the last century.The concept of dependence is no longer considered a character deviation, or as just a group of symptoms, but acquired contours of a mental disorder with specific characteristics (10) .
This points to the importance of practice with chemical dependent individuals, and the changing of the conceptions of these nursing professionals about the addict.However, it is important to reflect on the way in which these professionals perceive the disease, because although the phenomenon of drug addiction is complex and multifactorial, such as exclusively organic diseases, the psychosocial care model of health directed toward those with chemical dependency in the CAPS ad is different from the biomedical model.In this model, hospitals and teachers of nursing courses are still teaching (11) staff to consider the chemically dependent individual as a patient, directing the care toward individual, organic changes.
On the other hand, it is clear that, despite the change in the conception that professionals present when they are integrated into the context of the CAPS ad, some vestiges of common belief still remain where the use of psychoactive substances and emotional problems, or prior mental illness are associated.Even though these factors may trigger the beginning of use, they cannot be considered as a cause of addiction.This result refers to the low preparation of these staff to enable adequate understanding of the phenomenon, which leads, in the last analysis, to the realization that the professional failed to fulfill that knowledge gap.This fact was also observed in this study, which showed that more than half of respondents denied having received any preparation or content on the subject of alcohol and other drugs during training.
According to the above, and considering that the CAPS ad is configured as a workspace for mid-level nursing professionals in the care of the chemically dependent individual, it is essential to consider the formation and training of these professionals.Once the addiction is understood as a disease, and the chemically dependent individual is seen as a patient, staff must be prepared to understand not only the physical and psychological consequences involved in problematic use of psychoactive substances, but also the social, political, economic, legal and cultural issues inherent to this phenomenon (12) .Thus, the knowledge will help these staff members to value the psychosocial approach, as opposed to the biological approach, and will give them greater clarification, in order to ensure care that is guided by scientific evidence and formal knowledge.
Regarding the assistance in treatment, the professionals consider the importance not only of technicians, but also of friends and family members.This demonstrates the recognition, by some of these professionals, of the importance of including participants from the social network of the chemically dependent person in his/her treatment process.This acknowledgment should always be present in the care for these individuals in the CAPS ad, as social networks are considered central to the sense of identity and competence, especially in the attention to health and adaptation in situations of crisis (12) , enabling treatment based on psychosocial strategies proposed by the Law 10.216 / 2001 (12) .
Moreover, despite these professionals having identified family as part of the treatment, it must be seen in a particular manner, especially as the literature shows that for each subject involved with alcohol or drugs, four or five people, including spouses, partners, children and parents, are directly or indirectly affected (13)(14) .Thus, it is necessary that these professionals are also prepared to be attentive to the needs and difficulties of the family and its illness, which can interfere directly in the worsening of the problems experienced by the family unit, particularly the drug user himself (15) , as illustrated by the interviewees.
Preparing these professionals for this aspect can help the nursing staff to conceive of the family as an essential partner in treatment, rather than a propellant of the drug use by the subjects.Still, they must recognize the family members that have the potential to act as partners in treatment, helping the team to work on the limitations, difficulties and feelings of family members and, in particular, from the partner that is better able to interact with the chemically dependent person.Once he assumes the role of caregiver and feels responsible for that, positive outcomes of treatment will occur more readily.
Professionals also pointed to psychiatric comorbidities as a cause of psychoactive substance abuse.Although the literature reveals a high prevalence of mental illness in those with chemical dependency (16)(17)(18) , it is often considered not to be a causative factor for the use of psychoactive substances, but a consequence of it (19) , conceiving of or associating the dependence to a mental illness contributes to a reductionist view of the problem.Thus, since these professionals identify the presence of mental disorders in some users and perceive it to be a triggering factor of using, it is important that the team can advise them about the care, preparing them, according to their professional skills, to intervene along with these patients.In accordance with the statements of the participants, the occurrence of an additional disorder in the substance abuser can alter, in a negative manner, the symptoms, treatment and prognosis of both (19) .
Changing the concept about those with chemical dependency, after the beginning of professional practice in the CAPS ad, was an important finding consistent with literature findings (20)(21)(22) .According to a previous study (20) , direct contact with users of alcohol and other drugs in specialized services for the care of the needs resulting from the use of psychoactive substances, enables the nursing staff to overcome the influence of the moral model of explanation for the use of psychoactive substances, still common among health professionals (20,23) , and the emergence of a concept based on the psychosocial model, which is consistent with the model of care of CAPS.
Although practice does not replace formal education on the issue -it contributes significantly to better understanding and consequently to the change of view that the professional has of these individuals; the findings of this and previous studies (20)(21)(22) , reinforce the need for practical experience with stigmatized populations during training.This experience will enable better preparation of the future professional, to act in this new scenario of practice, assisting the individual in seeking necessary support for his/her recovery and social reintegration.
This awareness and preparation to treat these patients will only be possible when the issue is considered important and satisfactorily included in the training of these professionals.
This study has limitations because it was conducted only with nursing assistants and technicians working in the CAPS ad in São Paulo, and therefore it is not possible to extrapolate these results to other contexts or locations.However, it can make a significant contribution to the area of treatment for alcohol and other drugs, in particular as regards the midlevel nursing professionals, because little is known about the attitudes and conceptions of this category of staff about those with chemical dependency.
Moreover, it can support research aimed to propose improvement strategies in education, training and qualification of these professionals because, as suggested, they complete professional courses with conceptions of common beliefs but which have little technical-scientific basis, which are essential to treating and caring for those with chemical dependency in a comprehensive manner.

FINAL CONSIDERATIONS
The results of this qualitative study illustrate some important conceptions of mid-level nursing professionals that work with chemically dependent individuals, enabling the development of categories that can provide a basis to explain how the nursing assistants and technicians working in the CAPS ad understand the individuals who are dependent on alcohol and other drugs.
Those with chemical dependency are sick people, and social or family situations and their mental health are important factors to be considered in this illness.The results also make it possible to theorize that the contact and work with these patients in specialized services enable a change in the staff's conception of these individuals.This finding highlights the importance of including practical activities and internships in specialized services in the care of individuals with needs caused by the use of psychoactive substances in the Psychosocial Care Network (RAPS), in the curriculum of these mid-level nursing professionals.This will enable the formal education about alcohol and other drugs to be reinforced by practical activities with these users, and the future professional will be better prepared to work within the services of specialized care of RAPS -the CAPS ad.
They seek in the drug, what sometimes they do not have at home, because many do not have attention and then they seek from the drug what they will not find.(E.3) [...] What led the person to join the world of drugs could be a problem with the wife, or children, or father and mother, a conflict, they seek an escape in the substance, and it is generally what happens.(E.10)