Care for women involved with drugs : social representations of nurses

Objective: analyze social representations of nurses related to the care for women involved with drugs. Method: qualitative research founded on the theory of social representations, with 42 nurses from a public maternity ward of Salvador-BA, using identifi cation questionnaire, test of free association of words, and semi-structured interview. We analyzed the structure of social representations and the similarity tree of free evocations, and also analyzed the content of interviews. Results: care for women involved with drugs is represented by a set of words that shows theoretical questions and scientifi c techniques, but faced with experiences in the training, in the daily work and in ideas and values assigned to the consumption of drugs especially in the gravidic-puerperal period. Conclusion: The social representations of nurses show confl icts between social and cultural aspects around the problem of drugs and the health care provided to women involved with drugs. Descriptors: Nursing Care; Nurses; Women’s Health; Disorders Related to Drug Use; Drug Users. RESUMO Objetivo: analisar representações sociais de enfermeiras acerca do cuidado à mulher envolvida com drogas. Método: pesquisa qualitativa fundamentada na teoria das representações sociais, com 42 enfermeiras de uma maternidade pública de SalvadorBA, mediante questionário de identifi cação, teste de associação livre de palavras e entrevista semiestruturada. Realizou-se a análise da estrutura das representações sociais e da árvore de similitude das evocações livres, assim como análise de conteúdo das entrevistas. Resultados: o cuidado a mulheres envolvidas com drogas é representado por um conjunto de palavras que evidencia questões teóricas e técnicas científi cas, mas confrontadas com experiências na formação, no cotidiano laboral e em ideias e valores atribuídos ao consumo de drogas no período gravídico-puerperal sobretudo. Conclusão: As representações sociais das enfermeiras revelam confl itos entre e aspectos sociais e culturais em torno da problemática das drogas e o cuidado demandado a saúde de mulheres envolvidas com drogas. Descritores: Cuidados de Enfermagem; Enfermeiras; Saúde da Mulher; Transtornos Relacionados ao Uso de Substâncias; Usuários de Drogas. RESUMEN Objetivo: analizar representaciones sociales de enfermeras acerca del cuidado a la mujer consumidora de drogas. Método: investigación cualitativa, fundamentada en teoría de las representaciones sociales, con 42 enfermeras de maternidad pública de Salvador-BA, mediante cuestionario de identifi cación, test de asociación libre de palabras y entrevista semiestructurada. Se efectuó análisis de estructura de las representaciones sociales y del árbol de similitud de las evocaciones libres, y análisis de contenido de las entrevistas. Resultados: el cuidado a mujeres consumidoras de drogas está representado por un conjunto de palabras que evidencia cuestiones teóricas y técnicas científi cas, contrastadas con experiencias de formación, de cotidianeidad laboral y de ideas y valores atribuidos al consumo de drogas, particularmente en períodos de embarazo y posparto. Conclusión: Care for women involved with drugs: social representations of nurses Cuidado a mulheres envolvidas com drogas: representações sociais de enfermeiras Cuidado a mujeres consumidoras de drogas: representaciones sociales de enfermeras


INTRODUCTION
Women's involvement with drugs is characterized by production, trade, consumption, or by coexistence with persons amid this problem.This condition is socially invisibilized by gender issues that determine roles and conducts for women and has established essential elements for the development of social representations, from the recognition -in the current conjecture on drugs -of its repercussions.
According to national (1)(2) and international (3) epidemiological data, the number of women who consume and/or traffic drugs has increased significantly compared to men.Such female protagonism unleashes individual and collective repercussions, which intensify when the woman is in the gravidicpuerperal period, because of: the abuse of drugs that causes health problems to them and to their fetuses or newborns; the production and trafficking of illicit substances, when the female figure takes positions and carries out activities that constitute crime; and/or, the woman lives with people who have some form of involvement with drugs, often by abuse and trafficking.
Being a woman and being involved with drugs in the gravidic-puerperal period requires specific health care.After all, care is an existential, relational, and contextual phenomenon.When exercised by the nursing professional, it requires knowledge, skills, and decision-making evidenced in their actions in relation to the being under care, comprising the potentialities of individuals considering the process of life and death inherent in the human condition (4)(5) .
The maternity ward is a proper place to provide care to women in the gravidic-puerperal period and to newborns, being socially conceived as environment for generation of life, of family, emblematic location in which the established social role of being a mother is founded.This idea comes from studies that address issues of the gravidic-puerperal period and the female condition, which point subjectivities of women and of reproductive health (6)(7) .
With regard to the role of nurses in the maternity ward, they manage the nursing staff and implement standardized activities for women using the service.However, these activities should also be geared to women involved with the problem of drugs, a theme which is surrounded by prejudice and discrimination that are part of the social representations about drugs (8)(9)(10) .As a result, nurses, while part of society, show many of these representations (11) .
Social representations are constituted as conditions of practices, and these act as agents of transformation (12) .In this sense, it is considered that there are particularities of the drug problem that come with these professionals and consequently influence their representations.The particularities of nurses who work both in the primary and in the secondary and tertiary health care can be exemplified with the superficial awareness as to care for drug users and as to institutional and staff inadequacies in addressing the issue (13)(14)(15) .
Thus, maternity ward nurses, besides the aforementioned particularities, show peculiarities as to care for women involved with drugs in the gravidic-puerperal period, such as: more complex care, which requires technical and psychosocial competences from nurses, in addition to requiring systematic and integral follow-up for identification and intervention in special cases related to drugs; the existence of gaps in institutional projects and public policies for the inclusion of issues related to the completeness of assistance for these users of the service and for the staff that assist them; being a subject involving prejudice and discrimination, and society's condemnation of this woman's conduct in the problem; constitutes a period of prolonged coexistence with this woman and companion, in family planning, prenatal care, childbirth, abortion, and/or puerperium, the latter being commonly impacted by obstetric and neonatal complications associated with drug use.
Thus, this research was developed with the purpose of analyzing the social representations of nurses related to the care for women involved with drugs.

Ethical aspects
The data presented are excerpts from a thesis developed in the graduate program of the School of Nursing of the Federal University of Bahia (UFBA), whose project was approved by the Research Ethics Committee.

Type of study
It is characterized as a qualitative research, founded on the theory of social representations, with the structural approach.This approach is advocated by Abric (16) with contributions from Celso Sá (16) , employing the central nucleus theory, which seeks to demonstrate the internal organization of social representations with regard to the cognitive content, based on the central and peripheral system.

Study location
The location for production of data was a public maternity hospital in the city of Salvador-BA.This unit is part of the National Program for Maternal and Neonatal Health of the Ministry of Health, usually implementing care actions geared las representaciones sociales de las enfermeras expresan conflictos entre aspectos sociales y culturales referidos a la problemática de las drogas y el cuidado de salud demandado por las consumidoras de drogas.Descriptores: Atención de Enfermería; Enfermeras; Salud de la Mujer; Trastornos Relacionados con Sustancias; Consumidores de Drogas.
towards the disadvantaged population.Additionally, it is a practice field for activities related to teaching, research, and extension in agreements with UFBA and other universities and colleges of the Bahian capital and metropolitan region.

Data source
The social group studied was composed of nurses working in the research location.All 42 nurses who were working in the maternity ward became participants in the research, as they met the inclusion criteria, had been working for at least six months in the institution, in care and/or administrative activity.

Data collection and organization
Data production occurred in the period from February 2015 to January 2016 by employing the following techniques: free evocation of words and semi-structured interview.
After the period to become acquainted with the location and with the service professionals, we initiated application of the test of free association of words (TFAW), composed of an identification questionnaire and of the stimulus: "care for female drug user."The conception of women's involvement with drugs is still little disclosed in the media and in the means of common sense.In this sense, we chose the term "female drug user" to compose the inductor stimulus.
The technique of free association of words, due to its spontaneous character, enables easier and faster access to the semantic elements of the term or object under study, which -since they are implicit, hidden or latent -would be lost, suppressed or masked in the discursive productions (17) .
The TFAW was applied individually on days and in times that were previously scheduled with the 42 participants.We requested from the nurses the evocation of up to five words for the aforementioned stimulus and the justification of the word considered more important.
The interviews were carried out with 21 professionals considering the criterion of saturation of ideas (18) ; and occurred in the workplace, on day and in time previously scheduled with the participants.

Analysis of data from the test of free association of words
The evocations obtained with the TFAW were processed by the EVOC 2005 software, which enabled analysis of the four-frame house, this being a prototypical analysis that favors visualization of the arrangement of social representations, ensuring greater objectivity in the inferential analysis of representations (19) .Use of the EVOC enabled identification of the elements of the central and peripheral nucleus based on frequency hierarchy and average order of evocations (AOE) revealed in the four-frame houses (16) .
In considering that the multimethodological analysis can assist in configuring the terms that would structure the central nucleus (19) , we adopted in this study the similarity analysis, proposed by Flament in 1986 (16) .Thus, the participants' evocations were organized and processed in the IRAMUTEQ (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) 0.7 alpha2 software, which also allows the prototypical analysis.
Prototypical analysis has its validity based on evaluation of the salience of representational elements quantitatively, in crossing the frequency and order of evocation, and the central elements of social representations are more salient, being more present in the discourse.However, salience is an information which can be found also in peripheral elements (20) .
In the textual statistical analysis made by IRAMUTEQ we obtained a similarity tree for free evocations, guided by hierarchization of values of connections between terms and their adjacences for each house identified.This analysis is founded on graph theory, identifying the concurrences between the words and, consequently, showing the indications of the connectibility between the terms, which contributes to the knowledge of the structure of a textual corpus, assigning the common elements and the specificities according to the illustrative variables indicated in the analysis (21) .

Analysis of data from the interviews
The content of the interviews was recorded, transcribed fully, and analyzed following the steps of the analysis of thematic content, allowing for objective, systematic description of the content expressed in the communication (22) .In this process, we identified three categories with seven sub-categories, which show aspects of nursing care in the daily work in the maternity ward.

RESULTS
The results are presented from the characterization of social group, followed by the description of the four-frame houses, the similarity tree and, finally, the content analysis.We assume that determining firstly the structure of social representations is required to understand the results of the similarity analysis (23) .
The social group studied (42) was mostly composed of female nurses (39), aged 30 to 40 years (26), of self-reported black and brown skin color (37), of the Catholic religion (22), from the city of Salvador-BA (27), with income above BRL 4,000 (25).Half the participants had more than one employment, and most (29) reported less than 5 years of work in maternity ward.Regarding being up to date on the subject of drugs, eight of the participants reported having participated in a course/activity.
In response to the stimulus "care for female drug user", nurses evoked 207 words; of these, 40 were different and 26 were pointed out as the most important.
The four-frame houses were built by calculation and combined analysis of the average order of evocations (represented on the vertical axis and generated around 2.9) and by the average frequency of words (represented on the horizontal axis and generated around 8, when there was an inversion based on Zipf's Law), as shown in Table 1.
The set of words that appears in the first superior quadrant is pointed as probable central nucleus because these words were evoked more often and more readily (23) .In that quadrant, the terms "support" and "patience" appear highlighted.The first due to presenting the highest frequency among the terms evoked, and the second due to the lowest average order of frequency, indicating that this term is the most readily evoked.These characteristics confer a character of consensual organization of senses to the group's social representation.The words in the central system have some associated characteristics: they are part of the individuals' thinking through the fixation of collective memory; they constitute the consensual base that is shared collectively, which favors the homogeneity of the group; they are stable and coherent ideas, and, finally; they are a little sensitive to the social conditions (16) .
In this probable central nucleus, we identified elements of different dimensions of care: while on the one hand there is the latent content of the nurses about the "support" and "attention" directed to the woman involved with drugs; on the other hand, there is that term which reveals problems that directly affect this perception of care -the aforementioned observation of the "incompetence" and that this care is "difficult", requiring the act of making "no judgement." The transition elements, present in the first periphery, second superior quadrant ("guidance", "reception," and "strength") reinforce the ideas of the probable central nucleus.Generally, these elements promote the association between that which is lived (concrete reality) and the central system, hence they enable contextualization, mobility, flexibility, and integration of personal experiences and individual histories (24) .
In the 2nd periphery, the fourth quadrant of Table 1, despite containing elements that are less frequent and considered less important in the evocations (19,16) , there are evocations that refer to actions and limitations of nurses in the care for women involved with drugs.Thus, the terms "intensified care, exhausting, fear, prejudice, and vulnerability" represent the limitations present in the mentioned central nucleus.This finding contrasts with elements that collaborate to the development of care, when appear the words "love, care, refer, multiprofessional, respect, and services".
The elements with low frequency but considered important to the nurses about the phenomenon studied are in the contrast zone: "treatment, understanding, assist, humanization, and sexually transmitted infections."The terms evoked are in line with normative aspects of care expressed by the central elements.The contrast zone of the four-frame houses comprises evocations that mean changes or transitions of social representations.These elements characterize the variations of representations without, however, changing neither the essence of the central nucleus nor the own representations (25) .
In the perspective of detection of the connectibility of the elements considered as structuring of the social representations of the nurses about the care for female drug user, the same free evocations underwent similarity analysis through the tree (Figure 1) resulting from processing by the IRAMUTEQ software.
Results from this analysis confirmed the structure of the representational field about the stimulus studied through prototypical analysis and analysis of concurrences between words and connections with other terms configuring axes: support (13); attention (12); incompetence (11); guidance (10); patience (9); strength and reception (8); understanding and fear (7).
Based on the interpretation of the four-frame houses and of the similarity tree, we can point the centrality of the social representations and the relation between the central nucleus of the evocations.In this sense, in Figure 1 there is a linear tree that shows the elements of the four-frame houses arranged so as to understand the centrality of the social representations of the nurses about the care for female drug user.At the central level in the tree there are terms that match with aspects that are intrinsic to the process of care; however, these are surrounded by elements that impact negatively on care.
Thus, it can be said that, in relation to the terms of the central nucleus of Table 1, the words "support, attention, and patience" represent care as part of humanization for nursing assistance.The words "incompetence" and "difficult" represent cultural and social aspects related to drugs and to consumption of these substances by women, as well as to professional training and institutional structure.
The expression "no judgement" emphasizes the need to overcome prejudices related to the woman who uses drugs.Following this itinerary, the word "patience" reflects a characteristic considered by participants as necessary to care for women who use drugs, due to processes of abstinence and aggressive acts.The terms "reception" and "guidance" are interwoven in the process of care, as shown by their positions in the similarity tree, being evoked as a complement to the care developed by nurses.
The word "strength" represents the idea that it is something that requires willingness and desire as a way of coping, and, consequently, justify the permanence of the elements "incompetence" and "difficult" in the central system.
In order to understand the context of the representations under study, we analyzed the interviews, from which emerged a central theme associated with the care for women involved with drugs with three categories: support; incompetence and difficult; fear and prejudice.From such categories, 7 subcategories were obtained (Chart 1).
Nurses in the context of care for women involved with drugs develop as main actions: support and referral of these users of the service.The category "support" is subcategorized as "reception, actions of guidance, and specialized referral."These subcategories involve listening, giving attention in an attempt to improve the self-esteem of women aiming to foster self-care and care for the newborns in the perspective of them quitting the use of drugs.
The subcategories "actions of guidance" and "specialized referral" reveal that these are the common activities of the interviewees in seeking that other specialized professional(s) address the demands of the women, with regard to the consumption of drugs.Therefore, it is emphasized that this category reinforces the structure of the social representations of nurses about the care for female drug users, showing situations and ideas about the practice of these professionals.
With regard to the categories "incompetence and difficult" and "fear and prejudice", the participants reveal the incompetence of professionals and health services to implement specific care for women who use drugs.Nurses point out aspects of the lack of knowledge both in the level of training and of permanent education and institutional gaps (of public services), which hinder the care in the context under study.
Moreover, these professionals emphasize the need for intensified care, in the sense of alertness when providing care to these users in the maternity ward, reporting, for example: fear of violence from users of the service and their companions; transmissible infections prevalent due to the low education level of these women; when they need to investigate the women's type of involvement with drugs and their companions to establish the nursing care plan.

DISCUSSION
The social representations analyzed match the care reported in the interviews, based on the categories of Chart 1 "support" and "specialized referral", also present in the evocations, with "support" being an element of the central nucleus of the representations and "referral" a peripheral element that reinforces the "support" as element that structures the representation of care for female drug user.The representation of support pervades the practices adopted by the nurses, since all nurses report the support for the woman involved with drugs as fundamental for the implementation of other actions in the pursuit of integral care.Integral and humanized care requires multidisciplinary approach in serving to the needs of the person to be assisted (26)(27) .The results show that nurses represent the care for woman involved with drugs while multiprofessional work that requires referral to specialized professionals and services in order to provide support, attention, reception, and guidance to these women.
However, these actions are permeated by the reported incompetence of the staff and of health services considering the difficulties pointed out, implicitly leading to neglect the problem situation.This finding is similar the results of a research on the social representations of nursing professionals about the care for individuals with HIV (11) .
The limitations that emerged in the second subcategory of Chart 1 are associated with evocations with high frequency in the central system -incompetence (12) and difficult (12) -and with the transition elements of social representations -prejudice, fear, vulnerability, intensified care, and exhausting.Even if not exclusively associated with women who use drugs, these same limitations for care also appear in researches on the professional activity of the nurse (28) in the context of women's health (27) .
Importantly, the lack of training of the health team with regard to care for people who use drugs is one of the concerns of the Ministry of Health since 2004.The policy of care for people that use alcohol and other drugs mentions the lack of curricula with multidisciplinary approach and the counterproductive perception of health professionals regarding individuals who abuse drugs (29) .
It can be affirmed that the participants consider, in their practice, the relevant care for women's health; however, the female involvement with drugs modifies this practice, when they report limitations as to professional training to deal with these women and lack of support for this demand in the service, presenting problems, difficulties, stresses, and vulnerabilities both for the individuals assisted and for themselves.
In this sense, the results indicate that the social representations of nurses about the care for women involved with drugs are associated with cognitive-affective aspects influenced by knowledge, values and beliefs and are part of experiences in the professional and private life.The participants of the study acknowledge the existence of a growing problem and of the demands of women who use drugs, pointing personal limitations and shortcomings of the public health service.Their social representations are associated with values, knowledge, Chart 1 -Analysis of the Thematic Content of reports from nurses operating on a public maternity ward about care for women involved with drugs, Salvador, Bahia, Brazil, 2016 (N=21) It is observed that, similarly to a study on the professional practices of nurses (28,30) , the care for women in general is provided at individual level; however, in the case of women involved with drugs, the care is restricted to common procedures for women in the context of maternity.
In this sense, the nurses recognize elements that guide the care for these users of health services, but report several factors that interfere with their actions.Among them: they deem themselves as lacking training to address the problem of drugs when women in gravidic-puerperal period are involved; programmatic gaps of the health care for women involved with drugs; and feeling of helplessness due to specific situations experienced in the context of care under study.These factors appear in the discourse of these professionals to indicate reasons why they restrict the care for these women, distancing from issues related to the problem of drugs.

FINAL CONSIDERATIONS
The social representations about women involved with drugs show to be influenced by technical and scientific issues apprehended in the training process and in the everyday work of maternity nurses.Thus, positively, these representations are founded on principles that advocate the integral care and humanization in health care for women.However, there are representations, based on everyday issues of the maternity and of the private life of each participant while social subject, that show difficulties for the empowerment of nurses in the care for these women, that is, being trained to provide cordial handling, to manage the nursing staff, and to conduct the promotion, recovery, and maintenance of the health of women involved with drugs in the gravidic-puerperal period.Overcoming these issues requires individual, social, cultural, and political changes.
This study indicates that the context of care for women involved with drugs is complex and comprises, in addition to aspects of the care practice, problem situations related to the group's representation about the care for women involved with drugs.
The frequent occurence of women in the gravidic-puerperal period with the conduct of consuming and/or trafficking drugs or, even, with companions that use drugs confirms the existence of a social and health problem that requires new perspectives and political and managerial actions not only in health services but also in professional training.

Figure 1 -
Figure1-Tree illustrating the similarity analysis for free evocations of nurses for the inductor stimulus "care for female drug user", Salvador, Bahia, Brazil, 2016

Table 1 -
Four-frame houses of the nurses' evocations for the inductor stimulus "care for female drug user",Salvador, Bahia, Brazil, 2016 : corpus of thematic content analysis and practices that guide the conduct in daily social relations and are emphasized by means of discourses, expressions, attitudes, stereotypes, and feelings. Source