EVALUATION OF CARE FOR CHILDREN AND ADOLESCENTS USERS OF PSYCHOACTIVE SUBSTANCES: POTENTIALITY AND FRAGILITIES

Objective: to evaluate the care to the child and the adolescent in treatment in the general hospital for mental and behavioral disorders due to the use of psychoactive substances, from the perspective of the Nursing. Method: evaluative study, of the case study type, with the use of the theoretical-methodological reference of the Fourth Generation Evaluation. The group of interest was composed of 19 professionals of the Nursing team of a Unit allocated in a general and teaching hospital of the West of Paraná. Data were collected from June 2015 to February 2016 through 410 hours of non-participant observation, individual interviews, following the hermeneutic-dialectical circle and a negotiation meeting. Data analysis was performed using the Constant Comparative Method


INTRODUCTION
The care of children and adolescents with mental and behavioral disorders due to the use of psychoactive substances in the general hospital is an emerging health reality.The work of nursing professionals with this clientele requires efficient care and knowledge of the determinants of the use and abuse of these substances. 1 The changes that occurred in Brazil, in the area of Mental Health and the implementation of the Network of Psychosocial Care, 2 with the emergence of new services, provide the possibility to reflect on the nursing professional practice with this clientele.Closely related to reflection is the possibility of evaluating care as a means of contributing, through the production of knowledge, to subsidize this practice.
Considered as phases of physical, psychic and mental structuring, both the infantile phase and the adolescence are responsible for a total remodeling of the individual.Therefore, those who are at such stages of human development need differentiated care, as well as the introduction of effective educational actions directed specifically to their demands. 3This need is due to the fact that the individual gradually prepares to leave the exclusive family life and, as a means of personal identification, begins its insertion in other social groups. 4oing through complex processes such as growth and development alone make children and adolescents peculiar. 3] A peculiar characteristic of adolescence is the need for social approval and the susceptibility to suffer influences that favor the early consumption of alcohol and tobacco, for example, which can be the "gateway" to the use of other psychoactive substances.
] This behavior can be self-destructive in face of the physical, psychic and social damages that alcohol consumption can bring to the life of this young person.
For individuals in the childhood and adolescence phase, changes in behavior, thinking, and even their organic functioning due to the use of psychoactive substances can be confused with behaviors often associated with the phase in which they are found, since these individuals lack criticism about the harms, that the abuser status of these substances can bring to your health.Thus, they tend to deny that these behavioral changes result from the abuse of psychoactive substances. 7t is necessary, then, that nurses recognize that different environments interfere with behavior and child health, producing direct influences, be they negative or positive.9] With the appropriation of this knowledge, intertwined with the recognition of the subjectivities and specific peculiarities of the phase of childhood and adolescence, the nurse can then develop the care directed to the needs of each individual.
The emergence of beds for mental health treatment in the general hospital allowed the expansion of nursing activities, provoking the professionals in this area to reflect on the possibility of their professional practice with individuals with mental disorders; among them, those in treatment for mental and behavioral disorders due to the use of psychoactive substance. 10However, it requires the mobilization of a body of specific scientific knowledge, especially when it comes to children and adolescents.

4/14
Nowadays, the use of substances by children and adolescents at an early age is increasingly perceived. 11Thus, it is believed that because they are doubly vulnerable individuals, primarily because of the ease with which they are influenced, due to their age group and, mainly, the consumption of substances, given the physical and behavioral changes they cause in these individuals, the care of nursing directed to this clientele requires closeness, affection, touch and respect for the subjectivities of this specific and peculiar phase of human development.
It should be emphasized that care for children and adolescents with mental and behavioral disorders due to the use of psychoactive substance can and should be carried out, preferably, in open services such as Psychosocial Care Centers (CAPS).However, when the possibilities of care in these services have been exhausted, these individuals can be referred for evaluation and hospital admission when necessary. 11hen hospitalization is necessary for treatment, it should happen, preferably, in Psychiatric Units at the General Hospital -PUGHs.Care in such Units is developed by a multiprofessional team, whose largest contingent is formed by nursing, which, in turn, remains longer time close to the patient in care activities.
Considering the perspectives of the Brazilian Psychiatric Reform, which directly interfere in the way of thinking and executing care in the area of Mental Health, it is necessary to have an accurate look at the nuances of this care, in order to evaluate the way it is performed; making their potentialities and fragilities emerge, as well as proposals for improvements, listed from the perspective of the nursing team of the service itself.Thus, the evaluation process is of paramount importance because it is through it that one can glimpse possibilities of process improvements, such as nursing care and the production of knowledge and reflections of the practice in its development.
The use of the theoretical-methodological framework of the Fourth Generation Assessment makes it possible for a particular interest group to be heard and to openly expose its needs and demands through negotiation between the group and the researcher.The purpose of this negotiation is the possibility of thinking about new work dynamics through the validation of actions with the professionals involved in the evaluation process. 12ased on the foregoing, this study is justified, mainly, by the need to focus attention on the new public modalities, in mental health, aimed at attending children and adolescents with mental and behavioral disorders due to the use of psychoactive substances, such as the treatment units allocated in general hospitals, seeking to evaluate the care developed to these clients, in a qualitative way.
The guiding question is: "How does the nursing team evaluates the care of the child and adolescent in general hospital treatment for mental and behavioral disorders due to the use of psychoactive substances?"To answer this question, we defined as the objective of the study: to evaluate the care to the child and adolescent in treatment in the general hospital for mental and behavioral disorders due to the use of psychoactive substances, from the perspective of Nursing.

METHOD
This is a qualitative evaluative study, of the case study type with the use of the theoreticalmethodological reference of the Fourth Generation Assessment. 12The intention is to produce a high level synthesis, a consensus on a particular topic discussed, when possible.In this process, each participant comes in contact with the constructions of the other members, which allows the modification and expansion of their own constructions. 12he Fourth Generation Assessment is based on the constructivist paradigm, considering that reality is formed by social and mental constructions, existing as many as there are people, since 5/14 each one elaborates his in a subjective way, even if there is questioning if these many constructions are socialized.It also has a responsive approach that translates into a different way of choosing the parameters and limits of the evaluation that is desired, since the parameters are chosen through negotiation between evaluator and client.In the evaluation using the responsive approach, there is an interactive negotiation between the interest groups.By this characteristic of negotiation and interaction, it is said that the responsive evaluation is emergent, because it arises from a context. 12he hermeneutic-dialectical process is called the hermeneutic and comparative process, as well as the inherent contradiction of the dialectic. 12The choice of this reference was due to its power in the production of a correlation between individual constructions that can be examined by all the individuals involved in this process and also by its possibility to offer an interpretation through the hermeneutics and to work with the conflicts, the contradictions, the movements of the group and the consensus opportunized by the dialectic.
This study was carried out in a unit aimed at the care of children and adolescents diagnosed with mental and behavioral disorders due to the use of psychoactive substances, located in a general teaching hospital in the West of Paraná.This unit has 17 hospitalization beds and a multiprofessional team, composed of 19 nursing professionals (five nurses, eight technicians and six nursing assistants), a social worker, three psychiatrists, a team of elementary school teachers and a volunteer psychologist who attends six hours a week.
The following inclusion criteria were used for this study: being a professional of the nursing team, and developing activities of direct care to the patients.Thus, the participants of this study were all 19 professionals of the unit's nursing team.
It is important to highlight the importance that the general hospital has as a place for the care of the child and adolescent in treatment for mental and behavioral disorders due to the use of psychoactive substances, considering that these are beings at an early age, in the growth phase and development, and therefore the need for non-stigmatizing spaces to offer care.
Initially, contact was established with the Nursing Directorate of the Institution and coordination of the unit, in which the study was developed, for an exposition on the subject of the study, clarification of the objective, methodology, data collection procedure and possible doubts about the study.In this phase, the choice of the group of interest that was formed by the participants of the evaluation 12 which for this study was composed of the 19 professionals of the unit's nursing team, previously mentioned.The choice of a single interest group was attributed by the intention to develop the study from the perspective of the nursing team.
Contact with the field occurred through a meeting held in June 2015.Then, the data were collected through non-participant observation, with the purpose of approaching the object of study, which totaled 410 hours.Subsequently, the observation became more focused and focused on understanding the dynamics of care of the unit and extended, concomitantly with the interviews, until the end of the data collection.All observations were recorded in the field diary and included the analysis and part of the data presented in this study.
The interviews were conducted individually for each professional from August to December 2015, recorded in a digital apparatus, in a room determined by the coordination of the service, whose duration ranged from 25 to 90 minutes.In the interview with the first participant, a semi structured instrument was applied, containing the questions: "Tell how the child and adolescent nursing care is developed in this unit"; "Talk about the facilities for developing this care" "Talk about the difficulties for the development of this care" and "What factors could contribute to improving care here in the Unit?".
The interviews were organized from the hermeneutic-dialectical circle, for which the researcher chose the first respondent R 1 .This individual participated in an open interview, which had an initial 6/14 construction on the object of study, later, his comments were analyzed, as well as his observations on the difficulties and facilities in developing the care, besides the factors that could contribute to the operation of the service.In addition, it has been requested that R 1 indicate the next participant who could contribute with varied observations or even give more depth to the observations made by the first participant.The analysis of the interview took place immediately after its conclusion.From the analysis of the observations of this participant, the first construction of the evaluation (C 1 ) and served as a source of information for the upcoming interviews, and so on, successively, until the last study participant was reached.
At the end of the interviews, which ended the hermeneutic-dialectical circle, the data were analyzed by means of the Constant Comparative Method, which is characterized by the steps of identifying units of information and categorization.The units of information are the basis for further definition of the categories of the study and may be phrases or even paragraphs. 12The result of this analysis was then presented to the participants in the negotiation meeting.
The negotiation meeting took place at a date and time previously scheduled with the participants and was attended by all.For the meeting, a printed material was produced, containing the synthesis of the data obtained from the analysis of observations and interviews and delivered to each participant.Afterwards, the results obtained in the interviews were presented, with presentation at Power Point, with the purpose of promoting the discussion, negotiation and validation of the data, thus finalizing the data collection stage.
After the negotiation stage, the data were reorganized based on the joint constructions of the participants and, through consensuses established by the interest groups and will be described, henceforth called thematic categories.
This study complied with all the ethical determinations established by Resolution 466/2012.All participants were previously briefed during the meeting with the researcher about the purpose of the study and, if they proceeded with the reading, signing and delivery of the Informed Consent Term.
To ensure confidentiality and anonymity, the participants were coded with the letter "P" for both Nurses and Technicians and Nursing Assistants, followed by Arabic numbers in random numerical order (P1,...P19), not with no relation to the order in which the interviews were conducted.

RESULTS
From the results analysis performed from the grouping of the information and validation units in the negotiation meetings with the interest group, the topics related to care presented in Table 1 emerged.
After the negotiating meeting, a total of 16 topics of consensus were reached by the interest group, and in this article, the topics that were most highlighted in the study will be presented and discussed.Thus, from the analysis and validation of the themes by the interest group, the following thematic categories emerged: a) Child and adolescent care; b) Potential care; and c) Fragilities in care, which will be described below.

Child and adolescent care
Child and adolescent care has different characteristics from the other units of the institution, since this age group requires different care.Thus, the actions carried out have an emphasis on education for self-care, emphasizing expressiveness through the professional and patient relationship based on communication, since there is often a need to teach, assist, and supervise, from the most elementary physical care to the relational and emotional.The participants emphasized that it is not only about doing for them, but being with them, as you say next.
In other sectors care is more directed to pain, dressing, bathing, here are other care, it is very difficult for someone to be in pain, our care is to listen more (P5).
[...]Here we sit with them, we teach them to eat, chew, eat slowly, eat salad, season the salad with them.[...] I realize that nursing care here is much broader than simply doing for them, it is being with them.[...] Our routine is proximity to patients (P8).Some participants emphatically mentioned the care in the unit related to communication such as talking, listening to what they have to say, imposing limits and rules, giving affection and touch:

[...] we sometimes spend most of the time locked up with a teenager in his room, listening to it, taking advantage and giving advice [...] it is often necessary to impose rules (P5).
Communication is recognized by the participants as extremely important in the care of such clients, because when they are admitted they often arrive with signs and symptoms related to depression, anger and anxiety.Patients sometimes report very intimate situations through which they have passed and this reality is considered by the participants to be so unique in relation to the clientele of other treatment units that it also affects the caregiver: We are a little mother, of psychologists, a little of everything [...] we listen, we give advice, [...] we heard things of shivering [...] more complex things that happened in their lives that are more complicated and that they tell us (P5).we talked to them a lot because they came down depressed, angry, anxious, and it both affected both our psychological and theirs.[...] I believe our care here is almost all based on conversation (P13).

Potentials of care
The study participants discussed the importance of the mental health care network and focused on the "network meetings", one of the actions developed by the unit in conjunction with the other services of the Health Care Network.It should be noted that P12 refers to such "meetings" as mental health matriculation.According to him, this would be a Primary Care initiative in conjunction with the CAPS, but the unit took on the task, because it understood the importance of this action for the continuity of the treatment of children and adolescents.
I really like to organize and participate in the matrix, which we try to do with our patients, but it is to assume the responsibility of another one because the matrix has to be done there in the basic assistance, with CAPS and Basic Health Unit and as this is not done in a general way, we assume, because we understand that it is important, we cannot get out the way they were leaving, with no agreements out there (P12).
It was agreed among the participants that the planned and performed care activities together with other professionals, cited by P11 as a multidisciplinary consultation, include the potentialities of the care they develop in the unit and represent advance and gain for the patient and team, since the decisions are taken as a team and no longer restricted to a single professional.They mentioned that this is a learning space for the professionals involved, in which everyone can participate and be heard.They highlight gain to the patient when they report that the interdisciplinary actions contributed to the decrease of sedation, previously common practice in the Unit.
The multidisciplinary consultation was an advance, because today we attend as a team, today it is not the doctor who decides, or the nurse, or the coordinator.From the first consultation, when the patient arrives until the last attendance, everything is decided in team.[...].The doctor, the social worker, the nurse, the psychologist, the pedagogue, and someone from the team of technicians take part in this consultation.This has been a great gain for the patient and the team to develop work with this patient during the hospitalization cycle.[...] I think this is a learning moment (P11).

Fragility in care
Participants mentioned difficulties in care related to the insufficiency of human resources, the restricted physical space of the unit for the number of patients attending: o ur difficulty is in relation to the physical structure, the unit is small for the demand that it attends, it lacks human resources, because sometimes it has two technicians [.

..] and has a cycle with 17 adolescents. [...] the lack of human resources and physical space ends up being a difficulty to develop care (P1).
The most repeated difficulty of the participants was related to the structure, the restricted physical space and inadequate to provide activities to adolescents and children during the 40-day cycle that remain in full-time treatment at the Unit.Some of the patients may receive referrals to therapeutic communities during the hospitalization cycle and therefore do not remain in the unit for 40 days.Considering that this clientele is under development, aggravated by the problem of involvement with substances, it needs that its energy be used directed to activities that promote a healthy physical and emotional development.

DISCUSSION
Considered a singular and subjective act with the intention of promoting the well-being of those involved, the care, inherent in professional practice in the health area, is considered essential.Endowed with a relationship of interaction and proximity between those who promote and those who receive, this act produces the approximation between individuals within a given social context, enhancing the care that is developed in its most singular and comprehensive form. 13are has been part of human life since the emergence of humanity and is translated into an act of zeal, a demonstration of concern for the well-being of the other.Thus, it is said that care involves a set of actions that try to take care of the other for the maintenance of their lives with responsibility, affective involvement, respect and solidarity. 14hroughout its history, Nursing has been influenced by different currents of thought that enabled reflection on concepts that underlie its doing and promoted changes in its professional practice, which served both to expand its field of attention and to implement a differentiated way of thinking and caring.Some of these influences, once suffered, are based on the Cartesian positivist model and scientific rationality that understand the human body as a machine, disregarding its feelings, emotions and subjectivities.] In line with what the participants have said about the care offered at the unit, the literature emphasizes that during the course of their professional career, nursing has been trying to break away from the impersonal way of looking at the individual receiving care, in an attempt to establish a more with it.Increasingly, the individual presents himself without being heard, respected, recognized and understood in his subjectivity.For the development of its practice with this clientele, nursing needs to reflect on the human dimensions of its care that involves feelings, hopes, frustrations and expectations that characterize being as unique. 14n addition to the evaluation of care with a focus on educational actions for self-care, we note the mention in expressive actions when P5 recognizes that the care that the clientele of the unit demands has an emphasis on the subjective when affirming that it is more listening to the patients.
The recognition of the need for subjective care makes the need to know its dimensions, instrumental and expressive.The instrumental dimension of care is characterized by physical actions, directly related to the fulfillment of social roles, in which the care process is based mainly on scientific knowledge and practical actions such as administration of medication and body hygiene.The expressive dimension of care, considered as important as the instrumental one, especially considering the context in which it is applied, has an emotional nature and is the result of interaction with the other in which the expression of experiences, feelings and subjectivity is allowed of being, through a dialogical relationship. 14ssertively, the relationship of care that is established between nursing and the individuals under their care, a lot, is due to the process of communication between both.In this, the nurse plays a fundamental role since his activities developed with the patient are not restricted to the execution of techniques, but actions that denote a more comprehensive care that considers being in its totality. 15articipants were emphatic in mentioning elements of communication and interaction during care and, although they did not make explicit the therapeutic communication, it is known that closely related to the relationship of care, there is a need for the nurse to apply it with a view to performance of their activities with the person receiving their care.The purpose of therapeutic communication is to provide a relationship that allows an effective relationship that achieves the goals of nursing care globally.This process allows changes, based on the needs identified by the nurse, that match the wishes of the individual who cares. 16

10/14
Thus, it is important that the nursing team be able to identify the needs presented by the individual, since often, the form of communication in mental health, in practice, can be expressed through gestures, looks, touch.Because it is the closeness of the team to the individual that makes it possible to understand this form of expression, especially when developing care for children and adolescents.Thus, it is possible for the nurse to be able to plan care according to the needs of each individual, since he recognizes them in the individual himself through the therapeutic bond. 17he therapeutic link that nursing establishes with the patient is an important instrument of care, since it allows for the psychic reorganization of the individual, which allows himself to be understood in its totality, showing his needs, limitations and potentialities.][19] With respect to therapeutic listening, a survey carried out in a psychiatric hospital in Rio de Janeiro (Brazil), attended by 15 professionals from the nursing team, presented that mental health nursing care requires qualified, sensitive listening and needs to be performed in the daily practice of nursing, since by facial expression or even speech, an individual may signal something serious to the team as intensification of some symptom or even suicidal ideation. 17he one referred to by P12 as matrix constitutes, in fact, meetings of agreement of responsibilities between the unit and the municipalities that will receive the child or the adolescent.Although it is not entirely a question of the policy of matrix as envisaged in public policies, this initiative is important, since in the empirical evaluation of professionals, after the beginning of the meetings of agreement, the role of each primary care service is defined and contractualized from the municipality to the child or adolescent, a strategy that has contributed to the reduction of relapse and, consequently, hospitalization.
It would be important, however, for the municipality to organize the matriculation based on the documents of the Ministry of Health that defines matrix or matrix support as a differentiated way of producing health, in which the interconnection between two or more teams occurs in a construction process and through it a proposal of pedagogical and therapeutic intervention is created. 18atrix brings with it the integration proposal that aims to transform the traditional vertical logic of protocols and bureaucratic procedures, of little efficiency, into a dynamic with horizontal actions that integrate the components and their knowledge in the different levels of care.Thus, the matrix process is structured between the reference team and matrix support.Thus, the matrix and reference support teams are, at the same time, organizational arrangements and a methodology for health work management, in order to expand the possibilities of dialogic integration between different specialties and professions. 18t is important to understand that matrix support is something different from the care provided by a specialist within a traditional primary care unit.] Matrix is a tool of transformation, of the health and illness process and of the whole reality of these teams and communities, in order to enhance the interactivity between basic care and other services. 18,20Thus, it is not an exclusive tool of any specialty, since it belongs to the entire field of health, making it an interdisciplinary work process by nature, with practices that involve knowledge exchange and construction. 201] This ability is developed in matrix, by the reflective elaboration of the experiences made within an interdisciplinary context, in which each professional 11/14 can contribute with a different look, broadening the understanding and the capacity of intervention of the teams. 19he difficulty reiterated by the participants, which translates into fragility for the development of care, was related to the structure, the physical space restricted and inadequate to provide activities to adolescents and children in full time in the unit.
According to the literature, the implementation of beds intended for mental health care in the general hospital space requires that the service provide qualified multiprofessional staff, therapeutic space with an area outside the hospital for leisure, physical education and other socio-therapeutic activities.In addition to space, there is a need for this service to offer activities such as individual and group care with a family approach and guarantee of necessary referrals so that, after discharge, the continuity of treatment in referral services of the out-of-hospital care network. 22he physical space required for the implementation of beds for mental health care has become one of the greatest difficulties in the current structuring of general hospitals in Brazil.Another barrier found to be effective in the general hospital as a component of the mental health care network is the lack of professional qualification that directly reflects the lack of knowledge, understanding and, sometimes, the refusal to act according to the current model of attention to mental health.] As a limit of this study, it is pointed out that it has chosen as the interest group, in particular, only the nursing team, resulting in the construction of an evaluation process from this perspective.Undoubtedly, the inclusion of other professionals and managers would broaden the discussions in the evaluation process.The choice of a particular interest group was due to time and financial resources.

CONCLUSION
The joint constructions and reconstructions developed with the participants, presented in the analysis item of the results, are as foreseen in the Fourth Generation Assessment Framework, in a sophisticated synthesis; since the participants evaluated the nursing care provided in the study scenario as differentiated from the other units of the institution.Therefore, this care was considered as broad and complex mainly because they worked with children and adolescents with disorders related to psychoactive substances.
The care developed is permeated by communication with the patient and is transfigured in the essence of the care they offer, taking into account the subjectivities of the child and the adolescent, considering the peculiarities and specificities of their development phase, with emphasis on the actions that denote a care with characteristics prominently expressive.Care for this clientele sometimes includes the imposition of rules and limits at certain times, because they are individuals in the development and training phase, with peculiar characteristics, added to the proper aspects of the disorder due to the use of substances.
The participants emphasized how multidisciplinary actions, in which all the professionals of the unit participate, thus allowing discussion, learning reflection and the establishment of a joint action plan.Responsibility pacing meetings between the unit and the municipalities from which children and adolescents come were evaluated as essential for the prevention of relapse of substance use and new hospitalization, contributing to the continuity of treatment after hospital discharge.In summary, the item evaluated as the greatest potentiality, by the interest group, was the meetings of agreement of responsibilities with the services, a theme for which there was a full consensus during the course of the hermeneutic-dialectical circle.

4 .
More intense care in actions than the usual Nursing techniques.5.Readiness and internal availability for care.6.Multidisciplinary meetings as a moment of learning.7. Contributions to network meetings for care.8. Non-recognition of the work in the unit by the manager.9. Lack of professionals from other areas.10.Violence against the team.Issues for which there was no consensus 1. Detoxification and treatment.2. Prejudice in care.3. Need for in-service training.4. Resistance to change.5. Role of the nursing team in mental health care.Topic included for discussion at negotiation meeting 8/14 [...] We basically talk [...], we do artistic activities, things that are not done in other wings.[...]

Table 1 -
Consensus, non-consensus and included topics according to the interest group