Care of alcoholic persons in primary care services: perceptions and actions of registered nurses

Abstracts

OBJETIVO: Verificar como ocorre o atendimento ao paciente com problemas relacionados ao uso de álcool em serviços de atenção primária à saúde na percepção do enfermeiro, identificando suas condutas frente a esse usuário. MÉTODOS: Estudo exploratório, qualitativo, envolvendo dez enfermeiros de três serviços da atenção primária à saúde. Os dados foram coletados por registro autogravado e submetidos à análise temática do conteúdo. RESULTADOS: O atendimento ao alcoolista caracteriza-se por ser rápido e focado nos sintomas que norteiam as condutas do profissional. O tipo de assistência que vem prestando a essa população, gera insatisfação nos mesmos, pois acreditam que maior atenção deveria ser dada a esses indivíduos nos serviços. CONCLUSÃO: O atendimento ao alcoolista e as condutas do enfermeiro centralizam-se nos sintomas da intoxicação aguda, em detrimento de ações que visem à identificação precoce e prevenção do agravamento dos problemas relacionados ao álcool e ao alcoolismo.

Centros de saúde; Álcool; Alcoolismo; Cuidados de enfermagem

ORIGINAL ARTICLE

Care of alcoholic persons in primary care services: perceptions and actions of registered nurses^*

Atención a alcohólicos en servicios de atención primaria a la salud: percepciones y conductas del enfermero

Divane Vargas^I; Márcia Aparecida Ferreira de Oliveira^I; Margarita Antonia Villar Luís^II

^IPhD Professor at the Maternal Child and Psychiatric Nursing Department, Universidade de São Paulo. São Paulo (SP), Brazil

^IIFull Professor at the Department of Psychiatric Nursing and Human Sciences, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Ribeirão Preto (SP), Brazil

^{Corresponding Author}

ABSTRACT

OBJECTIVE: To describe the perceptions and actions of registered nurses regarding the care of alcoholic persons in primary care services.

METHODS: This was a qualitative exploratory study with 10 registered nurses from three primary care services. Data were collected through tape-recordings and categorized through content analysis.

RESULTS: The care of alcoholic persons was characterized by fast care and focused on symptoms needing immediate nursing interventions. This type of care generated dissatisfaction of the alcoholic persons, because they should receive more attention in primary care services.

CONCLUSIONS: Care of alcoholic persons and actions of registered nurses focused on the symptoms of acute intoxication only. There was no focus on early identification and prevention of problems related to the use of alcohol and alcoholism.

Key words: Primary Care Services; Alcohol, Alcoholism; Nursing Care.

RESUMEN

OBJETIVO: Verificar como ocurre la atención al paciente con problemas relacionados al uso de alcohol en servicios de atención primaria a la salud bajo la percepción del enfermero, identificando sus conductas frente a ese usuario.

MÉTODOS: Estudio exploratorio y cualitativo, envolviendo diez enfermeros de tres servicios de atención primaria a la salud. Los datos fueron recolectados en un registro autograbado y sometidos a análisis temático de contenido.

RESULTADOS: La atención al alcohólico se caracteriza por ser rápida y enfocada en los síntomas que orientan las conductas del profesional. El tipo de asistencia que se está prestando a esa población, genera insatisfacción en la misma, ya que creen que una mejor atención debería ser dada a esos individuos en los servicios.

CONCLUSIÓN: La atención al alcohólico y las conductas del enfermero se centralizan en los síntomas de la intoxicación aguda, en detrimento de acciones que tendrían por objetivo identificar precozmente y prevenir el agravamiento de los problemas relacionados al alcohol y al alcoholismo.

Palabras clave: Centros de salud; Alcohol; Alcoholismo; Cuidados de enfermería.

INTRODUCTION

In the last decades, the use and abuse of alcohol has increased greatly, and has become one of the main risks to health in the world population. According to the world health report, in 2002 the use of alcohol was the main risk to health in developing countries and in the American region it was the main risk factor among the 27 factors assessed in morbidity burden⁽¹⁾. In Latin America, it is estimated that disorders related to alcohol addiction represent more than 50% of all morbidity burden. Thus, among the more than 30 million people that can be diagnosed with disorders due to alcohol use, only 25% received some kind of medical care⁽²⁾.

In Brazil, the last national survey⁽³⁾ estimated that about 12% of all the population met the criteria for alcohol addiction, justifying the great percentage of individuals with alcohol problems and alcoholism in hospital admission units, or searching care in primary health units.

As for the presence of these people in primary health care units, the study⁽⁴⁾ carried out by the World Health Organization, pointed out that the prevalence of alcohol addiction in these units was 2.7%, the third most prevalent psychological disorder after depression and anxiety. In Brazil, recent surveys^(5-6) found significant percentage between 3% and 9.8% of people with alcohol problems and alcoholism in these units. These data corroborate the estimations of the Ministry of Health⁽⁷⁾ that 9% of the country's general population requires occasional care for mental health disorders (less severe disorders), including disorders due to the hazardous use of alcohol and other drugs.

These percentages show that nurses in primary health care units face every day problems related to alcohol and alcoholism in their professional practice. According to the literature⁽⁸⁾, primary health care professionals are in a privileged position to intervene in excessive drinking because a great deal of the population has access to these services. Primary care nurses have greater contact with these patients and, therefore, get more information on their patients' alcohol use⁽⁹⁾. Studies on this issue^(10-12) showed that nurses are efficient in reducing excessive drinking in primary health care. These professionals have a potential to reduce the prevalence of drinking problems, however, the practices to face the problem are underused⁽¹¹⁾ and have little effect⁽¹⁰⁾.

A study12 showing the opinions of nurses on drug users, demonstrated that they are predominantly viewed as sick and victims of social conditions.

Another study⁽¹³⁾ carried out with nurses from district UBS showed that nurses lacked knowledge about the problematic. Nurses were permissive with alcohol use; however, they were against excessive drinking. Additionally, these nurses saw alcoholism as a disease and the alcoholic as a sick person. However, there was a strong influence of the moral model on the explanation of the two concepts.

Overall, we may say that in the last years, several studies have been published on nurses and the issue of alcohol and alcoholism^(12-15). However, most of them have studied nurses in hospital units^(14-15), which a lack of studies with nurses in primary health care.

Considering that nurses in primary health care are a strategic resource to face problems of alcohol abuse⁽⁷⁾. Because they are close to patients⁽¹²⁾ and that they can significantly contribute in primary, secondary, and tertiary prevention of alcoholism, especially in primary health care, the objective of the present study was to assess how care to patients with alcohol use problems is provided in primary health care units according to nurses' perceptions and their behaviors with users.

METHODS

Exploratory study, with a qualitative approach, in three primary health care units in the city of Ribeirão Preto-SP. The choice of units was justified because they are reference basic units in the city with greater technical capacity and specialized care to individuals with chronic and/or acute complications in addition to care for the population 24 hours a day, non-stop. Data were collected from May to July 2004, through direct and semi-structured interviews, with the following guiding question: "How do you feel about dealing with alcoholic patients?"

Considering the characteristics of the qualitative research method and those of the theoretical methodological reference chosen, the study sample was defined by theoretical saturation of data and involved ten nurses that were intentionally selected according to their work shift in the unit, (morning, afternoon and night).

Data analysis used Content Analysis⁽¹⁶⁾, and thematic analysis⁽¹⁷⁾ as the theoretical reference, adopting the following methodological proposal: ordination, classification and final analysis of data⁽⁹⁾. Data ordination consisted in transcribing recorded tapes; rereading the material; organizing reports in a certain order according to the analytical proposal. Data classification was operationalized and performed by exhaustive and repeated reading of texts. Through this exercise, the relevant structures were understood based on the statements of study subjects from which the thematic areas have been identified. Later, each theme was assessed to understand interviewees' statements, care provided to individuals with alcohol problems in these services and how nurses manage these patients.

Ethical procedures for the study were approved by the Ethics Research Committee of the Escola de Enfermagem de Ribeirão Preto, USP. Participants gave their written consent.

RESULTS

Of the ten subjects of the study, only one was male, the most frequent age group was from 41 to 50 years old. Years after graduation was 16 to 20 years, there were 4 masters and 9 nurses with specialization in collective health.

Two categories, which will be presented next, emerged from content analysis of the interviews: Care for alcoholic patients in the unit and how it was managed by nurses and, Conceptions on how it is to work with alcoholics.

Care for alcoholics in the unit and how nurses manage it

Concerning care for alcoholics in the primary health care unit studied, results showed that nurses provide a quick care, focused specifically in detoxification, "We see, give glucose, and do a quick recovery" (E.4); "We puncture and give medication" (E.5). This type of care is supported by the unit dynamics which is characterized by a high turnover of people "The number of patients that come here is very high; it is a constant coming and going" (E.8). The increased demand of users looking for care in these units has a direct influence on the type of care provided to patients with alcohol problems, care is provided to stabilize the picture of intoxication as soon as possible so as to free the bed "When patients are better they are sent away because another person requiring that bed will soon come (E.5); Sometimes patients do not even lie down, they receive the medication on the chair and then they leave" (E.8).

Care focused on the immediate need of patients hinders a more specific care to these users, making it difficult to provide a more effective support and to establish a connection with patients "The bond is very small, when they recover a bit it is bye-bye" (E.1). This situation causes dissatisfaction in nurses because they can only focus on symptoms. They realize the need for greater attention to these individuals, and to have time for guidance and listening, "It would be good to talk to them, listening to her to find out what made a 16-year-old use alcohol this way, what it is going on, I think there should be a space for us to work this issue here in the service" (E.6).

The lack of possibility for a more specific work to deal with problems related to alcohol and alcoholism leads to feeling of helplessness, anguish and frustration in professionals since they cannot help patients properly. "It is very distressful to care for patients the way we care for them here" (E.6); "So, I was frustrated because I was not able to guide and talk" (E.7); "you cannot work with these patients; unfortunately, it is a bit frustrating here" (E.10).

They notice that the way they care for these users is not adequate and they point out the need for greater care to this type of patients. One of the interviewees questioned care provided by the units to patients, "We should find a way to really care for these patients, rather than what we do, is the unit really providing care?" (E.4). "I think we should have time to treat patients differently, because the way we do, people are not cared for; we just see them" (E.6).

From what was showed, nurses mention on their statements the ideal care. In this type of care, professionals should have time to care for patients properly, since with more contact and peace, they believe they could help people, making them reflect on their situation and, thus, contribute to their treatment, either to accept the problem or to refer them to specialized care. "With greater time and structure, we could talk to them about referral, and people could decide with greater security" (E.1); "We could talk to him, show him he needs help, he needs specialized care" (E.3).

As for care to these patients in the unit, nurses' statements show that some members of the staff despise and disrespect these patients as demonstrated by the following statements: "Some employees resist treating these patients with respect" (E.1); "The employee is ironic and does not respect the patient very much (E.2)"; "Normally, these patients are made fun of here in the unit" (E4). This behavior is disapproved by nurses because they believe alcoholic patients need to be treated with respect, they see alcohol addiction as a disease and, therefore, patients should be treated with respect just as any other user of the unit, "They need respect, just as everybody should respect professionals here, regardless of the reason, since alcoholism is also a disease" (E.1); "I think we have to treat them with respect, education, treat as a disease, especially chronic patients who are the most severe cases" (E.5).

Interviewees' statements⁽⁵⁾ reveal that chronic patients should receive greater attention because they are in an advanced stage of the disease and are therefore severe cases, "[...] Especially chronic patients Who are the most severe cases"; however, the analysis of the interviewees' speech show that this is a fact that makes the team pay little attention to users, because they are individuals known by the service and as being frequently intoxicated, they do not receive proper attention from these professionals who are cynical towards them: "Depending on the patient there is no special care" (E.1). "You have drunk again, why? And then you get the chart doctor X prescribes a glucose" (E.2); "The physician himself does not feel like talking, examining, if it is a repeated patients, who already knows, he just prescribes the glucose" (E.7).

According to the analysis of nurses' statements, care to alcoholic patients in the units studied is characterized for being quick and based on the treatment of symptoms. This type of care is a hurdle for a more specific care to this patient which leads to feelings of frustration in nurses since they consider it inappropriate. To these nurses, there should be a care that enabled greater attention to patients, and ideally, they would reflect on the problem. The statements of interviewees also show that care provided in these units involves refusal and lack of interest of the staff, a situation that is disapproved by those seeing alcoholism as a disease, and those suffering from it should have a respectful treatment.

As for the way nurses manage alcohol users in the units studied, the analysis of the statements show that they are consistent with the characteristics of care provided to alcoholics. In the unit, they refer mostly to those taken in cases of acute intoxication. Generally, care is fast and based on medication and performance of diagnostic procedures such as checking glucose. "We provide immediate care, check glucose, medication ad hydration" (E.3).

As a factor that determines how nurses manage patients is their clinical conditions upon arrival which, according to nurses' statements, is usually characterized by unconsciousness and coma. "Here we get them in coma" (E.1); "When they come, they are severely drunk" (E.4). Thus, patients' situation is pointed as a hurdle for a more affective intervention of nurses such as listening and establishing a relationship. "Here, there is no way to keep a relationship, everything is too fast" (E.8); "Patients arrive so drunk that there is no way of listening to them" (E.10). However, even though patients' conditions do not allow for a more directed care to the alcohol problem, there is the idea that individuals must be helped. "they are patients that need help, they need to be guided by people in the unit" (E.5).

Consistent with the perception that these are patients requiring help, the statements show that nurses look for strategies to offer help, represented by guidance, talk, listening, and an attempt for referral. Thus, in their statements they say that, whenever possible after the picture is stable, there is an attempt for using technique of therapeutic communication. "I try to talk, to listen to what they feel" (E.2). "I always try to listen and see if there is something I can do" (E.4); "I talk; I try to refer them to the AA or to provide follow up at the Primary Health Care to alcohol and drugs" (E.5).

However, one of the individuals mentions that the actions are not always effective, because patients usually do not accept the guidelines and referrals "but people never accept it, it is very hard" (E.4); Difficulty in accepting the guidelines and referral make nurses see these patients as not willing to help themselves or seek help, that is, patients do not feel like it, as demonstrated by the following statement" but people do not understand you, they are not in the mood, you see?" (E.7). Maybe this difficulty or refusal to accept help, together with the symptom present in acute intoxication lead to situations that marginalize individuals with problems with alcohol use within the unit, to such extent, that they are left in the background. In some cases, they are sent away from the unit, as the next statement shows "Actually, in a unit such as this one, they are left in the background and, sometimes, they are even sent away from the unit" (E.6).

The actions of primary health care nurses towards alcoholics, as expected, are consistent with the results referring to the type of care offered in these places, that is, care is fast, based on medications and immediate care to respond to symptoms. Thus, among the actions of nurses, there are measures to stabilize the picture, focused on symptoms and in some cases there are more specific approaches such as listening and referring patients, these last cannot always be performed because of patients' state when arriving at the unit, or due to the low acceptance of help offered by professionals.

Conceptions on the work with alcoholic patients

The work with alcoholic patients is considered difficult by nurses; "Working with a person that uses alcohol is very complicated, very hard" (E.1); "Alcoholics are difficult to deal with" (E.6). The explanation for this can be related to the characteristics of intoxicated individuals who usually refuse professional health; "they don't want to receive medication, they do not accept any kind of help" (E.2); Additionally, these patients are seen as aggressive which hinders their work; "It is difficult to work, because they do not understand you, they are aggressive" (E.7); "These patients are normally aggressive" (E.4).

These behaviors make work with alcoholics difficult, and seem to reinforce repulse against these patients in the unit, since they are seen as those patients that disturb, and upset the unit, making the team intolerant; "He becomes an annoying person, clinging and disturbs the unit, making us intolerant towards him" (E.5). Intolerance mentioned by the nurse in the previous statement is corroborated by the statement of one of the subjects, demonstrating that, in the idea of these nurses, this patient is aggressive, disturbs their work and takes the place and time of professionals that could be used with a person that really needs care: "Because, sometimes, you are worried with a more severe patient, he is aggressive, causing troubles, and giving too much work" (E.1).

As for the ideas of these nurses regarding work with alcoholics, individuals from the present study consider them difficult to deal with, which make the work harder, since they cannot understand some behaviors of these individuals, such as symptoms of diseases and acute intoxication. Additionally, there is an idea that alcoholics take the place of patients that "really" needed care.

DISCUSSION

Care provided to individuals with alcohol problems in these units, according to participants' statements, refers to care for acute intoxication and, therefore, focused on the symptoms, characterized as a fast care to stabilize the picture and discharge patients.

None of the nurses from the study mentioned actions to detect and prevent problems related to alcohol and alcoholism. We consider that these workers pay little attention to this issue, due to lack of technical preparation⁽¹³⁾, or because attention to these problems is not prioritized by health services, especially in this study with primary care⁽¹⁸⁾. This does not mean that lighter problems because of alcohol use are not present in these units^(5-6).

However, as showed by the literature, this type of patient is not always identified by the health team⁽¹⁸⁾. Authors⁽¹⁸⁾ point out that prevention, although is it widely discussed in theory, is rarely put into practice in health units, especially with alcohol and other drugs use and abuse. Alcohol addiction is not the main problem faced in basic health units since most individuals that present this problem are already undergoing treatment for alcohol-related problems. Therefore, the main focus at UBS should be detecting these problems and referring patients to treatment

As for nurses' actions regarding alcoholic patients, results are consistent with those from a similar study⁽⁸⁾, they are limited to treatment of symptoms, showing there are some attempts to sensitize individuals, one attempt of helping, either by making them reflect about their problem, or by referral to experts. This result indicates a tendency of positive attitudes of these nurses towards the problem of alcohol use and alcoholism, since studies⁽¹⁹⁾ show that nurses with more positive attitudes regarding alcohol and alcoholics are more willing to refer patients to treatment than those who present a negative attitude. Additionally, care provided to these patients makes professionals feel anxious and frustrated because they believe they could work more effectively to solve problems related to alcohol and alcoholism, approaching patients to talk about the issue after the picture is stable. This result is satisfactory when compared to other studies^(14-18), where one of the greatest problems reported by professionals in the care to this population was the approach to the problem of alcohol use.

Nurses from the present study are not familiar with Alcohol Dependence Syndrome and the symptoms of acute intoxication, since they see behaviors such as not accepting care for intoxication or referral to specialized services as a refusal to accept help and this is interpreted by these professionals as not wanting to help themselves. As reported by the literature^(11-15) this interpretation sees people with alcohol issues as not wanting to recover. Thus, alcoholics do not accept care or are aggressive not because they refuse treatment but rather because they are acutely intoxicated and have an altered behavior due to lack of consciousness, and this should not be a reason for being refused or sent away from the service.

There is lack of technical preparation to deal with the problem^(13-15) and the behaviors demonstrated by individuals are characteristic especially when the motivational stages involved in dependence are considered⁽²⁰⁾. In this sense, a therapeutic approach to identify the current stage of individuals is a more effective management than referring patients which, depending on the motivatio0nal stage patients are, will influence accepting guidance and/or referrals.

In agreement with the results from other studies^(13-18), the work with alcoholic patients is considered hard by nurses, and these patients are considered as not wanting to be helped and aggressive. There is also the idea that alcoholic patients disturb the routine of the unit. Despite these ideas, nurses believe patients should be treated with respect because they consider they have a disease, and sick people should be treated equally. This result is corroborated by other studies that show a consensus between nurses on the fact that alcoholism is a disease and alcoholics are individuals that deserve care^(13-18). However, when it is to work with these people, the ideas are not equivalent⁽²¹⁾. Negative attitude prevail supported by a moral model to explain alcoholism, with the dominant view that alcoholics are guilty for their disease.

Marginalization and staff's repulse to these patients show the influence of the moral model⁽²²⁾ in the care provided to these users. Authors⁽¹²⁾ have pointed out the fact that situations showing disrespect and practices with these patients that can be criticized in the ethical and moral standpoint are common.

CONCLUSIONS

Care of individuals with alcohol issues in the primary health care units studied is characterized by being focused in the treatment of symptoms of acute intoxication. Nurses' actions are limited to medicating intoxicated individuals. These results could have been influenced by the characteristics of the units that are considered reference basic units, and, therefore, they deal mainly with care for acute intoxication.

Nurses were not satisfied with the type of care provided to users and whenever they can, they use strategies to sensitize and refer alcoholic patients to specialized treatment. The work with these patients is considered difficult by nurses, which can be justified by the characteristics and behaviors of these individuals, showing lack of technical preparation and unfamiliarity with symptoms, both of acute intoxication and alcoholism.

Contribution to knowledge on the study theme reveals both how care has been provided to these patients and a tendency to positive attitudes of nurses to care for alcoholic patients in primary health care units, since they are willing to approach alcohol issue with patients, and to refer them to specialized care. They disapprove marginalization and repulse experienced by patients in these places.

Professionals' idea on alcoholic patients or of people that abuse alcohol seems to be related to individuals that are in advanced stages of the disease; thus, they demonstrate that, in these units, they do not know or do not pay attention to patients looking for care with nonspecific complaints which may be associated with the harmful use or with alcoholic dependence. However, this result can be justified by the guiding question which refers to how they deal with alcoholic patients and make nurses establish this association, which can have influenced the results. The present study showed the situation of care to these patients in these units, offering subsidies to discussions that lead to a better preparation of nurses, allowing professionals to focus not only on the signs and symptoms, but rather on meeting the demands imposed by the present context of alcohol and other drugs use and abuse, working especially in the early identification and, consequent prevention of alcohol problems.

The characteristics of the services investigated may have influenced the results because they were reference basic units that also cared for cases of alcoholic coma, as shown by interviewees' statements. Thus, further studies, similar to the present one, should be carried out in primary health care centers with other characteristics to corroborate the results we have obtained, and to increase knowledge on this issue.

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Received article 07/11/2008 and accepted 24/04/2009

*

Study developed in Ribeirão Preto, São Paulo at Escola de Enfermagem de Ribeirão Preto -USP.

Publication Dates

• Publication in this collection
  12 Apr 2010
• Date of issue
  2010

History

• Accepted
  24 Apr 2009
• Received
  07 Nov 2008