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Acta Paulista de Enfermagem

Print version ISSN 0103-2100

Acta paul. enferm. vol.24 no.5 São Paulo  2011

https://doi.org/10.1590/S0103-21002011000500009 

ORIGINAL ARTICLE

 

Organizational dimensions of a Psychosocial Care Center for chemical dependency*

 

Dimensiones organizativas de un Centro de Atención Psicosocial para dependientes químicos

 

 

Carla Aparecida Arena VenturaI; Angélica Silva AraújoII; Marciana Fernandes MollIII

ILawyer. Faculty, University of São Paulo, Ribeirão Preto College of Nursing – USP – Ribeirão Preto (SP), Brazil
II
Undergraduate Student in Occupational Therapy, University of São Paulo at Ribeirão Preto Medical School. Grantee, University of São Paulo Ensinar com Pesquisa Program - USP - Ribeirão Preto (SP), Brazil
IIIPh.D. student in Nursing, University of São Paulo at Ribeirão Preto College of Nursing – USP – Ribeirão Preto (SP), Brazil. Faculty, Universidade de Uberaba. – Uberaba (MG), Brazil

Corresponding Author

 

 


ABSTRACT

OBJECTIVE: To understand the vision of professionals about the structural and contextual dimensions of a Psychosocial Care Center for those dependent on psychoactive substances in the state of São Paulo.
METHODS:
This qualitative study used semistructured interviews with nine professionals and two managers to obtain the data that were analyzed using thematic analysis.
RESULTS:
The internal structure of the service was influenced by the external environment and is based on individualized care. As an alternative to facing the challenges, it emphasized teamwork and overload as a problem resulting from the dynamics of work.
CONCLUSION:
There is a need to contract professionals to improve internal operations, ensure quality service and integrate the organization with external actors.

Keywords: Substance abuse treatment centers/organization & administration; Substance-related disorders; Humanization of assistance


RESUMEN

OBJETIVO: Comprender la visión de profesionales sobre las dimensiones estructurales y contextuales de un Centro de Atención Psicosocial para dependientes de sustancias psicoactivas del Estado de Sao Paulo.
MÉTODOS: Estudio cualitativo en el que se usó la entrevista semiestructurada con nueve profesionales y dos gestores para obtener los datos que fueron analizados por medio del análisis temático.
RESULTADOS:
La estructura interna del servicio fue influenciada por el ambiente externo y se fundamenta en cuidado individualizado. Como alternativa de enfrentamiento de los desafios, se resalta el trabajo en equipo y sobrecarga como problema resultante de la dinámica de trabajo.
CONCLUSIÓN:
Hay necesidad de la contratación de profesionales para mejorar el funcionamiento interno, asegurar la calidad en la atención e integrar la organización con los actores externos.

Descriptores: Centros de tratamiento de abuso de sustancias/organización & administración; Trastornos relacionados con substancias; Humanización de la atención


 

 

INTRODUCTION

Psychosocial Care Centers for Psychoactive Substance Users (CAPS-ad) are set up in cities with more than 70,000 inhabitants, in compliance with Ministerial Decree No 336/02, which establishes that this service is to deliver psychosocial care to people with alcohol and/or drugs dependence, with an emphasis on these clients' rehabilitation and social reinsertion(1).

Based on this care proposal, it is considered relevant to understand the organizational system of the CAPS-ad, as an institution's organization interferes directly in the quality of care delivery.

CAPS-ad subsystem

Organizations are social entities, guided by targets and designed as deliberately structured and coordinated activities, connected with the external environment(2-3). In this perspective, a system comprises a set of interactive elements that receives inputs from the environment, transforms them and issues outputs into the environment(2). In this context, the open system concept emphasizes the relation of mutual influence between the organization and the external environment. Thus, organizations can be analyzed as systems that contain various subsystems (productions, borderlines and administrative limits) that perform specific functions, which are necessary for its survival(4).

The CAPS-ad, open subsystems, are influenced by all other health services in the Unified Health System care network, including: general and specialized hospitals, Family Health Strategy, among others.

The CAPS-ad are expected to offer daily care, prioritizing therapeutic planning in an individualized perspective of continuous evolution. They developed a series of activities that range from individual care to group sessions or therapeutic workshops and home visits. They also offer conditions for rest and outpatient detoxification for individuals who need this care and do not demand hospital care(5). At the CAPS-ad, care planning is based on the logic of Damage Reduction, with practices aimed at minimizing the global consequences of alcohol and drugs use and that do not put forward total abstinence as the only feasible and possible target for chemical addicts(5).

Thus, the CAPS-ad can be considered complex organizations and, therefore, they should ideally be understood based on a systemic approach, based on the relations between the structural and contextual dimensions, and between these and the external environment, in a dialectical and continuous process(4).

Structural and contextual dimensions of organizations as open systems

Organizations comprise a whole, constituted by mutually related parts in different positions and also related with the external environment(6). Organizational structure is considered as the degree and type of horizontal and vertical distinction, power coordination and control, centralization and formalization mechanisms in the organization. In general, organizational structures make it easier to achieve organizational objectives and to minimize influences from individual alterations and divide powers and decision levels. Structure influences the strategy formulation and implementation process for the sector(6). Thus, there is not only single organization, but organizations with different potentials and limitations, so that an organizational structure adapts to some tasks and conditions within a given period(7).

Organizational dimensions are summarized in structural and contextual categories; the structural categories permit describing an organization's internal characteristics, which enhances the measurement and comparison among organizations. Contextual categories characterize the entire organization (size, technology, environment and targets) and can only represent the environment, as well as describe the organizational adjustment that influences and molds the structural dimensions. Thus, to get to know and assess organizations, one needs to examine their structural and contextual dimensions(2).

The structural dimensions are formalization, specialization, hierarchy of authority, centralization, professionalism and staff rates. Formalization refers to the volume of the organization's written documents (procedures, function descriptions, rules and policy manuals) and represents the level at which organizational tasks are subdivided into functions. In this perspective, if specialization is extensive, each employee will perform only a narrow range of tasks while, in case of limited specialization, employees will perform a large number of tasks in their functions.

The hierarchy of authority defines who reports to whom and the control sphere for each manager. The hierarchy is pictured by the vertical lines of the organizational chart and is related to the control limit. When control limits are narrow, hierarchy tends to be high. When control limits are broad, the hierarchy of authority will be lower. Centralization refers to the hierarchical level that is authorized to make a decision. When decision-making is reserved to the highest level, the organization is centralized. When decisions are delegated to lower organizational levels, it is decentralized.

Professionalism refers to the employees' formal education and training level, and is considered high when they receive long training periods to take up functions in the organization. Generally, it is measured as the employees' mean years of education. The staff rate is related with the dismemberment of people according to different functions and departments. Staff rates include the administrative, bureaucratic and professional advice levels and the proportion of indirect on direct workforce, measured by dividing the number of employees in one classification by the organization's total number of employees.

The contextual dimensions, on the other hand, are size, organizational technology, environment, targets and strategies and organizational culture.

Size corresponds to the organization's dimension in terms of staff numbers. As organizations are social systems, the number of employees should be used to measure size. Organizational technology includes the actions and techniques used to offer the service. It refers to how the organization accomplishes in transformation process of organizational inputs into outputs. It is highlighted that, in service technology, the product is intangible, simultaneously produced and consumed, and that human elements are very important (interaction among members), making it very difficult to measure service quality.

The environment includes all elements, besides organizational limits that can affect it fully or partially. Therefore, it is important for the organization to receive information about environmental changes. Decision makers do not always have clear information though, i.e. the level of uncertainty in the external environment is quite high, as its variables change a lot, hampering possible event forecasts.

Organizational targets and strategies define their purpose and the means to achieve it. They establish the scope of organizational action and its external and internal relations. To achieve these targets, the impulses that motivate behaviors should be taken into account, so that individuals achieve their objectives. And, finally, culture refers to the underlying set of values, beliefs, knowledge and essential standards organizational members share.

The structural and contextual dimensions are interdependent and provide a base to measure and analyze characteristics that cannot be casually observed, revealing significant information about organizations. Thus, this study aimed to understand professionals' view on the structural and contextual dimensions of a Psychosocial Care Center for psychoactive substance addicts in São Paulo State.

 

METHODS

A qualitative research was carried out, which is appropriate when the study phenomenon is complex, social, does not tend towards quantification and involves an interpretative and natural approach of the study object(8). Initially, a descriptive research was accomplished, using secondary data through a bibliographic review on organizations, the psychiatric reform process and the evolution of alcohol and drugs user care services in Brazil.

After the research project had received approval by the University of São Paulo at Ribeirão Preto College of Nursing, participants signed the Informed Consent Term and semistructured interviews took place. The first interview was held with the person responsible for the hospital service who guided the creation of the CAPS-ad in the city, in order to seek information on its structure and check its structural and contextual dimensions. Next, semistructured interviews were held with the current service manager and organizational employees (three men and six women), who represent 45% of all staff and belong to the following professional categories: one psychiatrist, one social worker, one physical education teacher, one nurse, two psychologists, one occupational therapist and two nursing technicians. The interviews were interrupted when the interviewer perceived saturation of the themes the participants addressed. Data were analyzed through inductive thematic analysis, in two phases: identification of units of meaning and dense description of the meanings or thematic cores, discussed in the light of knowledge produced in the area(9).

 

RESULTS

A low level of administrative formalization was detected, as it was reported that the organization neither had a formal organizational chart nor a large volume of written documents, which supports observations on the low level of formalization. Formalization was verified though, especially regarding service users' files and documents required by supporting and supervisory entities. This reveals a "bureaucracy promoted by external requirements":

There's one day that is heavy because we fill out forms the municipal government demands us to complete? (...)there's a bureaucracy we lose two days to fill out. (A)

It is alerted, though, that the "bureaucracy does not hamper service access":

There's no bureaucracy for the patient to be treated. He does not need forwarding from another service and, that's one of the service's main advantages. (...) he woke up one day and decided he had to stop drinking, all he has to do is come here. (I)

A low specialization level was revealed, due to the small number of employees and the fact that each professional performs different tasks, according to the organization's need and demand. Hence, "the joint effort on behalf of the service and the absence of strict outlines for the tasks performed" is verified:

I think there's a lot of respect among people, there's no dispute. Over this period, I've been here for 11 years, I've always seen that an attempt is made to offer a good service and that individual efforts exist, if someone is unable to make that effort at a given time, another professional covers for him. (I)

Despite the presence of a double bond of authority, represented by the two coordinators, the hierarchy of authority is almost non-existent, as the employees do not need to report to them in order to perform tasks. The decision making process is decentralized. Through observation, strong articulation among professionals was verified, who attempt to discuss all cases individually with the team members. The group solves organizational decisions, considering the different professionals' – general clinician, psychologist, occupational therapist – opinions, a fact that, according to the team, takes place to optimize treatment and interventions.

In this perspective, when asked about the dynamics of work at the CAPS-ad, the professionals emphasized the theme "joint work and decisions made in the team as a family":

A multiprofessional team is an organization, so that there's no manager who orders and everyone obeys. Everyone talks, everyone has opinions, everyone attempts to manage themselves and the service, it's a bit more work, but everyone constructs it. (B)

When discussing the work process at the CAPS-ad, the "work overload" is observed, which team members frequently mention and also entails the decreased specialization level of work:

I perceive that our work increased a lot, that the number of service users increased a lot, so everyone is a bit overloaded (...) but, as a general rule, we attempt to maintain at least the minimum. (B)

It should also be highlighted that teamwork does not imply that conflicts do not exist, which are the base for creative innovation and which the group should cope with. At this service, team meetings favor this coping. In this perspective, many interviewees mention "teamwork characterized by conflicts" when explaining their work routine:

I think that, at times, the climate gets tense, and I expect that because, no, sometimes, a lot of harmony, we supposed that differences are not appearing (...). The team is proactive in that sense. (E)

The organization's level of professionalism is high, as the professionals who constitute teamwork graduated or received specific training for the function they perform. Regarding staff rates, the following professionals work at the service: general clinician, psychiatrists, psychologists, occupational therapists, social workers, nurses, physical education teacher, nursing technicians and secretaries. Based on the combination of the structural dimensions, at the CAPS-Ad, teamwork and relations of coordination predominate among the professionals, to the detriment of valuating subordination. As for the physical structure, the interviewees consider it is "adequate, but has some limitations":

I think it's adequate. It could be more functional, perhaps there are some things we could do differently, yeah, there's some equipment in here that could be better organized, but I think that, in general, we don't face any work difficulties because of the structure. (E)

With respect to the contextual dimensions related to the external environment, the size of the organization is small, as 20 proposals work in the service's therapeutic proposal. The level of organizational technology is also low, because it is based on interpersonal relations between health professionals and service users/relatives.

The work of CAPS-Ad people rests on care delivery to people performed by people. Thus, people are the chemical addict's care network, which facilitates the predominance of teamwork and, consequently, the low hierarchy of authority observed in the organization. In that context, the values founding the service culture are "respect for human beings and ethical conduct":

Great concern with listening to the subject, right? And I think that's a value we carry. (C)

We have something to offer and who's coming here is coming out of desire to get treatment, so it is a free and open treatment environment. (I)

To deliver care based on these values, some activities are developed, such as "team meetings, get together, symposia":

If we have a team meeting every week? So, once per month we collect money among team professionals and, during the team meeting, we have a party for the people who celebrate their birthday that month. (B)

Each year we organize a symposium, open to the general population. That's something that has happened for four years now (...). (H)

Among the activities mentioned, some interviewees cited the existence of "assessment meetings" in the past, which represented important moments of reflection for the team and an opportunity to cope with conflicts and to creatively search for joint solutions:

We even had a reflection meeting, where did that help? (G)

The organization's external environment is quite complex, comprising "the Municipal Health Secretary, psychiatric hospitals and other health units, schools, relatives and service users". With regard to alcohol and drug dependence, various risk factors present in the external environment are highlighted.

So, we face difficulties in that sense. With respect to the school, that he needs to go back studying and there's no place, yeah, employment situation, social situation, family, so, the whole municipal service network does influence care and the person's treatment progress. (B)

As for the external environment, "insufficient funds" were a recurring theme in the interviews. Also, with respect to the users, many users are concerned with the "increased number of users as a factor that hampers service quality maintenance":

We perceive various limitations, mainly due to the structure, number of patients, increased demand. (B)

Finally, the interviewees assessed the CAPS-ad as a "high-quality service and reference in the Country":

I consider it, like, an excellent service. (A)

In general, various inter-relations were observed between the structural and contextual dimensions. The external environment is the variable and affects the organizational structure, provoking changes in the work dynamics accomplished at the CAPS-ad, confirming that this service is an open system. It is suggested that activities like meetings to enhance integration and reflection among team members should be even further valued:

We periodically held a reflection meeting for two or three hours, and then internal relationship difficulties come up, so, it served to reflect… For some time we haven't done that, and we try to settle things, like, among us. (B)

 

DISCUSSION

The low formalization level seems to be ideal for a small organization like the CAPS-ad, but bureaucracy needs to exist, as registering and monitoring care delivery in quantitative terms is important. The structure is horizontal, functionally characterized by teamwork, low levels of specialization and hierarchy and joint efforts on behalf of the service.

In that perspective, multidisciplinary teamwork is essential at psychosocial care centers. Teams are improved forms of work groups, as they set unison targets for collective work(10). Like the users, team workers are members of the same community: of action, interaction, knowledge and intersubjectivity, permeated by social, ethnical and cultural differences(11).

The meetings, during which care-and administration-related aspects are discussed were one resource that contributed to improve team performance. These meetings correspond to a rite that enhances the professionals and the team's growth. To achieve the benefits of meetings, it is fundamental that they are held in spaces for discussion, reflection and knowledge dissemination, instead of a mere attempt to solve emergency problems(10).

During the meetings held, direct coping with conflicts induces the team's collective learning(4), as the fact that teamwork exists does not imply that conflicts do not. In that sense, teamwork is considered a strategy to face the intense specialization process in health, which vertically deepens knowledge and intervention in individualized aspects of health needs(12).

In the organization under analysis, despite the high level of professionalism, the specialization level is low, with a view to integrating the team in care delivery and articulating different actions and individual knowledge(10,12). In function of the work philosophy itself, which characterizes the organization's internal structure and values, it was observed that the interviewed professionals identify themselves with their work and deliver quality care.

Thus, as an open system, the organization influences the external environment, especially through care delivery to alcohol and drugs users. The CAPS-ad's external environment is very complex, comprising different (health and education) institutions and relatives and service users, which interfere in the organization through the following aspects: financial restrictions to accomplish established activities, health network professionals and society's lack of understanding about the role of the CAPS-Ad, the service's integration difficulties with users' families and the stigma towards chemical dependence. It is important to approximate mental health service professionals with Family Health teams, with a view to qualifying the professionals working in Family Health for comprehensive care delivery(13). Also, integration and cooperation among existing health services should be prioritized, so that primary health care can develop actions that value the identification of demands for specialized mental health care within the territory(13).

When discussing the targets, the professionals mentioned that no formal organizational planning existed, whose directives are guided by individualized care, centered on each user's particularities. Despite this individualized care, alcohol and other drugs are a common problem among service users and overcoming chemical dependence presupposes the service objective(14).

To enhance users' bonding with the service, usually, the professional who first interviews the user is designated his/ her reference technician and assumes the responsibility for monitoring that person's treatment, also involving the team, with a view to determining individual and group activities necessary for rehabilitation(15). Different professionals conduct group activities at the CAPS-ad, which signals the low specialization level. A range of groups with distinctive therapeutic goals was observed, which are called: welcoming groups, monitoring, therapeutic workshops and assemblies(14). One important component for good group functioning is the coordinator, which different professions can represent, according to each group's focus(14).

Thus, the socially constructed daily reality at the CAPS-ad, which society knows and acknowledges as such, as well as the recurrently established psychosocial diagnoses can turn into work management axes, which will support teams' interdisciplinary activities and collective health promotion(13).

It is affirmed that the mental health community care strategies for chemical addicts with a view to psychosocial rehabilitation offers effective results and should be expanded in the context of the Unified Health System, despite financial, infrastructural and service organization needs(16). It is highlighted that the psychosocial model is the most used treatment model in the Brazilian context(17), as it permits comprehensive care delivery. Thus, it is considered relevant to qualify the care the CAPS-ad offers, which induces the need to value the structural and contextual dimensions with a view to improving this institution's functioning and management.

 

FINAL CONSIDERATIONS

The CAPS-ad organization displays important interrelations among its organizational dimensions. Its internal structure reflects its size and culture, based on the values of individualized care, in line with the national policy centered on social reinsertion. As a consequence of this identity between the structural and contextual dimensions, joint coping with challenges was identified through teamwork.

The work overload is a source of concern though, which can negatively influence the organization of meetings and the integrated and individualized care proposal, based on the high level of professionalism and the low level of specialization. In that sense, alternatives should be sought to hire professionals with a view to the better functioning of the internal environment and guaranteed care quality.

As suggestions to achieve advancements and intense organizational learning, the maintenance of this horizontal and decentralized structure is appointed, as well as the intensification of team meetings with a view to integration and reflection and external assessments to provide a critical view on care delivery.

Also, the service's interaction with the community is suggested, through symposia and other forms of opening the service to society, especially to users' relatives, with a view to clarifying the role of the CAPS-ad and facing the social stigma alcohol and drugs users are exposed to.

Finally, the need for further integration between the CAPS-ad and the external environment is highlighted, especially with other mental health services, so as to optimize user care and integrate a care network, in line with the bases of the Brazilian psychiatric reform.

 

REFERENCES

1. Borba LO, Schwartz E, Kantorski LP. A sobrecarga dafamília que convive com a realidade do transtorno mental.Acta Paul Enferm. 2008;21(4):588-94         [ Links ]

2. Daft RL. Organizações: teorias e projetos. São Paulo:PioneiraThomson Learning; 2002.         [ Links ]

3. Lacombe FJM, Heilborn GLJ. Administração: princípios etendências. São Paulo: Saraiva; 2003.         [ Links ]

4. Martinelli DP, Ventura CAA, organizadores. Visão sistêmicae administração: conceitos, metodologias e aplicações. SãoPaulo: Saraiva; 2006.         [ Links ]

5. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. DAPE. Coordenação Geral de Saúde Mental. Reforma psiquiátrica e política de saúde mental no Brasil.Documento apresentado à Conferência Regional deReforma dos Serviços de Saúde Mental: 15 anos depois deCaracas [Internet]. Brasília: OPAS; novembro de 2005.[acesso 15 nov.2010]. 56 p. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/relatorio_15_anos_caracas.pdf        [ Links ]

6. Olivares JEL. Negociação para configurar o desenho daestrutura organizacional em rede. Cad Pesq Admin.2002;9(3):13-26.         [ Links ]

7. Drucker PF. Management Challenges for the 21st Century.New York: Harper Collins; 2004.         [ Links ]

8. Minayo MCS, organizadora. Pesquisa social: teoria, métodoe criatividade. 20a ed. Petrópolis: Vozes; 2002.         [ Links ]

9. Grbich C. Qualitative data analysis: an introduction.London: Sage Publications; 2007.         [ Links ]

10. Abreu LO, Munari DB, Queiroz AL, Fernandes CN. O trabalho de equipe em enfermagem: revisão sistemática daliteratura. Rev Bras Enferm. 2005;58(2):203-7.         [ Links ]

11. Sanduvette V. Sobre como e por que construir, (re)construire avaliar projetos terapêuticos nos centros de atençãopsicossocial (CAPS). Psicol USP. 2007;18(1):83-100.         [ Links ]

12. Peduzzi M. Equipe multiprofissonal de saúde: conceito etipologia: atualização. Rev Saúde Pública = J Public Health.2001;35(1):103-9.         [ Links ]

13. Schneider AR. A rede de atenção em saúde mental: a importância da interação entre a atenção primária e os serviçosde saúde mental. Rev Ciênc Saúde. 2009;2(2):78-84.         [ Links ]

14. Bourguignon LN, Guimarães ES, Siqueira MM. A atuaçãodo enfermeiro nos grupos terapêuticos do CAPS AD doestado do Espírito Santo. Cogitare Enferm. 2010;15(3):467-73.         [ Links ]

15. Alves VS. Modelos de atenção à saúde de usuários de álcool e outras drogas no contexto do centro de atençãopsicossocial (CAPSad) [tese].Salvador: Instituto de SaúdeColetiva da Universidade Federal da Bahia; 2009.         [ Links ]

16. Siqueira MM, Barbosa DA, Laranjeira R, Hopkins K.Substâncias psicoativas e a provisão de cuidadosespecializados: o caso do Espírito Santo. Rev Bras Psiquiatr.2007;29(4):315-23.         [ Links ]

17. Tomasi E, Facchini LA, Piccini RX, Thumé E, Silva RA, Gonçalves H, Silva SM. Efetividade dos centros de atenção psicossocial no cuidado a portadores de sofrimentopsíquico em cidade de porte médio do Sul do Brasil: umaanálise estratificada. Cad Saúde Pública. 2010;26(4):807-15.         [ Links ]

 

 

Corresponding author:
Carla Aparecida Arena Ventura
R. Aristides de Oliveira, 360
Ribeirão Preto - SP - Brazil
Cep: 14076-190
E-mail: caaventura@eerp.usp.br

Received article 09/10/2010 and accepted 09/05/2011

 

 

* Research accomplished at a Psychosocial Care Center for chemical addicts in an interior city in São Paulo State.

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