Partnership between a university and an international organization with a view to drugs research training for Latin American nursing teachers

This article reports on the experience of the specialization course called: Research training program for nurses to study the drugs pheonomenon in Latin America, which was offered by two institutions, one of which is local (University of São Paulo at Ribeirão Preto College of Nursing) while the other is an international organization (Interamerican drugs abuse control commission CICAD of the Organization of American States OAS). This program was offered consecutively in 2002 and 2003. The report discloses data on the negotation and didactical planning process for the first course, the distribution of contents and activities, experiences acquired during the teaching process and student evaluations. According to the participating students, teachers and institutions involved, offering partially in-class and partially distance courses, like the above mentioned program, has proved to be a successful experience with political, academic and social repercussions for the participants. Descriptors: nursing, health, research, alcohol and drugs, teaching, international cooperation, technical cooperation


INTRODUCTION
Nowadays, studying theme areas related to drugs provokes human sciences, constitutes a problem for health sciences and a true challenge to the paradigmatical debate.
The emotional impact of this subject among lay people and even in academic-scientific means does not occur without reason, since difficulties in facing different related factors turn it into a complex phenomenon.
The use of drugs involves internal (people and their environment) as well as external (when they influence the course of societies) questions.In this sense, drug traffic is particularly harmful: a marginal structure that runs loose in national and international integration circuits (1) .
In view of these peculiarities, the study of this phenomenon requires a more profound analysis and its containment demands strategies beyond national fronteers.In other words, a structural and not only a conjunctural view on the drugs reality is needed.
To reach this perspective, there are still obstacles in research about questions related to psychoactive drugs, since this is a painful subject at the individual and sociocultural levels, and especially due to its legal, political and diplomatic dimensions.
In the academic-scientific sphere, little research has been done from a theoretical standpoint.Perhaps as a result of the care needed to develop the research, since the process is loaded with difficulties, ranging from how to obtain information, mainly when talking about illegal drugs, due to their illegality and relation with drug traffic, to overcoming obstacles caused by moral prejudices against the use of psychoactive substances or consumers.These factors do not only interfere in project development but also limit the study range.
The incapacity of traditional forms of empirical and pragmatic analysis, in combination with social tendencies, perspectives and actions realized on the American continent and in other countries, have made room for broader interpretations about the phenomenology of drugs, especially at the end of the XXth century (1) .
Although problems related to drugs use do not exercise the same impact in all countries on the American continent, they have undoubtedly entailed harmful consequences for their societies in general, affecting the social as well as the health aspects.However, ambivalent attitudes towards the abuser, the social stigma associated with substance abuse and the criminal nature of drug traffic, as mentioned above, have led to a lack of precision, reliability and objectivity in data collected from non-sistematic research.Even epidemiological surveys carried out in different countries have produced incomparable data.Therefore, a trustworthy view is not available yet, mainly with respect to the clinical or public health aspects of drugs abuse problems (2)(3) .
Being a problem with international implications, treating the drugs phenomenon requires the involvement of a larger and more diversified number of social actors, whether in research, drug traffic combat or community health care in general and assistance to drugs users in particular.

HISTORY
In the 1990's, national governments increasingly emphasized measures to reduce the demand for legal and illegal drugs and international health bodies (WHO, PAHO, OAS) have been developing strategies to monitor consequences for health, as well as to prevent and control substance abuse on a national and international scale.
Since 1996, the global strategy by the Inter-American Drug Abuse Control Commission -CICAD of the Organization of American States -OAS, has been complementing initiatives from countries in the Americas, offering a signification contribution to the formation of specialized professionals to work with drug demand reduction.
In 1997, subsidized by the Japanese government and, further on, with the additional support of the United States and Canada, CICAD undertook an experimental project, applied in selected nursing schools from Latin America and aimed at stimulating health promotion, preventing drugs use and abuse and integrating abusers into society.This pioneer initiative stands due to its orientation towards a key professional category in health care.Moreover, in industrialized as well as developing countries, few higher education institutions have included psychoactive drugs and related questions in their curricula.
From a nursing perspective, the subject broadens health professionals' perspectives in care and research.In their relations with individuals and communities, nurses can make significant changes in cultural patterns and activities related to drugs and alcohol consumption.The proximity with people and their environment enables nurses (directly or through their auxiliaries) to identify problems related to drugs use in a community.That is why nursing was chosen among the health professions to start the drugs research training program, with the support of CICAD/OAS.
As a result of their generalist formation, focused on individual, group and community care, in the framework of the CICAD Drugs Demand Reduction Program, nurses offer new functions that demonstrate their leadership and contribute to the study of this phenomenon from the perspective of International Health.
The goal of the CICAD project for nursing schools has been the creation of a cadre of professional nurses with scientific knowledge and technical abilities to act in the field of drug demand reduction in Latin America.The basic components and project activities center on three guidelines: education, extension and research.The project emphasizes specific activities for each: in education, it proposes the inclusion of the psychoactive substance theme in graduate nursing study curricula, besides training programs for teachers with respect to drugs and social and health problems related to this phenomenon; in extension, priority is given to activities involving teachers and students in the implementation of educational programs about this issue, centering on aspects of health promotion, prevention of drugs use and abuse in the general population and the development of social integration projects aimed at specific groups; in research, the project offers a regional and an international program to train teachers from higher nursing education institutions in qualitative and quantitative research methods, in order to apply this knowledge to the development of individual or multicentric research on subjects related to drugs (aspects of health promotion, use and abuse prevention, social integration).

IMPLEMENTING THE REGIONAL PROGRAM
In order to implement the Regional Research Training Program for nurses to study the drugs phenomenon in Latin America, in 2001, CICAD invited the University of São Paulo at Ribeirão Preto College of Nursing (EERP-USP) to become its partner.The agreement involved the development of the course plan, didactical and administrative organization and implementation.
The EERP-USP accepted this challenge with the same entrepreneurial spirit that has characterized the fifty years of its existence, considering this invitation a highly relevant project for the institution and a unique opportunity for nursing in Latin America.
The school possessed a history of agreements with higher nursing education institutions in Brazil and other countries (Chile, Mexico) for doctoral education, apart from its experiences in undergraduate and graduate programs for students from all over Brazil, Latin America and Africa.However, the CICAD program presupposed the partnership of an international body and interrelations with a group of eighteen participants from nine higher education institutions in Latin America.This diversity was new to the EERP-USP, and meant a great challenge to everybody, which was experienced by the institutions involved in a process that involved the following steps.
The design of the joint proposal had to attend to the interests and goals of the two institutions involved in the process.It took about one year to arrive at the final version and obtain the technical and legal approval of the participating institutions (EERP-USP and CICAD).
CICAD was responsible for obtaining the necessary financial support to implement the program.Both Regional Research Training Programs for Nurses were financed by the Japanese Government, with the collaboration of the OAS/Scholarship Program, which offered 50%-grants to participants in the two programs.In both cases, the budget had to be adapted in accordance with the financial resources available, as well as the demands of the financing country and the OAS.
After the project had been technically approved obtaining the technical approval by both institutions and resources had been allocated, the OAS demanded a letter of intentions, prepared and approved by the institutions' legal sector, in order to start disbursements for the implementation of the Regional Research Training Program.This process took several months and, even afterwards, several exchange problems caused delays.On several occasions, the EERP/USP had to cover some initial expenses before the money was finally made available to be used in the program.

THE TEACHING PROCESS: EXPERIENCES AND INTERRELATIONS (PERSONS AND INSTITUTIONS
Participants in the two Regional Research Training Program represented ten universities from nine countries in Latin-America.This required a huge effort from all parts involved in the process (OAS/CICAD, EERP/USP, and students) to achieve the aims and goals that had been proposed.
Many variables were at stake, since two groups of people got together.Over time, they started to reach a broader understanding, accept and tolerate differences.In an attempt to reach mutual respect and collaboration, they gradually turned into a group.Formal knowledge about research in the context of psychoactive substance use was obtained to a greater or lesser extent during the participants' stay in Brazil.Nevertheless, the greatest knowledge resulted from personal contacts between "students" and "teachers".Discussions in class, during breaks and at other times, during which everybody could share the realities of his/her private and professional lives, were unique learning opportunities.
In order to make up a group, it is not enough to join a number of people.A context is needed or, better, some characteristics have to be developed, including: meeting out of common interests, establishing mutual exchanges and seeking a common goal within the group.These are the particularities that grant a group its own existence, which is the third characteristic needed to define a group of persons as a group (AUBRY; ARNAUD.1983).We can infer that, during their stay in Brazil, the participants in the two Regional Research Training Programs turned into a group, which is still growing.
It is obvious that, in joining representatives with different nationalities, this kind of initiatives allow for broadened personal, professional and global perspectives and favor the creation of friendship and professional bonds among countries.Participating in the CICAD program resulted in a unique experience, to which the EERP-USP has added a lot of efforts with a view to increased understanding and dialogue among institutions in the international advance of the profession.

THE STRUCTURE OF THE I AND II REGIONAL RESEARCH TRAINING PROGRAM
The

EVALUATION OF THE TWO REGIONAL RESEARCH TRAINING PROGRAMS
Evaluations should be aimed at making the group of participants (students and teachers) evolve with a view to better performance and higher levels of professional and personal maturity.This idea constitutes the framework for the main items evaluated by the students, presented below in the form of tables.
Table 2 demonstrates that, for most students, the course offered new knowledge.
Table 3 show the students' evaluation of the different modules in accordance with different evaluation levels, revealing that both groups considered the program contents either very good or excellent.
Table 4 indicates that students' evaluation of this topic was either good, very good or excellent, predominantly "very good".
Table 5 indicates that, with respect to teaching methods and techniques, evaluations ranges from good to excellent.Most students ranked the three modules as either very good or excellent, on the basis of the total number of students (33).
Table 6 shows that the teachers are the course's main strong point, whether due to the support and relations they establish, or to the knowledge and experience they demonstrate.The importance of interactions among students during the course must also be highlighted.Other strong points are: organization, administrative and logistic support, as well as reaching the academic aims, which includes making the participants more aware about the importance of the Psychoactive Drugs theme in nursing formation, care and research.
According to Table 7, language continues being an important difficulty for some students.Although these comments only correspond to 26% of the statements, alternatives have to be considered to overcome this barrier.Another difficulty seems to be related to distinct knowledge (whether in terms of drugs or scientific methodology) and research practice levels, which is why some students from the 2002 groups asked for greater participation in class, while students from the 2003 group asked to avoid repeating contents they already knew.One of them even suggested to hold a "pre-test" to evaluate student knowledge before the beginning of the course.
It seems that not enough time is dedicated to reading and project elaboration, although one week was reserved for the structuring of the project in the 2003 group.Language difficulties seem to interfere in reading skills and, consequently, realizing the project becomes much more difficult.Although suggested by only two students, leaving the morning or afternoon period free has to be taken into consideration.
Course coordinators and teachers are guided by the premise that education is a process in which "studying means assuming a serious and curious attitude towards a problem" (5) , with a view to the comprehension of facts, analysis, interpretation and intervention.Hence, the task faced by teachers and students is not easy, since it requires creation and recreation, apart from alertness about our teaching aims -learning, our actions, interests and results in a continuous evalution process (by the students themselves).This process stimulates creativity and discourages dogmatism, conformism and passiveness.
This evaluation allowed us to get a picture of the extent to which teachers in the Regional Research Training Program were successful in reaching the program aims and goals, as well as the participation of students during the entire learning process.

IMPACTS OF THE REGIONAL RESEARCH TRAINING PROGRAM
The contacts between teachers and students in class and at a distance and the development of a socially relevant theme are producing different kinds of changes, some of which have already come up, while others have just started to appear.
When imagining nursing as a professional group that needs to be strengthened, the above mentioned characteristics for small groups would be very welcome, since considering human behavior merely from an individual perspective is both wrong and restrictive.
The personal system is constantly interacting with the individual systems of others and with the organizational systems they belong to.Each person relates to the other in various contexts (family, work), and this relation assumes specific modalities that exercise a decisive influence on each person's behavior.Relations between persons include expectations, demands, affection and power, with different qualities and intensities as important factors for individual behavior (6) .
Considering Latin-American nursing as a large group requires the existence of relations between different sub-groups (nurses from Latin-American countries) and a peculiar configuration of mutual relations, which will influence on each sub-group's way of reacting.It also presupposes that each group has its own expectations, demands, knowledge, affection and power at different levels.
Knowledge about the dynamics of the group or, in the case of nursing, the sub-group the person is inserted in helps us to understand many actions and reactions.The inputs for the global interaction process are constituted by the ideas, knowledge, opinions, actions, behavioral demonstrations, feelings, attitudes, values and philosophies of each member (or "sub-group") of the group.The reciprocal influence of each person's exclusive repertoire is present, nothing is immune to exchange with others (6) .
The above can apply to the individual as a unique entity that participates in a group, as well as to the so-called set of nursing sub-groups from different countries in the Americas: everybody possesses the above mentioned inputs, which are present in the group interaction process and exercise mutual influences.
In view of these considerations, it can be inferred that the nursing institutions involved in the CICAD project as a whole and especially in Research Training efforts, have gone through changes, since they have established interactions during which they shared their ideas, knowledge, expecations, feelings, values and other inputs that made up their cultural spectrum.
Based on the premise that culture is a phenomenon that characterizes human life in society and results from a combination of values, standards, attitudes and other bio-psycho-social elements, it constitutes a broad framework of symbolic, intellectual, affective and other references for a society, organization or group (7) .
We can also talk about a culture, cultural system or sub-system whenever a set of cultural elements can be identified, including values and prescribed standards of behavior in relation to role structures, with a level of interdependence and mutual influence that provides internal consistency, and involving specialized or different characteristics in relation to other sets, apart from a relatively permanent nature.This is valid and adequate when studying specific organizations and groups (7) .Hence, it applies to the nursing group.
It should not be ignored that a universal phenomenon such as culture (no matter the context it is used in) is dynamic and varies as a function of space, time and life in society itself.By means of their capacity to create and recreate, introduce innovations, transform and reformulate evolutionary answers, the actions realized by human beings also contribute to this dynamism.That is why it a culture originated in a hypothetic Nursing group cannot be seen as a static construction.
Who knows the growing exchange between "sub-groups" will not constitute the basis for the process of constructing a Latin-American nursing culture that gives as much consideration as possible to the inputs offered by each participant (sub-group) in the hypothetical group.A professional culture in which ideas are based on reality, imposition makes room for dialogue and negotiation, sacrifice is substituted by pleasure, the healing concept is replaced by rehabilitation and exclusive attitudes are replaced by understanding of differences.

REPERCUSSIONS
The two Regional Research Training Programs for Nurses to Study the Drugs Phenomenon in Latin America have marked the efficiency of the conceptual and educational model used for its implementation when talking about the cost-benefit relation and efficacy of the project that has been reached until now.
The eighteen participants in the First Regional Research Training Program concluded their research and presented their technical research report to CICAD.Moreover, they elaborated a poster of their research results for the VIII International Meeting of the CICAD Demand Reduction Project with Nursing Schools, held in Lima, Peru in August 2003.They also submitted a research paper for publication in the Latin American Journal of Nursing of the EERP/USP.This Journal, which is indexed in important national and international databases and distributed in different countries, aims to disseminate scientific knowledge produced by nursing and related areas.
The fifteen participants in the Second Regional Research Training Program are implementing their research in their countries of origin, and should equally prepare a technical research report; send it to CICAD; present a poster of their results at the IX International Meeting of the CICAD Demand Reduction Project with Nursing Schools, which will be held in 2004.These participants will also have to prepare a research paper for publication.The positive results that were reached through the two Regional Programs have stimulated the Governments of Japan and Canada to support the project aimed at transforming the Regional Research Training Program into an ON-LINE course and expanding it to all health professionals interested in working and researching on the drugs phenomenon in Latin America.During 2004, CICAD and the EERP/USP are collaborating in the transformation process to offer the program online in 2005.

FINAL CONSIDERATIONS
The nursing profession's range of vision, its leadership and transformation capacity have also revealed themselves through its participation in initiatives aimed at reducing drugs demand, thus allowing for the opening of new professional areas.
The development of research projects, aimed at different community groups, is showing to local and international authorities that nurses (when specifically trained) can actually cooperate in the increase of knowledge about the drugs phenomenon in Latin America and can help in the elaboration of programs aimed at improving the quality of life and health of the population.The success of this agreement model, created by an international organization like CICAD, the University of São Paulo at Ribeirão Preto College of Nursing and other Nursing Schools has allowed us to expand this experience to schools for public health and health education in Latin America.
two Regional Research Training Program for Nurses to Study the Drugs Phenomenon in Latin America are specialization courses with a total hour load of 540 hours, divided into two education modes: (i) Part I -in class, totaling 345 hours; and (ii) Part II -distance, totaling 195 hours.Part I -involving two months of intensive class presence at EERP/USP/Brazil -consisted of three mutually integrated Modules, to be able to offer the necessary technical and scientific knowledge to enable the participant nurses to develop research projects on (legal and illegal) drugs.The three Modules deal with the following aspects: (i) Module I -International Health and the Drugs Phenomenon; (ii) Module II -The Drugs Phenomenon in the World and in the Americas; and (iii) Module III -Quantitative and Qualitative Research Methods Applied to the Study of the Drugs Phenomenon.Part II -consisted of Module IV -Distance Research Monitoring -and is offered to the participants on their return to their home countries to implement the research projects.Each participant chooses one advisor according to personal affinities with the teacher and the following criteria: study object and methdological reference framework.Participants and advisors stay in contact every two weeks or every month during six months, by e-mail, fax, telephone or mail.The hour loads per module are shown in table 1 below.

The
Regional Research Training Program for Nurses to Study the Drugs Phenomenon in Latin America constituted the basis for the implementation of the First International Research Training Program for Nurses to Study the Drugs Phenomenon in Latin America, at the University of Alberta/Edmonton/Canada during the summer of 2003.