Psychosocial Care Center for Alcohol and Drugs ( CAPS ad ) : Nursing Insertion and Practices in São Paulo City , Brazil

This exploratory study with a qualitative approach aimed to identify nurses’ insertion and practices at Psychosocial Care Centers for alcohol and drugs in São Paulo City, Brazil. Sixteen nurses participated in the study. Data were recorded and were analyzed by dialectic hermeneutics and guided by Brazilian psychiatric reform premises. The results evidenced nurses’ difficulties to take part in the care recommended at these services, as their practices are more linked up with the traditional mental health care model. Causes of this phenomenon include nurses’ lack of preparation to act in psychoactive substance-related issues and lack of knowledge on specific contents that would favor their insertion into care practice in these scenarios. It is concluded that more attention should be paid to these contents in nursing education, as the legal requirement of nursing presence at these services is insufficient as a strategy to guarantee their actual insertion.


Introduction
In recent decades, the Brazilian psychiatric reform movement has reoriented the country's mental health model.The progressive incorporation of its principles took form, among other factors, through the regulation of Ministerial Decrees 224/1992 (1) and 336/2002 (2) , which address the creation and regulation, respectively, of a diversified care network aiming for the gradual substitution of mental health services, which used to be hegemonic.The decree that regulated the CAPS in 2002 (2) not only redefined them, but also classified these services by increasing order of population coverage, care complexity and target population.In this new classification, Psychosocial Care Centers for alcohol and drugs (CAPS ad) were set up across the Brazilian territory.These are psychosocial care services for care delivery to people suffering from disorders, deriving Vargas D, Oliveira MAF, Duarte FAB. from psychoactive substance use and addiction.Today, they are one of the main strategies to cope with alcohol and other drugs problems in Brazil (3) .These services depart from the principle of guaranteeing welcoming to the population within its territory, which needs mental health care related to psychoactive substances.Trained professional should be present during their opening hours (2) .Guided by the psychosocial model, the CAPS ad are proposed as a space for creativity, for the construction of life which, instead of excluding, medicalizing and disciplining, should welcome, deliver care and establish bridges with society, considering users in their subjective and sociocultural implications and choosing them to be the protagonists of their treatment (4)(5) .
Besides redefining and classifying CAPS ad all over the country, decree 336 (2) represented a landmark for psychoactive substance nursing as, by defining a minimal team to work at these services, it regulated nursing workers' inclusion in these teams.Hence, as CAPS ad are full expanding across Brazil * , it is presupposed that job offers for nurses in this activity area have increased (3) .This finding alone would already justify research on the theme as, given the recent establishment of these services, it constitutes an extensive nursing research area, including the assessment of nursing professionals' insertion and practices in this new activity area.As these services are recent (less than 10 years old), few studies have been published on Nurses' insertion and practices at CAPS ad (4) .This is not the case for Mental Health CAPS (5)(6)(7) and other regulated substitutive services in Brazil (8)(9)(10)(11) , which seem to have received greater attention in research in the last decade.
Although not specifically addressing nurses' insertion in the CAPS ad context, studies (5)(6)(7)(8)(9)(10)(11) have addressed these professionals' insertion and practices in the sphere of substitutive mental health services.And their results evidence that, in these spaces, new knowledge has been demanded from nurses, constructed based on interdisciplinary practice, which has contributed to turn them into more autonomous professionals (4,(6)(7) .Thus, nurses' insertion into mental health teams has allowed them to interfere and conduct the care and follow-up process of mental health services, which has demanded that they expand their knowledge to act in this new care context (6) .Other studies (9)(10)(11) , however, evidence that, despite this new possibility of acting in substitutive mental health services, today, nurses have experienced a practice marked by the vagueness of their role, which has made these professionals center their practices on bureaucratic-administrative activities instead of serving as therapeutic agents.In view of these results and considering that CAPS ad have recently turned into activity areas for nursing professional and that research in these scenarios is scarce, this study was carried out to verify nurses' insertion and practices in CAPS ad in São Paulo city.

Method
This exploratory and descriptive qualitative study  (12) .The Psychiatric Reform was adopted as the theoretical reference framework, understood as a complex process, comprising four articulated dimensions that give each other feedback: the first dimension refers to the epistemological or theoretical-conceptual field that represents knowledge production; the second is the technical-care dimension that emerges in the care model; the third dimension refers to the legal-political field that re-discusses and redefines social and civil relations in terms of citizenship, human and social rights; and the fourth dimension is the sociocultural, which expresses the transformation of the social place of madness (13) .
The interviews were recorded, transcribed and then submitted to exhaustive reading.Thus, the themes emerging from the interviewees' discourse were

Sociodemographic characteristics of subjects
The research subjects were mainly women (68.8%), with a mean age of 48 years, graduated for more than 25 years (43.8%), from private schools (68.8%).In the group of interviewees, 68.8% had worked at the CAPS ad for less than 4 years, and half of the sample (50%) affirmed they had worked at some mental health service before the CAPS ad.Approximately 56.3% of the nurses informed having another job besides the CAPS ad.With regard to specific training on alcohol and other drugs, 68.8% of the nurses mentioned no training in the area.

Nurses' insertion and practices in CAPS ad
These study results permit grouping data, in the light of the Brazilian Psychiatric Reform, in two

Category I: Nurses' insertion in CAPS ad
The analysis of the category Nurses' insertion in CAPS ad produced three sub-categories: a) Spaces for nurses' insertion in CAPS ad, b) Factors facilitating nurses' insertion in CAPS ad and c) Factors hampering nurses' insertion in CAPS ad, as follows.

Spaces for Nurses' Insertion in CAPS ad
Nurses' insertion in the context of CAPS ad occurs in the therapeutic groups, workshops and team meetings.Among these, those related to group activities evidence nurses' actual insertion into service dynamics.Regarding this fact, the nurses said: I coordinate the self-help group that takes place every Monday (E.10).We work with multiprofessional care here, mainly in the therapeutic groups (E.16).Another space for insertion the interviewees mentioned are the team meetings, where the nurses can express their opinions and discuss the cases they consider pertinent with other professionals.During this technical meeting, the professionals present some case for discussion by the entire team and I, as a nurse, participate actively in these meetings (E.12);We always decide what to do during team meetings, we always decide as a group what's going to be done (E.9).
Welcoming, which is the user's first contact with the service, also appears as a space that permits nurses' insertion, also guaranteeing the possibility of proposing and coordinating the user's therapeutic project, as a reference technique inside the CAPS: Tuesdays and Thursdays I welcome new patients, I assess the possibilities for their treatment here at the CAPS (E.9).All patients I welcome here at the CAPS, I take responsibility as their technical reference point, which is as if I were a case manager (E.15).Another space that permits nurses' insertion in CAPS ad contexts includes outpatient detox, according to the following statements: I accompany the patient during detox, that's my responsibility here (E.4).I work more directly with the patient during detox (E.10).We do the outpatient detox, which is done by the service nurses (E.15).

Factors facilitating nurses' insertion in CAPS ad
The flexibility in work division among team professionals adopted at the service appears as a facilitator of nurses' insertion in CAPS ad.In this respect, the nurses say that: Here at the service, great room exists for all professionals' work, including nurses' (E.7); Nurses participate like any other team member, they can fully talk, inquire, express opinions and are always respected (E.10).
In this work perspective, nurses' insertion in CAPS ad is broader and differs from the characteristic of the hospital model, in which work relations are vertically hierarchized.This characteristic represents a factor that facilitates nurses' insertion in CAPS ad: The relations here differ from those at the hospital.In hospital, the professional, the psychologist, the physician feel superior, they do not exchange with us very much, over here we talk about everything related to the patient, from peer to peer (E.8).In line with this statement, another factor that appears as a facilitator of nurses' insertion in CAPS ad is these professionals' valuation inside the team, as disclosed in the following statements: Respect exists for the nurses' decisions inside the team, they are acknowledged professionals in their area (E.2).I feel that they greatly respect my decision in here (E.8).skills to deliver care to patients with alcohol and other drugs related disorders.In this respect, the nurses comment:

Factors hampering nurses' insertion in CAPS ad
They did not value our way of delivering care to the patient, our patient approach, from the nursing perspective (E.1).I think that nurses are somewhat left aside in this part of mental health, and that makes it a bit difficult (E.5).
In line with this statement, one of the interviewees reveals that, despite acknowledging the importance and need to establish an approach that is more directed at the problem with service users, care is needed when playing this role as, according to that statement, other Another factor that hampers nurses' insertion in the service is the fact that they see themselves as professionals with little technical preparation to act on the patient's psychic demands, which can be evidenced in one of the nurses' statements: It has to be a therapist to do therapy or the psychologist, so, I think that, in this respect, we are somewhat more limited, there's not much to do (E.5).

CAPS ad
The second category refers to nurses' practices in the CAPS ad context.Its analysis permitted classifying the results in two sub-categories: a) Care practices; b) Administrative practices, as follows.

Care practices
Regarding nursing professionals' care practices in the context of CAPS ad, as expected, the analysis of their statements revealed that these professionals perform activities related to their specific knowledge core, including: medication administration, test collection and control of vital signs.In this specific nursing knowledge core, emphasis on medication administration and patient observation issues can be perceived, as the following statements illustrate: We control medication, which is for them to take home, in the afternoon (E.10);Right now, I am more active with giving medication and observing patients (E.12);I assume the part of medication administration and observation really (E.16).
Another care practice nurses perform at CAPS ad refers to closer follow-up of patients with some physical or psychic comorbidity, such as mental illness and HIV: I do the whole care delivery to HIV/AIDS patients and the worse psychotic patients, right?In those cases, I've got closer followup here at the service (E.13).
Data analysis regarding nurses' care practices at CAPS ad permits evidencing that these workers tend to establish an internal division, separating clinical from "psi" or mental health nurses and, in the latter's list, the subjects' classification include patient follow-up and observation in the abstinence period, There's one activity specific to nurses in mental health care, which is followup during patients' initial abstinence period (E.7).However, even when attributing the follow-up of abstinence to the mental health area, nursing practices in this context remain aligned with the clinical model, in which they are responsible for following the evolution of signs and symptoms and clinical manifestations characteristic of this period, as one nurse mentioned: I follow the patient during detox, right?When he gets here, we have to pay attention to the evolution of the patient's symptoms (E.10).
In line with the division the nurses establish between clinical and mental health or more "psi" practices, it is evidenced that the nurses do not conceive the latter as an inherent practice of their profession at CAPS.Strengthening this result, some nurses reveal that actual nursing activities take place in clinical or urgency situations.These, in turn, are represented by the subjects as directly related with the "nurse's role".
There are these things which, then, you end up acting more as a nurse; sometimes, a patient arrives throwing up a lot, with fever (E.3).That kind of activities is directly related with nurses' role, which is emergency, urgency care (E.7).

Administrative practices
Administrative practices occupy a large part of nurses' time inside the CAPS ad, again, as evidenced in the results related to care practices.These professionals perform administrative practice within the specific core they master, either involving the coordination of the service's nursing work, represented by nursing team supervision.Due to the lack of staff at the service, however, this task also includes supervising other workers, such as pharmaceutical technicians for example.I end up supervising a pharmaceutical technician, which is not my responsibility, but I'm the one who takes care of it (E.13).
filling out papers and scheduling consultations for other service technicians, assuming the role of organizer.I get into the pharmacy and control the drugs that are going to be manipulated during the day (E.2).We have a lot of paperwork to do here, it's something we spend a lot of time on (E.3).We schedule the consultations, for the psychologist, for the psychiatrist, The organization of other service technicians' work is also evidenced in the following statement, appointing nurses as the professionals responsible for organizing the service when other professionals are absent, guaranteeing its functioning: Something else I also have to take care of is the lack of other technicians, for example, if the psychiatrist doesn't come today, there won't be any psychiatrist present, so then I already let everyone know (E.8).

Discussion
According to the obtained results, nurses' insertion in CAPS ad is marked by proposed interdisciplinarity.In this perspective, communication is imperative and implies overcoming specialized and closed terms, producing a single language to express various subject areas' concepts and contributions, which will permit understanding and exchanges (4) .Team meetings constitute spaces where interdisciplinarity is put in practice as, according to the nurses, they are characterized as a space for exchange and listening in the entire team.By contributing with his/her specific knowledge area, each professional seeks unique knowledge on the individual, so as to propose the therapeutic project.The meetings are also characterized as strategies that allow nurses to get closer to other team technicians (6) .
Nurses' insertion in CAPS ad seems to be facilitated by a good relationship with the multiprofessional team, for which the perspective of interdisciplinarity entails the ability to absorb nurses' knowledge and acknowledge that it is important for the success of the therapeutic proposal.Interdisciplinary work demands that team members socialize their roles, favoring a decrease in hierarchized organization, towards collective and equalitarian work (7) .On the other hand, professional relations are also appointed as a factor that hampers nurses' effective insertion in the context of CAPS ad.
According to the interviewees' statements, this is due to the little valuation some team members grant nurses as technical professionals who are capable of working with patients with alcohol and other drugs-related disorders.
In this respect, a study (14) appointed that the approximation among professional areas in technical work is accompanied by tensions regarding the values of different activities.Also, a certain type of hierarchical relation is reproduced, mainly between medical and nonmedical professionals.This appears in the results when one subject reveals that, in the attempt to approach a service user more specifically, she faces difficulties with other professionals, for whom this conduct can mean the occupation of their activity areas (9) .
The concrete difficulty of uniting, integrating and articulating the team can occur due to the fact that professionals stick to their specificity, isolated in task accomplishment or compliance (6) .The result remits to the difficulty other studies (12) have already appointed, recommending precaution, as the exercise of the psychosocial paradigm is lambasted by antagonistic pulsations; these include the dominance of the fragmentation process of work and the divergence between the development level of technology and the development level of the workforce.
Another factor hampering nurses' insertion in CAPS ad is the fact that they do not recognize themselves as professionals who are apt to work with patients suffering from alcohol and other drugs-related disorders, reducing their professional activity to attendance to clinical needs (4) .In line with this result, a research (11) appoints that, after the psychiatric reform, most nurses do not feel prepared to work in psychiatric nursing or mental health and, consequently, in the psychoactive substance context, which ends up compromising their insertion into new mental health care devices.This fact entails difficulties for nurses to recognize their work as capable of helping in this population's treatment.This is partially due to the fact that they do not feel prepared to act in this area or because they do not understand their activity space among technical team professionals (11) .participants mentioned that they did not receive formal preparation to work with patients with psychoactive substance-related disorders.This lack of preparation to work in CAPS ad becomes more concerning, as little attention has been paid to these issues during the undergraduate program, which has also contributed to the lack of preparation in view of new job market demands in this area (8) .
To discuss the results regarding nurses' practices, it needs to be taken into account that the institutionalization of knowledge and its organization into practices takes place through the constitution of cores and fields (15) .The core comprises the knowledge and constitution of a given standard of practices, including the production of values attached to their use, outlining the identify of one knowledge area and its professional practice; the field, on the other hand, is a space with imprecise limits, in which each discipline and profession seeks support from others to comply with its theoretical and practical tasks (15) .In the proposal of substitutive services, the specific core of the nursing profession, although preserved, is broadened, departing from the interconnections between different cores, to be transformed into action in the psychosocial field which, among others, can enhance users' psychosocial rehabilitation (5) .
According to this premise, the results related to the practices nurses perform at the CAPS ad under analysis are in line with those found in other studies (6) .In mental health services, these professionals have performed activities that are common to their specific knowledge core like in any other work field.The organization of CAPS ad, however, allows nurses to expand their practices, moving beyond historically constituted practices in psychiatric nursing and mental health (observation, control and medication administration), requiring that nurses use other knowledge supporting their work practices during workshops and therapeutic groups, in welcoming, psychotherapy and when dealing with different situations that come up there.
The care practices the subjects appoint tend to focus on the clinical issues deriving from drugs abuse, a frequent practice among nurses active at mental health services nowadays (11) .The focus on patients' clinical and physical problems ends up distancing nurses from any intervention that is possible for the patient (10)(11) .The explanation for the predominance of these clinical practices in nursing work, to the detriment of "psi" practices in the context of CAPS ad, can be the lack of preparation to act in the field of psychoactive substances, in addition to the little knowledge on its particularities (4) , which can limit these professionals' insertion in the field of CAPS practices.
This creates an uncomfortable feeling as, although CAPS have another proposal, certain groups' knowledge still works in these spaces as an element of power (4) .One example is the use of technical terms from psychiatry to describe symptoms and establish diagnoses, which delimits a power space, consequently setting the spaces of those who master this knowledge against those who do not, putting nurses in the latter group, as both preparation to act in the field of psychoactive substance and that regarding "psi" knowledge (4) have been little explored during their education.This would justify the fact that nurses in this study identify more with clinical issues as, in the absence of specific knowledge to act in these scenarios, they may feel safer when taking charge of those practices they easily master, thus assuming those practices more oriented at clinical issues and service administration, which would ultimately compromise their true insertion in the service and, consequently, contribute little to the desired interdisciplinarity in the approach of CAPS ad users.
Administrative and bureaucratic practices inside the service contribute to the distancing between nurses and CAPS users, which nurses have spent plenty of their time on, occupying a space other workers could occupy, besides facilitating and organizing the work of other technical team professionals.By taking charge of these activities, their work becomes the means or work instrument of other professionals, such as: physicians and psychologists, so that nurses practically do not work specifically in care, but are consumed by routine, bureaucratic, strictly medicalized and affectively distanced procedures, which do not permit any expression of individual subjectivity (8,(9)(10)(11) .This fact can be expected as, considering that they are not prepared to deal with specific situations involving psychoactive substances, it is natural for these professional to feel safer when organizing the work and functioning of the practice field than when actually taking part in it.This avoids their exposure before the team and their activity will not arouse conflicts, as it will merely organize the space for other professionals' activities.

Final considerations
In the context of the Brazilian Psychiatric Reform, the CAPS ad allows nurses to work in a broader sense.
These professionals have faced difficulties though to occupy this new space, and they have tended to transfer their clinical-hospital practices, for which they are better prepared, to this scenario.Nurses' lack of preparation to work in psychoactive substance-related issues and their lack of knowledge on specific contents, enhancing their insertion into care practice in these scenarios, can be appointed as causes of this phenomenon.The lack of training to act in the field of psychoactive substances seems to represent the main obstacle regarding nurses' actual insertion in the CAPS ad team.Generalist nursing education needs to be reconsidered with a view to work in these new mental health services, preparing them to act not only in their specific knowledge area, but also to support it on knowledge from the collective practice field, granting these professional instrument to overcome a practice mirrored in the hospital model, which has added little to improve psychosocial nursing care to psychoactive substance-related disorders.
involved 16 nurses from 13 Psychosocial Care Centers for alcohol and drugs functioning in São Paulo City between October 2007 and February 2008.Data were collected through semistructured interviews with two guiding questions: "(1) What are your tasks here at the CAPS;(2) In your opinion, how are you inserted in this service?'The interviews were held at the subjects' workplace and took 40 minutes on the average.Dialectical Hermeneutics was the model chosen for data analysis.Hermeneutics permits comprehension based on the understanding of historical facts, daily life and reality, while dialectics establishes a critical attitude by studying disagreement, change and macro-processes extracted from the testimonies and grouped into theme categories, compatible with the theoretical framework used.The thematic units were classified and grouped in two analytic categories: Category I -Nurses' Insertion in the Context of CAPS ad and Category II -Nurses' Practices in the Context of CAPS analytic categories: One related to the Insertion of this professional in the service, and the second related to Nurses' Practices in the Context of the CAPS ad, whose results are shown next.
If, on the one hand, flexibility in work relations in the context of CAPS ad and nurses' valuation in the team constituted facilitators of these professionals' insertion in the service, some nurses appointed elements hampering this insertion into therapeutic activities at CAPS, mainly regarding the low credibility level some team professionals grant nurses with, regarding their technical and therapeutic Vargas D, Oliveira MAF, Duarte FAB.
at the right time (E.14).During these administrative and organizational practices inside the service, nurses end up characterizing themselves as professionals who organize and facilitate other professionals' practices, since they do not only take charge of scheduling patients for other technicians, but also assume tasks like transcribing prescriptions and writing down test results in the patient files.To evidence this practice, some nurses mention: I do the prescriptions and the physician signs them (E.8).I help the physician to write down tests in the patient file, to organize patient files (E.11).
The lack of preparation nurses experience to work in CAPS ad can be justified, among other factors, by the present study results on nursing education to act in the field of alcohol and other drugs.Almost 70% of Vargas D, Oliveira MAF, Duarte FAB.
Until January 2009, 186 CAOS ad had been registered at the Ministry of Health, most of which, 46 (24.7%) were concentrated in São Paulo State, 15 * professionals do not see this conduct positively, nor do they acknowledge this type of intervention as a nursing prerogative.As one subject denounces: Because then, suddenly, the psychologist arrives and sees you talking to the patient and says -Hey, you can't.You cannot pay much attention, talk a lot-.I don't agree with that, I think that you have to leave this room.It's a moment when you have contact with him and you should use it to help him, instead of just performing procedures (E.5).