RESEARCH ARTICLES
Demands for self-care in therapeutic group: health education with users of psychoactive substances
Selene Cordeiro VasconcelosI; Iracema da Silva FrazãoII; Eliane Maria Ribeiro de VasconcelosIII; Ana Márcia Tenório de Souza CavalcantiIV; Estela Maria Leite Meirelles MonteiroV; Vânia Pinheiro RamosVI
IPediatric Nurse, Master in Nursing by the Federal University of Pernambuco. Assistance Nurse of the Psychosocial Attention Center for Alcohol and other Drugs. Emergency Care. Recife, Pernambuco, Brazil. E-mail: selumares@yahoo.com.br
IINurse, Doctor in Social Service, Adjunct Professor 2, Graduate Program of Nursing, Health Sciences Center, Federal University of Pernambuco. Recife, Pernambuco, Brazil. E-mail: isfrazao@gmail.com
IIINurse, Doctor in Nursing, Adjunct Professor 1, Graduate Program of Nursing, Health Sciences Center, Federal University of Pernambuco. Recife, Pernambuco, Brazil. E-mail: emr.vasconcelos@gmail.com
IVNurse, Doctor in Child and Adolescent Health, Adjunct Professor, Graduate Program of Nursing, Health Sciences Center, Federal University of Pernambuco. Recife, Pernambuco, Brazil. E-mail: anapopita@gmail.com
VNurse, Doctor in Nursing, Adjunct Professor, Graduate Program of Nursing, Health Sciences Center, Federal University of Pernambuco. Recife, Pernambuco, Brazil. E-mail: estelapf2003@yahoo.com.br
VINurse, Doctor in Neuro-Sciences, Adjunct Professor 4, Graduate Program of Nursing, Health Sciences Center, Federal University of Pernambuco. Recife, Pernambuco, Brazil. E-mail: vpinheiroramos@uol.com.br
ABSTRACT
This study aimed at understanding the contributions of Therapeutic Group on health education to the identification of therapeutic demands for self-care among users of psychoactive substances. Descriptive, exploratory study with a qualitative approach, involving eight users in treatment in a Psychosocial Attention Center for Alcohol and other Drugs (CAPSad), Recife-Pernambuco. Data was collected between July and September 2011, through research in patient files and interviews, audio recordings and thematic analysis of the content. Contributions were identified as opportunities to self-knowledge, reflections on lifestyle and personal and family losses. This group provided a therapeutic environment of health education through exchange of knowledge which resulted in critical and reflexive learning about the health-disease process and the use of psychoactive substances, as well as support for acquisition of healthy habits, redemption of autonomy and improved self-esteem.
Keywords: Nursing; health education; self-care; substance-related disorders.
INTRODUCTION
A Nurse can work in different ways as a caregiver, from acting in the promotion of primary attention to interventions of higher complexity. It is an essential role for a Nurse the articulation of educative actions for health assistance to the individual, family, groups and community, as a way to promote access and exchange of knowledge in order to assure the user’s autonomy and the possibilities of self-care and co-participation in his therapeutic process.
This learning process is continuous, ignited from the identification of demands connected to the addition of actions that allow the user to decide and intervene in his self-care to answer his specific needs according to his organic and social context1. It is necessary an active hearing by the nurse of the demands for self-care.
We must consider that there are health problems that may threaten the critical sense and the capacity of judgment of a person, as for psycho-active substances2 that endanger all the educative process that allows user to perform self-care actions. Users of these substances cannot realize their reality and their actions are directed exclusively towards drug use. It is also known that use of those substances has grown with initiation increasingly earlier, creating an expansion in the demand for services and vacancies for specialized treatment3.
In this scenery the Psychosocial Attention Center for Alcohol and other Drugs, CAPSad, is inserted, a health equipment specific to the care of users of psycho-active substances, in which the Nurse acts in the individual treatment, planning and coordination of therapeutic groups and therapeutic recreation outings, send users to health services and clinical case discussions.
From this point of view the importance of using the concept of self-care must be emphasized, as a guideline of Nurse’s interventions, according to the theory of Dorothea Orem, aiming to promote a co-participative construction, involving professionals, users and family in the self-care process. As for public health, the demands in the context of mental health require competences and skills of the Nurse in order to deal with this problem.
That said, the work focused on understanding the contributions of the Therapeutic Group on Health Education in order to identify demands of self-care of users of psycho-active substances.
THEORETICAL FRAME
When the scientific background of Dorothea Orem’s theory was considered, regarding the Nursing Theory of Self-Care, it was identified a relationship between its assistance methodology and the practice aimed, through the interaction between the nurse, users and family1.
The nurse performs specialized assistance to people with disabilities. Self-care has a regulatory role that individuals use in their own benefit or to others, aiming at supplying and keeping physical and psychological operation and development, in adequate conditions to human life1.
The theory highlights, in the nursing process, the phases self-care demand, planning of nursing assistance, in which goals are set, objectives, system and help methods. In this study the theory is emphasized for support and educative actions in the perspective of individual self-care, in which competence to self-care encompasses the individual power and capacity to engage and search resolution for therapeutic demands1.
In the health context, nursing is inserted in a complex and relational reality that encompasses constraint and personal factors of those involved, acting through help methods such as act doing to the other person; guide; give physical and psychological support; provide and keep an environment of support to personal development; and teach1.
METHODOLOGY
Descriptive study, exploratory with qualitative approach, conducted at Eulâmpio Cordeiro Psychosocial Attention Center for Alcohol and other Drugs, CAPSad Eulâmpio Cordeiro, reference to treatment of users of psychoactive substances of the Sanitary District IV, Recife-PE. The number of participants was determined by theoretical saturation2, totaling eight users of intensive mode in the afternoon shift. Inclusion criterion: participation of at least four sessions of Therapeutic Group on Health Education, coordinated by one of the researchers, and agreement in participating of the research. Group sessions lasted one hour, once a week, with seven to thirteen participants.
Themes were listed from the demand of the participants, highlighting: self-perception; fears and insecurities; concepts of drugs; repercussions to users and their family; coping with chemical dependence; family care and autonomy to self-care. Data was collected through semi-structured interviews audio recorded in July and August of 2011.
After the interviews, transcription was done and after that analysis according to Bardin, following those phases: pre-analysis, fluctuating reading of the material; exhaustive readings to deepen knowledge over the material, subsiding codification and discourse clippings, in which language and situation are represented5.
Clippings were done considering the regularities in the formation of discourses, coping with heterogeneous meanings. Themes units were constructed from the discourse, represented in corpusin the analysis of this study5.
Data collected was treated by inference and interpretation, with discussion grounded in Dprpthea Orem’s Theory of Self-Care1.
In order to conduct the study, bioethical principles were respected according to Resolution nº 196/966, with approval by Ethics Research Board (CEP) of the Federal University of Pernambuco, CAAE - 0075.0.172.000-11. To keep users’ confidenciality biblical names were used, such as: Amos, Moses, David, Jonas, Peter, Sarah, Esther and Ruth.
RESULTS
Age group varied between 22 and 59 years, five men and three women, three single, four separated and married. Among the research’s eight subjects, two women were crack users and the rest were addict to alcohol. Only one user had his own income and the others were supported by their families. As for schooling, two were illiterate and the others abandoned formal education.
Dependency classification is based in a bad adaptation pattern of use of psychoactive substances with psychological, physical and social repercussions to human beings7.
1st Category – Self-care deficit
From speech analysis appeared the theme category: identification of self-care deficit. It means finding oneself as an active subject and co-responsible for his own treatment becomes the main focus of care. Recognizing situations of negligence with their own health contributes to the identification of their own therapeutic demands of self-care:
I used to wander in the streets, I did not take showers, I did not change my clothes, I did not care to anything, I did not eat[...].(Amos)
An user realizes that being in the group discussing health issues made him identify his own losses due to alcohol use:
I was drinking a lot, I could not stop and I had no compromise to work, I did not care to anything, I did care to myself.(Moses)
Other users expressed their understanding on the importance of identifying the need for behavior change in order to become healthier:
[...]I did not care to anything [...]I did not bath, I did not eat, I did not eat, I did not change my clothes[...]my only thought was drinking.(David)
[...]I took cans in te garbage to smoke crack.(Sarah)
This reality is shared by other users:
[...]before, the person does not care, the person attends the group meetings, that is good. When I was only drinking I did not care to anything, I did not even shower, I did not even brush my teeth, nor changed my clothes.(Jonas)
2nd Category – Support to self-care
Another user carried on affirming that his/her participation in the group contributed to reflect his/her behaviors and identify what needed to be changed, helping define the second theme category: Support to cope with therapeutic demands of self-care.
I was surrending to drinking and relaxing [...]you explain what we must do[...]to the health it is good.(Peter)
The therapeutic group helped the participants to wake to their own needs for health and contributed to their change of behavior, according to the speech:
[...]I learned to prevent myself not to be sick [...]damage reduction, must eat, must drink water[...].(Sarah)
Exchange of knowledge enabled by the group was indicated as a learning facilitator on health and especially on self-care, as many users report lack of information on these issues, as can be seen in the following narratives:
They say how we have to do [...]once you have health education, you know what to do[...].(Esther)
[...] the folk attends the group, it is good. The good part is that you talk on health [...].(Jonas)
From these speeches, users demonstrated understanding of the human degradation process triggered by the consumption of psychoactive substances.
DISCUSSION
In order to develop self-care in an efficient way, one needs to learn to identify the deficit and search for support to cope with the therapeutic demands to self-care, that is the addition of self-care actions demanded by the person to meet his/her needs1.
To this research it was considered Orem’s concept, in which self-care is “the performance or the practice of activities that individuals perform in his/her own benefit to keep life, health and wellness. When self-care is effectively done, it helps to keep the structured integrity and human operation”1:17.
These concepts can guide nursing interventions that aim to help people to identify and understand their own demands for self-care8. From this point it is considered that health needs of the users of psychoactive substances demand specialized services that offer a proposal of amplified care, mainly for family relationship, social coexistence, work and health9.
Through this perspective, the therapeutic group constitutes a scenery for care favorable to nursing operation, in which group activity provides the opportunity to share projects that help to rebuild the history of each individual10. Beside, the group may be used as a strategy of health education as it helps the exchange of knowledge, the reflection on health problems and the construction of a critic view on health situation of those involved11 and the influence of the social determinants in the health/disease process.
When the Nurse realizes his/her role, he/she is vested in the function of agent for change, promoting autonomy and personal development for those involved in the educational process, based on the apprehension of the reality of the members of the therapeutic group. The exchange of knowledge stimulates participants to think, question, search for answers and build other possibilities for growth12.
Team work enabled the promotion of an objective communication, breaking through barriers of prejudice and demonstrating faith in the potential of human recovery. It was based on Orem’s theory as for the planning of activities of support and teaching. Educative intervention promotes mutual benefits, for both users and professionals involved13, as it allows the construction of a relationship of trust and respect between nurses and users.
It is noticeable that Health Education Therapeutic Group promotes reflection on physical, mental, social and emotional damages caused by the consumption of psychoactive substances. Self-perception of the problem contributed to the identification of health therapeutic demands and accountability for his/her own care process.
The group also allowed the connection of technical and popular knowledge, so that a new approach to the process of care came to light. It also enabled learning in the context of the process health/disease and, consequently, the identification of possibilities of development of healthy habits14. Besides, it promoted discussions related to health issues and acquisition of new skills, autonomy recovery and improvement of health condition of those involved15. To sum up, the Health Education Therapeutic Group enabled the construction of new knowledge that prompted users to make changes in their behavior, after realizing that self-care is a continuous process, necessary to overcome dependency and to promote health.
When it works interpersonal relationships, the group becomes a place for communication and integration. Therefore, CAPS is an arena for care that allows interaction between health team and users, enabling the construction of a process of collective work17. In this perspective, the nurse shall demonstrate specific characteristics and enough knowledge to conduct the reflection, the dialogue and the discussion on drugs, as well as contribute to explain situations based on principles and concepts of health18.
That said, it must be highlighted that this study promoted reflections among professionals over the complexity of the context experienced by the users of psychoactive substances and over the work process of dealing with these clients, emphasizing autonomy and self-care.
CONCLUSION
Understanding the contributions of the Health Education Therapeutic Group to the lives of users of psychoactive substances pervades the perceptions of professionals on the complexity of the phenomenon of use of alcohol or psychoactive substances, as well as the adequacy of their interventions, considering each person’s subjectivity.
As an activity learned throughout life, self-care interferes and is influenced by self-esteem and by the conquest of a personal, social and cultural identity. Therefore, its exercise is connected to a voluntary decision, by the psychoactive substances user, to engage in its actions. In a group environment, health education interventions disseminates a process of caring based on respect for personal freedom of choice, stimulus to the construction of knowledge based on the reflection and understanding of each person’s life story, and it helps the conquest of support to actively engage in self-care.
This study contributes to the reflection for nursing professionals on the multidimensional aspect of the context users of psychosocial substances are involved, as well as the meaning of therapeutic interventions and management of groups.
Therefore, Health Education Therapeutic Group provided help for users to cope with situations related to abuse of alcohol and drugs, considering its damages. It also awoke users to possibilities of building up attitudes and behaviors engaged in self-care – being responsible for their own treatment.
Notwithstanding, the study found out as a restraint the scarce scientific literature on self-care for users of psychoactive substances and therapeutic groups.
esides, the discussion on the theme does not come to a close with this research, as it aims at awakening interest on developing new studies focused on group approach in different aspects, as it offers an appropriate environment to the exchange of knowledge and interaction among participants.
REFERENCES
1.Orem ED. Nursing: concepts of practice. 6th ed. St Louis (USA): Mosby; 2001.
2.Laranjeira R, Bordin S, Figlie NB. Aconselhamento em dependência química. São Paulo: Roca; 2010.
3.Vasters GP, Pillon SC. O uso de drogas por adolescentes e suas percepções sobre adesão e abandono de tratamento especializado. Rev Latino-Am Enfermagem. 2011; 19(2):[8 telas].
4.Grubits SL, Noriega JAV, organizadores. Método qualitativo: epistemiologia, complementaridades e campos de aplicação. São Paulo: Vetor; 2004.
5.Bardin L. Análise de conteúdo. Lisboa (Por): Edições 70; 2010.
6. Ministério da Saúde (Br). Resolução 196/96 do Conselho Nacional de Saúde. Brasília (DF): Editora MS; 2012.
7.Organização Mundial da Saúde. Classificação de transtornos mentais e comportamento da CID-10: descrições clínicas e diretrizes diagnósticas. Porto Alegre (RS): Artes Médicas; 1993.
8.Landim CAP. A competência de pessoas com diabetes mellitus para o autocuidado em um programa educativo multiprofissional [dissertação de mestrado]. Ribeirão Preto (SP): Universidade de São Paulo; 2009.
9.Gonçalves SSPM, Tavares CMM. Atuação do enfermeiro na atenção ao usuário de álcool e outras drogas nos serviços extra-hospitalares. Esc Anna Nery. 2007; 11: 586-92.
10.Cunha ACF, Santos TF. A utilização do grupo como recurso terapêutico no processo da terapia ocupacional com clientes com transtornos psicóticos: apontamentos bibliográficos. Cader de Terap Ocup da UFSC. 2009; 17: 133-46.
11.Lopes EM, Anjos SJSB, Pinheiro AKB. Tendências das ações de educação em saúde realizadas por enfermeiros no Brasil. Rev enferm UERJ. 2009; 17: 273-7.
12.Fernandes CNS, Munari DB, Soares SM, Medeiros M. Habilidades e atributos do enfermeiro como coordenador de grupos. Rev RENE. 2008; 9: 146-53.
13.Herculano MMS, Sousa VEC, Galvão MTG, Caetano JA, Damasceno AKC. Aplicação do processo de enfermagem a paciente com hipertensão gestacional fundamentada em Orem. Rev RENE. 2011; 12: 401-8.
14.Tamai SAB. Avaliação de um programa de promoção da saúde na qualidade de vida e no estado de bem estar em idosos [tese de doutorado]. São Paulo: Universidade de São Paulo; 2010.
15.Soares LC, Santana MG, Thofehrn MB, Dias DG. Educação em saúde na modalidade grupal: relato de experiência. Cienc Cuid Saude. 2009; 8: 118-23.
16.Benevides DS, Pinto AGA, Cavalcante GM, Jorge MSB. Mental healthcare through therapeutic groups in a day hospital: the healthcare workers’ point of view. Interface - Comunic, Saude, Educ. 2010; 14: 127-38.
17.Pereira DB, Coimbra VCC, Kantorski LP, Oliveira MM, Soares MC, Schrader G. A integralidade no cotidiano das práticas em um centro de atenção psicossocial. Cogitare Enferm. 2011; 16: 430-6.
18.Lopes GT, Belchior PC, Felipe ICV, Bernardes MM, Casanova EG, Pinheiro APL. Dinâmicas de criatividade e sensibilidade na abordagem de álcool e fumo com adolescentes. Rev enferm UERJ. 2012; 20: 33-8.
Received: 06.11.2012
Approved: 26.01.2013