ORIGINAL ARTICLE

 

Assistance to drug users in emergency care: perspective of health professionals

 

Atención a los usuarios de substancias psicoactivas en presto servicio: perspectiva de los profesionales de salud

 

 

Sara Pinto Barbosa^I; Maria Conceição Bernardo de Mello e Souza^II

^IMaster's student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^IIPhD, Associate Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil

Correspondence

 

 

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ABSTRACT

The objective was to analyze how is the care of drug users from the perspective of practicing professionals in an emergency care service in Ribeirão Preto-SP. For data collection, it was used a semi-structured interview conducted with 17 participants and found the Content Analysis of thematic type. It was found that most professionals do not have the knowledge to meet this demand, they feel insecure and their postures were guided by moral judgment and prejudice. Actions proved ineffective in attendance, as often the same were concentrated on clinical problems. It was reinforced the need for training of health professionals for this service, mainly due to the increasing demand for these services.

Descriptors: Drug Users; Emergency Medical Services; Mental Health.

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RESUMEN

Se objetivó analizar como ocurre el servicio de usuarios de substancias psicoactivas, desde la perspectiva de los profesionales actuantes, en un servicio de presto servicio del municipio de Ribeirão Preto-SP. Para recogida de datos se utilizó entrevista semiestructurada realizada con 17 participantes y se procedió el Análisis de Contenido del tipo temática. Se constató que la mayoría de los profesionales no dispone de conocimiento para el servicio la esa demanda, se sienten inseguros y sus posturas eran guiadas por juicio moral y preconcepto. Las acciones se mostraron poco eficaces en el servicio, visto que casi siempre las mismas se concentraban en problemas clínicos. Reforzamos la necesidad de formación de los profesionales de salud para ese servicio, especialmente debido a la creciente busca de estos servicios.

Descriptores: Consumidores de Drogas; Servicios Médicos de Urgencia; Salud Mental.

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Introduction

The abuse of psychoactive substances is now a social, health and public safety problem and have increasingly occurred early in people's lives⁽¹⁾. It must be noted the increase in health care costs due to the potential complications of the use of these substances in clinical already installed⁽²⁾.

This issue is still regarded as one of the reasons of increasing demand for emergency services that address mental health⁽³⁾ and thereby also causing the increasing occurrence of cases with clinical complications.

In this sense, the adequacy of services to the assistance to this demand is now one of the priorities of the Ministry of Health as a possible treatment suited to users of psychoactive substances⁽⁴⁾. To serve this clientele is ministerial political improve the care in services that compete for the attention of greater complexity, such as the emergency services who are dedicated to attend in cases of intoxication and abstinence⁽⁵⁾.

Thus, the aim of this study is to analyze how is the assistance to users of psychoactive substances in a Basic District Health Unit (UBDS) of the Western District of Ribeirão Preto, from the perspective of professionals working in the emergency care service of the same.

 

Methodology

Research with descriptive and analytic characteristics with qualitative approach, performed in the period from April to August 2011. To obtain data it were used semi-structured interviews with professionals who work in a general ED in a Basic District Health Unit (UBDS). The interview questions were about the care of patients with specific demand in mental health and psychiatry.

The study site is a service of Emergency Room (ER) of one of the five health district of Ribeirão Preto, in the state of São Paulo. The same is bound to Faculty of Medicine, University of São Paulo (FMRP-USP) known to be an important place not only in health care, but in teaching and practical training for new professionals. All health professionals of this ED were invited to participate in the study giving an interview to the researcher, the only exclusion criterion was not accepting to participate. In this study there was only one case of denial to be interviewed and was respected this right of the professional.

The number of participants was obtained through theoretical saturation of the data, ie, when there is already a theoretical depth and the collection of new data would point a few new elements for analysis⁽⁶⁾. Thus, this study consisted of 17 participants. The same, after accept to participate in the research, signed a Statement of Consent (TCLE). Thus, the interviews were conducted in a room reserved of service and lasted on average 30 minutes. The samples were audio recorded and later transcribed.

The interviews were analyzed about the content, and such being obeyed the following order: pre-analysis, which was performed fluctuating readings, ie, superficial readings, in order to explore the full interview transcript material, material exploration when it was started the grouping of the data in units of record, and finally processing and further interpretation of the results, in this step being performed the categorization, ie, the grouping according to similarity rating them due to their common characteristics⁽⁷⁾. In this study it was used the content analysis of thematic type with the thematic nuclei being extracted from the interviews that focused on attendance to drug users in service in ER.

The research conformed to the ethical rules of Resolution 196/96 which provides for research in humans and for implementation was approved by the Ethics and Research Committee of the FMRP-USP under 445/CEP-CSE-FMRP-USP process . The names of the participants are fictitious and some have been chosen by them during interviews.

 

Results and discussion

First the profile of respondents is presented (Figure 1), followed by analysis and discussion from the interviews with health professionals. Of the 17 participants interviewed five are nurses, eight are nursing assistants, two are nurse technicians, and two are doctors. Regarding gender, seven are men and ten are women. The age range of professionals ranged  from 26 to 54 years. Eight participants reported having another job, one of them being outside the area of health and one is a professor of higher education.

About participation in courses for formation in the area of mental health, seven participants reported that they had watched presentations offered by educational institutions at the service location, none of these presentations was given by the Municipal Health Secretary. This suggests little investment by the municipality in specific formation in mental health. Seven higher education professionals reported having done postgraduate course, two of these - a doctor and a nurse - said the postgraduate course they have is in the area of mental health. The working time in the service of ER varied from one month to 18 years and may be observed that the permanent staff (except residents who take turns more often) presents certain permanence.

In the city of Ribeirão Preto-SP, users who require hospitalization or who are in situations of urgency or emergency due to use or abuse of psychoactive substances can be easily found in ER services, as in these sites are carried out screening for attendance in more complex levels of health services.

The Psychosocial Care Center for Alcohol and Drugs (CAPSad) attends patients through spontaneous demand or referrals. During data collection, this service available in the city was in trouble for not having a psychiatrist on its staff of fixed professionals, which made ​it impossible for drug users to seek the service, making sometimes the ER as the only place available to attend this demand.

This can be proved by the reports of the participants of this study that, in general, said that the search of drug users in the service is frequent. Professionals relate the search of these users in the service with having difficulty to find a place to live because of social exclusion experienced by them, also hindering the establishment of links with the healthcare team, as Ricardo explains: many drug users arrive who are homeless and want to stay here. And of course it is also difficult for staff to deal with such a situation... Which empathy will be there? Low, and it is really difficult... (Ricardo)

Current rates of prevalence of disorders by psychoactive substance use are high in the population in general and therefore the growing need for emergency services more prepared to receive this population⁽⁸⁾.

Thus the ER is an important location of the route the user of psychoactive substances on the network. However, in order to use this site properly, it is necessary that professionals have an empathic attitude. It is known that it is through the empathic process that professionals can understand and perceive meanings of the feelings and experiences of users, then it is necessary that they be accepted as they are, regardless of their behavior⁽⁹⁾. It becomes difficult, if not impossible, to maintain a therapeutic and help relationship to the user if the understanding for his suffering and his life experience part only of moral judgment coming from the professional. Moral judgment is to design something as undesirable to deal with, as a "problem" with a negative charge. Thus, both the problem and the holder of the problem are denied, it negatively influences the actions pertaining to the treatment process⁽¹⁰⁾.

It is necessary that health services professionals are able to establish empathic relationships to be able to provide proper care and overcome the obstacles of preconceived moral judgments. The provider must have the ability to imagine themselves in the situation of the others who suffer, especially if the suffering is so morally unacceptable by society as in the case of abuse of psychoactive substance and alcohol. This process should be initiated even before the earliest contact with ER.

The situation of the ER as a place to wait inappropriate adjustment for other services was beaded by participants, mainly because the service does not offer activities to users during the waiting period, which often contributes to patient evasion of the service, as it is clear in the testimony of Flora: It happens, often the person goes out and take a walk. Here he does not have any activity, he is there in the room waiting, stay the whole day aimlessly ... Sometimes he comes out, goes, comes back and who ensures that he leaves, comes back and does not use drugs? (Flora)

Several studies show the impact of psychoactive substances abuse on the user population, which signals a need to adapt and improve the targeted assistance to them. Frequent use of alcohol, for example, has caused health problems and called out high economic costs relating to health in adults.

In a pilot study conducted in ER services the city of Ribeirão Preto-SP it was concluded that 90% of respondents aged between 34-40 years alcohol was the predominant drug use, including a daily pattern in both sexes⁽¹¹⁾. With this demand is expected to trigger actions towards professional formation and appropriateness of services for these assistance.

It is understood that part of the suitability of these services is the acceptance of this demand and understanding that the use or abuse of psychoactive substances denote care that pertain to the field of mental health. However, in the service of this study, participants reported that these users are not part of the demand for mental health, as explained in the following statement: Because it is not just say that he is psychiatric, most are chemically dependent. And then? (Alice)

The importance of actions in ER services that go beyond the attendance of situations of abstinence and intoxication is seen as important particularly because the tracking of abusive users allows access who had never asked for help regarding the difficulties confronted  by addiction⁽¹²⁾.

There are cases that, if they had not been evaluated in the ER, they could leave the service without any treatment or information about the opportunities available to help them. The emergency room can represent perhaps the only opportunity to receive information about addiction and be the start of an appropriate treatment⁽¹²⁾.

Another issue which also explains the importance of the formation for the identification of substances users in ER is the fact that most of the morbidity and mortality rates due to alcohol use occurs in individuals who do not attend specialized services, but the other devices on the health network⁽¹³⁾. Undoubtedly the emergency services can be one of these.

Thus, identification of users with risk behaviors may facilitate the implementation of preventive strategies that have proven effectiveness and efficiency and lower costs by reducing the more severe clinical, which are more costly to the public health system⁽¹³⁾. This identification could have as one of the places their own ER that routinely receives users, however it must have formation and understanding of the importance of such activity. This possible dissociation between substance use and care needs pertaining to the field of mental health can be due to the stereotype of unrest and violence given to patient with demand in mental health which is not associated in this service with users of substances as Elias reports: the drug user is not even a psychiatric patient, is not it? He arrives quiet, he does not arrive agitated, you know? I saw a few that arrived here agitated, most of them arrive with chest pain and tachycardia. (Elias)

In one study⁽¹⁴⁾ with the nursing staff of the emergency room of a general hospital, they reported that these situations of violence in the service are most often related to users under the influence of psychoactive substances. In the current study on the difficulties encountered during services rendered to users of psychoactive substances they report to be a local sought by the family as a possible support for themselves and the user, as the following quote: The user makes use of illicit substances and is away from home for a long time, then the family, when can find him, bring the user to try some help to stop the use of these substances. (Regina)

Although the service is a place where the demand for drug users is large, it is clear that professionals do not have adequate formation to perform service to this population, which is recognized by Heloise: No, is not the same ... It's a bit like, for example, I in my case, I feel a bit confused on how to attend the patient. I never know, for example, how to treat a patient in drug. (Heloísa)

The formation, particularly of professional nursing category presents unfit for these can provide care for drug users⁽¹⁵⁾, a fact that worries due to the importance of these professionals in health care, since they participate in the design process and implementation of prevention programs of health, including prevention of use and abuse of substances⁽¹⁶⁾.

The difficulty of performing an appropriate approach is identified by professionals as a result of the limited availability of time, so can be suggested training for achievements of brief interventions (BI)⁽¹⁷⁾. This could circumvent this obstacle, since these interventions is adapted for use in emergency rooms . The BI could still equip health professionals of ER to talk about substance use with patients of the service , a mistake they often make for believing that it is not be the appropriate place⁽¹⁷⁾. It is also necessary to train professionals in order for them to understand that the information itself , in the case of substance use , is an important form of support⁽¹⁶⁾. The use of BI in emergency room has been appointed as largest facilitator in the derivation of the specialized treatment in severe cases of alcohol dependence⁽¹⁷⁾, reducing the risk of damage, chances and development conditions of the problems commonly observed as a result of substance use⁽¹³⁾.

The moment of criticizing or not the use of the substance by the user determines the professional performance. Regina explains that the interaction with the patient depends on what time he is: If he came because he is a drug user, for example, and he wants to stop, he wants to treat the addiction, it is different. So can you talk... (Regina)

There is a need for a integrated service network for dependent attendance and the emergency room is an important space where not only allows intervention in clinical problems due to substance use, but the awareness that the user can initiate the process of change⁽¹⁴⁾.

In the period of motivation the individual feels more able to change behavior in relation to substance use and is more receptive to team performance⁽¹⁷⁾. To take advantage of the motivation or even to sensitize users, one of the solutions identified in studies that could be used in ER would be the Brief Intervention (BI) which proved to be effective in people who have a risk and harmful consumption of alcohol. The BI is appropriate to apply in emergency care, which will require training of professionals. In this type of intervention the focus is to detect substance use and motivate changes⁽¹⁷⁾.

It appears that in the service of ER, where was developed the current study, there were not many qualified professionals to perform appropriate approaches to this clientele, and it was even clearly stated by the participants in the interviews.

The reports of delay in the process of vacancy for hospitalization in cases already evaluated by a psychiatrist and that require hospitalization are worrying. This is an alarming fact, especially because in the treatment of psychoactive substance use the motivation item is very important, and when users are motivated to start the treatment process, the delay, somehow misses the opportunity to carry out therapeutic work, since in the service there is not an activity or intervention provided to these users during this period of greatest hopes, which may contribute to the "escapes" of the service.

There is a pressing need for an integrated service network for dependent attendance, and the ER is an important space that allows intervention in clinical problems due to usage, and also the awareness so that the user can initiate the changing process⁽¹⁶⁾.

 

Final considerations

In relation to attendance of drug users it seemed clear from the content analysis of participants' speech that they are attended as users with demand in mental health. Professional conduct still seem to be guided by prejudice and moral judgments, inadequate attitudes of health professionals. These difficulties appeared to be from a professional formation unsuited to mental health care. This formation is required for professionals who deal with this demand in the service, as patients pass by them in moments of psychosis, intoxication or abstinence, among other situations in which the team should be prepared to welcome, attend, guide and to refer the patient if it is required for other general or specialized health services. It is worth highlighting the need for further studies on this topic and public investments in Emergency Services to be possible to improve the quality of care in this area.

 

References

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Correspondence
Maria Conceição Bernardo de Mello e Souza
Universidade de São Paulo. Escola de Enfermagem de Ribeirão Preto
Departamento de Enfermagem Psiquiátrica e Ciências Humanas
Av. Bandeirantes, 3900
Bairro: Monte Alegre
CEP: 14040-902, Ribeirão Preto, SP, Brasil
E-mail: consouza@eerp.usp.br

Received: Jan. 24^th 2013
Accepted: Mar. 5^th 2013

 

 

1 Paper extracted from master's thesis "Psychiatric Patient Care: a daily emergency service in the state of Sao Paulo", presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.