Assessment of organizational dynamics in a Psychosocial Care Center from the multidisciplinary team’s perspective

Evaluación de la dinámica organizacional en un Centro de Atención Psicosocial desde la perspectiva del equipo multidisciplinario

ABSTRACT

Objectives:

to assess organizational dynamics in a Psychosocial Care Center for Alcohol and Drugs from the multidisciplinary team’s perspective.

Methods:

an evaluative, qualitative study, supported by the Fourth Generation Assessment theoretical-methodological framework. It was carried out in a Psychosocial Care Center for Alcohol and Drugs from September 2019 to March 2020. Data collection took place through observation, individual open-ended interviews and negotiation sessions. The informants were 12 professionals. Analysis was based on Constant Comparative Method.

Results:

it was highlighted as potential of organizational dynamics, being an outpatient service, trying to address the deficiencies of RAPS and understanding the importance of matrix support. Among the challenges are the fragility of teamwork, reception, insufficient training, worker profile and overload.

Final Considerations:

the importance of understanding the work process and the care flow is highlighted, in order to strengthen the Psychosocial Care Network.

Descriptors:
Health Services Evaluation; Mental Health Services; Substance Abuse Treatment Centers; Institutional Practice; Patient Care Team

RESUMEN

Objetivos:

evaluar la dinámica organizacional en un Centro de Atención Psicosocial por Alcohol y Drogas desde la perspectiva del equipo multidisciplinario.

Métodos:

estudio evaluativo, cualitativo, sustentado en el marco teórico-metodológico de la Evaluación de Cuarta Generación. Realizado en un Centro de Atención Psicosocial por Alcohol y Drogas, de septiembre de 2019 a marzo de 2020. La recolección de datos se realizó mediante observación, entrevistas individuales abiertas y sesión de negociación Los informantes fueron 12 profesionales y el análisis se basó en el Método Comparativo Constante.

Resultados:

se destacó el potencial de la dinámica organizacional como un servicio ambulatorio, tratando de abordar las deficiencias del RAPS y entendiendo la importancia del soporte matricial. Entre los retos se encuentran la fragilidad del trabajo en equipo, la acogida, la formación insuficiente, el perfil y la sobrecarga del trabajador.

Consideraciones Finales:

se destaca la importancia de comprender el proceso de trabajo y el diagrama de flujo de la atención, con el fin de fortalecer la Red de Atención Psicosocial.

Descriptores:
Evaluación en Salud; Servicios de Salud Mental; Centros de Tratamiento de Abuso de Sustancias; Organización Institucional; Grupo de Atención al Paciente

RESUMO

Objetivos:

avaliar a dinâmica organizacional em um Centro de Atenção Psicossocial Álcool e Drogas na perspectiva da equipe multidisciplinar.

Métodos:

estudo avaliativo, qualitativo, apoiado no referencial teórico-metodológico da Avaliação de Quarta Geração. Realizado em um Centro de Atenção Psicossocial Álcool e Drogas, de setembro de 2019 a março 2020. A coleta de dados ocorreu por meio da observação, entrevista aberta individual e sessão de negociação. Os informantes foram 12 profissionais, e a análise se baseou no Método Comparativo Constante.

Resultados:

foram destacadas como potencialidades da dinâmica organizacional ser um serviço ambulatorial, tentar suprir as deficiências da RAPS e entender a importância do matriciamento. Dentre os desafios, estão a fragilidade do trabalho em equipe, do acolhimento, a insuficiência de capacitações, o perfil e sobrecarga do trabalhador.

Considerações Finais:

salienta-se a importância de compreender o processo de trabalho e o fluxograma de atendimentos, a fim de fortalecer a Rede de Atenção Psicossocial.

Descritores:
Avaliação em Saúde; Serviços de Saúde Mental; Centros de Tratamento de Abuso de Substâncias; Organização Institucional; Equipe Multiprofissional

INTRODUCTION

The Psychosocial Care Network (RAPS - Rede de Atenção Psicossocial) comprises new work processes and organization of mental health and psychosocial care services in a network format, capable of working on subjects’ individual aspects on the premise that they can inhabit their social circle and transit through this vast and complex territory. However, even given the witnessed innovations, there are specificities in the field of mental health that are still challenging for the health system, such as in the case of drug use(¹).

In this context, the Psychosocial Care Center for Alcohol and Drugs (CAPS ad - Centro de Atenção Psicossocial Álcool e Drogas) is a RAPS specialized service aimed at substance users, which works from the perspective of reorganizing the assistance of public services. It advocates universal access and free movement of users in the territory, offering quality comprehensive care, centered on demands and based on respect for users’ human rights and the autonomy(²). In the case of consumption and dependence on psychoactive substances, CAPS ad is a reference service, as it works with subjects, also in the sense of problematizing the effects of substance use, in addition to the relationship that individuals establish with it(¹).

CAPS ad are complex organizations that provide services at medium and high complexity levels. Having a team that shares their knowledge in favor of improving care is a challenge in the work process in the face of the Psychiatric Reform (PR) proposal(³). Thus, the work process is directly related to quality of care and effectiveness of the service organizational dynamics, both in its organizational variables (such as structure, routines, communication, division of work, systems, organizational environment, norms, values, technologies, people) and in their interrelationships(⁴-⁵).

In the context of mental health care, and considering that the psychosocial model in which CAPS ad is inserted, it faces several challenges, such as those related to dimensions of care, infrastructure, articulation with the points of RAPS, management practices of people and operation of the service. These factors affect quality of care and hinder users’ adherence and social reintegration, highlighting the importance of evaluation processes in these places(⁵).

The Fourth Generation Assessment emerged as a type of responsive assessment, in which stakeholder claims, concerns and issues (CCIs) serve as an organizational focus, i.e., the basis for determining what information will be needed, based on dialectical logic and hermeneutic interpretation. It is a theoretical-methodological process, implemented through constructivist paradigm presuppositions(⁶).

Considering that everyone involved in the care, professionals, users and family members, are part of the assessment process, as interest groups that are involved in the work process and that directly influence quality of care, the importance of carrying out the Fourth Generation Assessment in a Psychosocial Care Center for Alcohol and Drugs is justified.

In this sense, the study raises the following research question: how is the organizational dynamics offered by CAPS ad assessed from the interest group formed by professionals? Thus, this study is justified by the need to understand issues related to professionals’ work process and the articulations made with the other points of care of RAPS.

OBJECTIVES

To assess organizational dynamics in a Psychosocial Care Center for Alcohol and Drugs from the multidisciplinary team’s perspective.

METHODS

Ethical aspects

This research was submitted and approved by the Research Ethics Committee (REC) of the Universidade Estadual de Maringá (UEM), complying with the ethical principles that involve studies with human beings, determined by Resolution 466/2012 and 510/2016 of the Brazilian National Health Council (Conselho Nacional de Saúde). To maintain participants’ anonymity, their names were identified using the letter “P” for professionals, followed by a sequential number corresponding to the order in which the interviews were carried out. After becoming aware of the objective of the research, all authorized their participation by signing the Informed Consent Form (ICF).

Theoretical-methodological framework

The study was based on the AQG theoretical-methodological framework(⁶), with a hermeneutic-dialectic approach and a constructivist and responsive nature. It is hermeneutical because of its interpretive character; dialectical, as it proposes the debate of opinions about the object under assessment; constructivist, because it enables the (re)interpretation of facts in an interactive and negotiation process; and responsive, because it encompasses important aspects for assessment: stakeholders’ CCIs for the evaluation process(⁶).

Study design

This is an evaluative case study(⁷), with a qualitative approach, supported by the AQG theoretical-methodological framework(⁶). The study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) precepts.

Study setting

The study was carried out at CAPS ad in a medium-sized municipality in the state of Paraná between September 2019 and March 2020. This service provides monitoring for people using alcohol and other drugs and their families, through a multidisciplinary team (psychiatric doctors, clinical physician, nurses, nursing technicians, psychologists, social workers, social educators, occupational therapists, and artisan), which develops various activities, such as individual and group care, therapeutic workshops and home visits. It operates from Monday to Friday, from 7 a.m. to 9 p.m., welcoming users or family members by spontaneous demand or referred by public devices, such as Basic Health Units. The choice of this location is justified, as it is a specialized center for monitoring family members and users of alcohol and other drugs in the city.

Data source

Of the 39 CAPS ad professionals, 24 were included in the survey for having at least six months of experience in the service and providing direct care to people with mental disorders and/or their families. Of these, four were excluded because they were on vacation during the collection period and eight refused to participate. Only the medical-clinical and artisan categories had no representatives among the study participants.

Thus, in this study, 12 professionals who make up the multidisciplinary team participated, including a psychiatric doctor, three nurses, three psychologists, a nursing technician, a social educator, a social worker, an occupational therapist and the service director.

Data collection and organization procedure

Data were initially collected through non-participant observation (60 running hours) and participant observation (158 running hours), according to the service routine. Then, there was an individual interview (16 hours) carried out by the main researcher.

Non-participant observation made it possible to follow the service flow, such as consultations and care provided by each professional, the preparation of the Singular Therapeutic Plan (PTS - Plano Terapêutico Singular) for each patient and scheduled activities, such as groups and workshops under the responsibility of coordinating professionals.

After becoming familiarized with the routine, dynamics and team of professionals, the presence of the researcher was incorporated into the service, where she followed direct care to patients with professionals, such as welcoming and approach, occupational therapy groups, craft workshops, education and health groups with nursing, support groups with the social worker and weekly team meetings held in both morning and afternoon periods.

Participant selection was guided by the Hermeneutic-Dialectical Circle (HDC)(⁶) as follows: the first respondent (R1) was chosen for convenience (professional with longer service time), answering two triggering questions: how does the CAPS ad you work at operate? What are the strengths and weaknesses of CAPS ad? At the end of the interview, R1 was asked to assign the next participant (R2).

R1’s responses were analyzed, determining its initial construction (C1). In the interview with R2, he answered the two triggering questions and was then asked to give his opinion about C1. Their considerations were analyzed, giving rise to the new construction (C2), which in turn was presented to the new participant assigned, and so on, until the moment when new information stopped expanding the constructions already elaborated (Chart 1).

Chart 1
Construction of Hermeneutic-Dialectical Circle by the multidisciplinary team

Triggering questions

Buildings made at the end of HDC

How does the CAPS ad you work at operate? What are CAPS ad’s strengths and weaknesses?

- Outpatient characteristics of CAPS ad - Socialization and the social reintegration of individuals - Assistance in crisis situations and the presence of other mental health problems - Inappropriate referrals - Lack of protocols in the service - Home visits and work in the territory - Family role - Matrix support role - Team work - Team meetings - Form of reception - Unpreparedness for mental health care - Worker profile - Professional overload

HDC - Hermeneutic-Dialectical Circle; CAPS ad - Care Center for Alcohol and Drugs.

Interviews with professionals were conducted by the main researcher, scheduled on a day and time according to availability, in a reserved place in the service itself, and audio-recorded using a smartphone. The interview time ranged from 30 to 90 minutes.

Negotiation session

Once the circle was completed, the negotiation session was held. At this stage, the information collected throughout all the group interviews was organized, synthesized and presented, so that participants had access to the entire material and, in a group, to decide what could or could not remain as a result of the study, by consensus(⁶).

Due to the COVID-19 pandemic, it was not possible to carry out the negotiation in person, in compliance with the safety standards recommended by the Ministry of Health. Thus, the negotiation took place virtually, through PowerPoint via Google Meet, with the participation of six professionals, lasting 90 minutes. It should be noted that the cooperation of the largest number of respondents is always sought at this stage, but there is no minimum number for this(⁶). Therefore, in this study, the absence of 50% of participants in the negotiation did not invalidate this step.

The material was presented to the participants during the negotiation, based on the following topics: Health Department role; Disclosure of CAPS ad in RAPS; Work process of teams in CAPS ad; Service structure; Family care; Importance of reception in welcoming patients; Professionals’ emotional aspects; Potentialities of CAPS ad.

Data analysis

Data were analyzed using Constant Comparative Method(⁶), which allows for analysis concurrently with data collection. This method provides for the identification of information units and categorization. Units of information are sentences or paragraphs, obtained from the empirical material, recorded in a way that is understandable to any reader, not just the researcher. The categorization aims to unify, into provisional categories, all information units related to the same content, seeking the internal consistency of the categories to, later, from negotiation, build the definitive categories(⁶).

From the previous analysis of the collected data, thematic nuclei were built, which were presented to the research subjects in the application of negotiation, allowing for a discussion on the themes raised by the subjects. There was a high degree of consensus regarding the issues, which were accepted and validated by the participants as legitimate.

RESULTS

In the CAPS ad assessment process, the organizational dynamics was pointed out by professionals with recognition of the service’s strengths and weaknesses, which allowed the emergence of two categories: Organizational dynamics in a CAPS ad from professionals’ perspective and Work process in a CAPS ad: challenges to be overcome.

Organizational dynamics in a CAPS ad from professionals’ perspective

Regarding the service organization dynamics, professionals recognized the outpatient characteristic of CAPS ad in a positive way as, by keeping individuals in the community, it enables socialization and social reintegration in the territory.

[...] we see that at least some people managed to be rescued that they will need permanent monitoring, in a less intensive way, but that they managed to change the reality of their lives. So, I think that this potential is to rescue self-esteem, to rescue productive power, autonomy, that’s it. (P2 - Nurse)

I think this is a great potential of CAPS, it doesn’t take him out of the environment where he lives to treat. (P4 - Psychologist)

It was pointed out that CAPS ad professionals need to respond to the various needs presented in the service’s routine, such as care in crisis situations and the presence of users with other mental health problems.

We feel a lot about the crisis situation. So, there are times when the flow is higher and there are times when you calm down. (P6 - Nurse)

We have several substance users with severe mental disorders that predate substance use. And the big question is: do you stay in CAPS [ad] or will you go to CAPS III or CAPS II? (P10 - Social Worker)

Furthermore, CAPS ad is the main place of care for alcohol and drug users, where they are referred, even when their needs can be met in other RAPS services. However, the lack of standardization, responsible for this situation, also impacts the development of local care, as there is no standardization of decisions about care actions.

When using any substance, it could sometimes be supported in the basic unit. The case is not that serious and they are sent directly here; sometimes, you could have support at the unit, but if you talked about alcohol and drugs, it’s CAPS ad. (P11 - Psychologist)

I believe it would help [a protocol in the service], on account of one team wanting to act in one way, another to act in another. What one thinks is bad use, the other already thinks not [...]. (P5 - Social Educator)

It was also evaluated that CAPS ad understands the relevance of work in the territory and believes in it. In view of this, in order to be effectively responsible for the matrix support of primary care teams and for care in the territory, the team must be available for this action.

We believe in working in the territory, but we need supervision in CAPS and better composition of the team so that this team can go out into the field. (P10 - Social Worker)

This structure that is here, it works well to meet the demand that is here, if you start moving professionals, to do matrix support, which is a requirement, you would need a larger team. (P7 - Psychologist)

Work process: challenges to be overcome

Regarding the challenges faced by the CAPS ad teams, teamwork was evaluated with ambivalence by professionals in relation to the development of actions in the service.

We have a good team, but a team that is a little weak in its decisions, a little divided in terms of positioning. (P3 - Nurse)

I think there is a lack of dialogue. But this is hardly achieved, especially in the moment of friction, as no one has the ability to hear the other anymore. (P12 - Director)

The team meetings, defined as a strategy for exchanging information and strengthening, were assessed by professionals as a point to be improved, as they should be a space for discussion with a view to aligning the behaviors between workers and the teams that make up the service.

Who is seen in the morning, the night group is not arguing, there are limitations, if the person shows up here intoxicated. We are going to take the actions that the team at that time understood. The behavior does not always match what the other person in the morning is thinking, does that happen? It happens or vice versa. (P10 - Social Worker)

When meetings were held with the whole team, I think things had more continuity. Now, as it’s morning and afternoon, many things are discussed, we don’t have the opportunity to discuss among people. (P4 - Psychologist)

Another difficulty reported by the interviewees refers to the form of the user’s first reception/approach in the service. The first contact takes place at reception, which, for the most part, is made up of administrative professionals.

We could have a general meeting with everyone, we already have our meeting, but the reception, the operational staff do not participate [...]. (P5 - Social Educator)

The reception really had to be a little more welcoming, because the person already arrives in a complicated situation, admitting that they are sick, that they are looking for treatment, is difficult. (P9 - Nursing Technician)

The professionals highlighted that, in some situations, they felt unprepared for caring for patients in mental distress, citing professionals’ capabilities and profile as responsible for these limitations.

I think there are personal issues, which you need, in addition to constant training, it’s a lot about each one’s individuality, besides that, you don’t have the profile to work with mental health. (P3 - Nurse)

Working with mental health is very difficult, you have to have the ability to conduct, to perceive. A moment you punctuate, a moment you just listened, a moment when you were a little more flexible. (P8 - Occupational Therapist)

Emotional overload was also mentioned among professionals, as they also need care directed at their own mental health.

When I came in, I couldn’t quite handle frustration with patient. We see very heavy things here; I, at the moment, use medication, do therapy [...]. (P2 - Nurse)

Working with mental health is very difficult, especially chemical dependency. So, we’re all tired, worn out. (P8 - Therapist)

DISCUSSION

In the present study, the importance of CAPS ad was highlighted as an outpatient service that enables users’ social reintegration and maintenance in the community. This agrees with the definition that CAPS ad is characterized as an open and territorialized service, which aims to offer care to people who use drugs considering their processes of suffering and illness and promoting citizenship and autonomy(⁸).

It is observed that, thus, CAPS ad is in consensus with the objectives of RP, which culminated in greater financing of substitute services to keep the user in the community through outpatient treatment and implementation of intersectoral actions. Users began to be understood as the protagonists of their care, together with their families, while the funding of psychiatric hospitals was reduced, with the closing of their beds(⁹).

However, it should be noted that the changes that have taken place since 2017 in the Brazilian National Mental Health Policy (Política Nacional de Saúde Mental) have interfered with RP’s achievements. This is because Resolution 32 of December 14, 2017 inserted the psychiatric hospital as a point of care of RAPS and emphasized the use of therapeutic communities through greater partnership and support between them and other bodies involved in user assistance of mental health services(¹⁰).

Subsequently, several decrees, regulations and ordinances strengthened the segregation and long-term institutions, culminating in the new Brazilian National Policy on Drugs (PNAD - Política Nacional sobre Drogas), presented in Decree 9,761/2019. With it, it is observed that the care of users of alcohol and other drugs distances itself from the Brazilian National Policy on Mental Health, since it is no longer linked to the Ministry of Health while it turns to the prolonged and continuous hospitalization of these individuals, with emphasis on therapeutic communities and on segregation, abstinence, prohibition of use and exclusion from harm reduction in care(¹¹).

Even so, CAPS ad continues to assist users and their families according to their needs and at different times of treatment. For this, there is the support of the PTS, which is defined for each user and comprises actions aimed at meeting the identified demands. Their actions can be individual, collective, directed to the family and/or the community, combined according to the proposed treatment, both in routine and emergency care. It should consider the use of different territorial resources when seeking to meet users’ demands, both within and outside RAPS(¹²).

As a service that seeks to reduce the deficiencies of RAPS, CAPS ad has attended to numerous cases that could be followed up elsewhere in the network, suggesting its fragmentation and impacting the comprehensiveness of care. A study showed that one of the reasons for this is that the professionals who work in RAPS are unaware of the devices belonging to the network, mainly in the integration between the different levels of services(¹³).

Moreover, a study carried out with a team from a CAPS ad in Pernambuco showed that, in practice, inter-institutional partnerships to share demands are little evident, with repercussions on the team’s work process. Primary Health Care (PHC), in particular Family Health Strategy (FHS), which would be the main link with CAPS, is not effective as a space for welcoming people who use drugs. This overview is worrisome, as FHS is a device, together with CAPS, to guide the network dynamics, in addition to being the space where the movement of deinstitutionalization and decentralization of mental health care is directed(¹⁴).

Still, professionals assessed the matrix support actions and care in the territory as positive for follow-up and monitoring of patients and for alignment of actions with PHC professionals. However, it is important that the team that makes up CAPS ad is organized to meet this demand for activities.

Matrix support involves the interconnection between two or more teams, in a shared construction process, a proposal for pedagogical and therapeutic intervention, with the integration of different specialties and professionals, and actions that integrate the components and their knowledge at different levels of care, aiming at enhancing resolutive care among health services(¹⁵).

Despite the Unified Health System (SUS - Sistema Único de Saúde) guaranteeing the integration between professionals and services, the difficulties of maintaining these meetings persist. Studies carried out draw attention to the difficulties in carrying out moments between primary care and specialized service, as some units do not work within the logic of FHS. There are transport limitations for the movement of matrix support teams from one service to another; there are obstacles to reconciling agendas between services for joint discussion; there are relational problems among those involved; there are misconceptions in the demand for matrix support due to difficulties in aligning understandings, among others(¹⁵-¹⁶).

When justifying the low number of professionals to carry out matrix support and care in the territory, it is important to emphasize Federal Council of Nursing (COFEN - Conselho Federal de Enfermagem) Resolution 543/2017, which establishes parameters for nursing staff sizing. Article 4 brings considerations to assist psychiatric and mental health patients, demonstrating that, in CAPS ad, 10 hours of nursing per patient are recommended. Regarding the professional/patient ratio in different work shifts, one professional for every 2.4 patients is considered. The percentage distribution of the total number of nursing professionals must observe a minimum proportion of 50% of nurses and other nursing technicians(¹⁷).

However, in the Ministerial Decree of 2002, which regulates and establishes the specifications for each type of CAPS, the minimum required staff is in disagreement with this sizing, as it is based on a context of last decade. In this sense, with the growth of establishments and the complexity of the required attributions, one must take into account the need to readjust the number of professionals allocated in CAPS, within the organizational logic of RAPS(¹⁸).

Another aspect evaluated by the interviewees is related to teamwork in CAPS ad. For a service to be considered effective and of quality, each professional must know and take on their role, since everyone is involved, from reception to discharge. Thus, each professional must bring, into their practice, the attributions and specifics of their technical training, together with the guidelines established for CAPS services, as there are activities common to all professionals and specific activities carried out in accordance with ethical and legal status of each professional category(¹⁹).

In this context, when professionals are not aware of their role in the service, there is a risk of carrying out their practices diverging from the PR proposal. For this, higher education institutions (HEIs) have a fundamental role, as they must facilitate the academic learning process in the possible fields of action in mental health(³).

It is also known that teamwork is marked by reflection on professional roles, problem solving and negotiation in decision-making processes, from a dialogic construction of knowledge, and with respect to the singularities and differences of the various centers of knowledge and professional practices(²⁰). However, despite the constitution of CAPS ad teams being multi-professional, they do not work under an interprofessional logic.

Researches point to interprofessional work as a privileged space, which allows professionals to interact and organize themselves considering different views of reality and improving the quality of care offered(²¹-²²). In this sense, professionals assessed the interaction and communication in the service as a weakness, highlighting the ineffectiveness of team meetings. Team meeting is not just about exchanging information between professionals, but a participatory process that allows for the construction of consensus in the work routine and the articulation of different professional categories(²³-²⁴).

The way to receive the spontaneous demand that seeks care was also an aspect evaluated by the study professionals as challenging. The difficulty is related to the fact that it is performed by professionals in the administrative area, as they may not have the necessary preparation and knowledge for such action, making it difficult to establish the bond that promotes the appreciation of the first contact.

Based on what is established by the Brazilian National Humanization Policy (PNH - Política Nacional de Humanização), which refers to the care and importance of interpersonal relationships, in order to provide welcoming, resolute and humane care, it is observed that reception must occur in any environment and be conducted by any professional(²⁵). Still, a study carried out in CAPS ad showed that the link between service and user is mainly impacted by the availability to meet spontaneous demand, more than by professionals’ characteristics(¹).

In view of this, one of the alternatives suggested by the professionals during the negotiation session, to intervene in this difficulty, was to cover all service employees, including those at the reception, in general or team meetings, so that they can be guided and trained in order to carry out this first contact with the user as recommended and expected by the team.

Skills were identified in this research as important for all professionals. A study on the perception of professionals who care for people using alcohol and other drugs showed a lack of knowledge to work directly with this audience, due to the lack of contact with the subject, in addition to the lack of interest and because they feel unprepared. The acquisition of knowledge occurs during daily professional performance, highlighting the need for continuing education in mental health. It is also suggested that, during the training process, a theoretical-practical association is made in the internship field, arousing interest in improving in this area(²⁶).

Regarding participants’ notes about the profile that CAPS ad professionals must have, as it directly impacts the quality of care offered, it was identified in an evaluative study carried out in CAPS ad in southern Brazil that professionals should enjoy working in service and being open to changes. Its practice must be based on innovation and creativity, seeking to develop actions according to individuals’ needs, even when these are not part of traditional care(²⁷).

Returning to the importance of teamwork and the organized work process, already discussed here, we cannot fail to highlight another weakness identified as a result of their fragmentation: workers’ emotional overload. This overload was mentioned in an integrative review, demonstrating that mental health workers feel more emotionally drained than in other areas, relating job satisfaction with the resolution of activities and, consequently, greater emotional balance(²⁸).

Furthermore, emotional overload sometimes also arises from work overload, resulting from several weaknesses identified in this study, such as inadequate sizing and allocation of resources, lack of definition of care flow and lack of routines that allow applying the psychosocial model. Therefore, there is a need for investment in public management to solve the main problems faced by the points of care of RAPS(⁵).

Study limitations

As a possible study limitation, the fact that the assessment process only includes a CAPS ad professionals can be pointed out. Studies that analyze the organizational dynamics of other specialized services are needed. In addition to this, including the various actors involved in the process, such as users and family members, will provide greater knowledge of points of RAPS and will contribute to the construction of an articulated and integrated mental health network.

Contributions to nursing, health, and public policies

This study shows that CAPS ad has been organized, in accordance with current public policies, to assist users of alcohol and other drugs, but that it needs to overcome several challenges, starting with the legislation that supports the psychiatric counter-reform. Notably, the results of this assessment may support the demonstration that substitute services have acted according to the premises of deinstitutionalization and that they have sought to minimize the challenges to be overcome whenever possible, despite suffering impacts from local management actions. For nursing, the results demonstrate that, as a member of the mental health team, reflections are needed on how to better act in this service and contribute to overcoming the challenges encountered.

FINAL CONSIDERATIONS

The study made it possible to understand the CAPS ad organizational dynamics from the multidisciplinary team’s perspective. The service’s outpatient feature is highlighted as a potential of the service, which culminates in the possibility of socialization and social reintegration of users, as well as the search to meet users’ health needs according to their characteristics, the attempt to address the RAPS deficiencies and the understanding of the importance of matrix support, even if it still needs organization of the team to occur.

However, teamwork fragility, team meeting non-use to discuss cases, initial (lack of) welcoming, training/qualification insufficiency, the service workers’ profile and professionals’ emotional overload were identified. It is noteworthy that the absence of team meeting hinders, or even prevents, the (re)construction of the PTS in the service, which is essential for mental health care.

From this perspective, it is understood the need for investments by public management in mental health, in order to qualify the professionals involved in specialized services so that they can understand the work process of all points of care and thus align the service care flow. It is also observed that the strengthening of RAPS is necessary, since, with the proper performance of other points in the network, CAPS ad will be able to enhance its actions Thus, attention to users and families will be qualified and based on comprehensiveness, equity and universality.

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Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Maria Itayra Padilha

Publication Dates

• Publication in this collection
  10 June 2022
• Date of issue
  2022

History

• Received
  14 June 2021
• Accepted
  28 Nov 2021