Nurses’ Coping Strategies When Caring for Mental Health Care Users Diagnosed with Substance Use Disorders

Abstract

Caring for Mental Health Care Users (MHCUs) diagnosed with Substance User Disorders (SUDs) is challenging and demanding as nurses reported that these users are untrustworthy. This leaves the nurses emotionally and physically drained. Some of these MHCUs are violent, aggressive, suicidal or homicidal. However, there is no literature found on the nurses’ coping strategies when caring for MHCUs diagnosed with SUDS. The purpose of this chapter was to explore and describe the current literature on the nurses’ coping strategies when caring for MHCUs diagnosed with SUDs. A narrative literature review was used in this chapter. JSTOR, Google Scholar, Sabinet Online, African Journals and Science Direct databases were used to search relevant and current literature using the following keywords: coping, coping strategies, nurses, care, caring, mental health care users, psychiatric patients, substance abuse, substance-related disorders and substance use disorders. Six themes emerged in this chapter namely nurses’ resilience, peer support, management support, strengthening the multidisciplinary team (MDT) approach, open-door policy as well as education and training. The findings and recommendations of this chapter may assist nurses of all categories to provide quality care, treatment and rehabilitation services when caring for MHCUs who are diagnosed with SUDs.

1. Introduction

The World Health Organisation (WHO) reported that there are 2 billion alcohol users and 185 million drug users worldwide in the general population [1]. Around the world, almost all people use one or more substances that affect their Central Nervous System (CNS), relieving physical and mental anguish or producing euphoria [2]. This is in spite of the fact that globally, there are approximately 250,000 deaths per year due to illicit drug use, and 2.25 million are caused by alcohol use [3]. Substances from all over the world currently flood South Africa (SA) [4]. The high prevalence of Substance Use Disorders (SUD) in SA makes it one of the top 10 substance-abusing countries globally [5]. This is a serious problem that needs to be attended to as soon as possible. The prevalence of substance use among forensic Mental Health Care Users (MHCUs) in Kenya is 74.8% [6]. Among the admitted Norwegian MHCUs, the prevalence of SUD is as high as 50% [7]. These statistics show that the high rates of SUDs among the MHCUs are well documented in literature [7]. From these statistics, it could be possible that most of the countries’ SUD is above 50%. This is a problem that needs further research. These high statistics are a serious concern and there are no studies or book chapters found on the nurses’ coping strategies when caring for MHCUs diagnosed with SUDs. These are the reasons that prompted us to write this chapter. This chapter might add important literature in the field of psychiatry and mental health nursing science. The chapter might also be relevant for other mental health care practitioners, researchers, educators and policymakers who are also concerned about the nurses who are caring for MHCs who are diagnosed with SUDs.

On the other hand, some of the authors refer to Nigeria as a substance culture [6]. For instance, the Nigerians use substances such as coffee or tea for waking up in the morning, they take soft drinks or smoke cigarettes for staying alert throughout the day, they take alcohol as a way of relaxation, and they take paracetamol for pain [6]. This shows that there are some Nigerians who are taking substances every day or 365 days a year. According to the authors of this chapter, there is a possibility that more countries can also be regarded as “substance cultures” particularly SA because literature indicates that it is one of the top 10 substance abusing countries globally [5]. Interestingly, SUD does not discriminate among its victims, it affects women, men and people of all races and ethnicities [8]. However, SUD is among the most prevalent mental disorders. This includes Alcohol Use Disorder (AUDs) [3]. The following information is the DSM-5 criteria for SUDs [2]:

Problematic pattern of use that impairs functioning. Two or more symptoms within a one-year period:

1. Failure to meet obligations.

2. Repeated use in situations where it is physically dangerous.

3. Repeated relationship problems.

4. Continued use despite problems caused by the substance.

5. Tolerance.

6. Withdrawal.

7. Substance taken for a longer time or in greater amounts than intended.

8. Efforts to reduce or control use do not work.

9. Much time spent trying to obtain the substance.

10. Social, hobbies, or work activities given up or reduced.

11. Craving to use the substance is strong.

From the above information, it is clear that SUD is a serious problem for the users, their families and nurses. As a result, we strongly recommend that something must be done as a matter of urgency. SUDs among MHCUs can be diagnosed with comprehensive interviews such as Psychiatric Research Interview for Substance and Mental Disorders (PRISM), Mini-International Neuropsychiatric Interview (MINI) as well as the Structured Clinical Interview for DSM-IV (SCID) [7]. Detecting and addressing SUDs proactively and systematically is essential for two reasons. Firstly, to protect the safety of all MHCUs and to enable healthcare professionals such as nurses to recognise problems early and intervene swiftly [9]. In many countries such as South Africa, when the MHCUs are finally diagnosed with SUDs, nurses are the ones who care for them. This includes assistants, staff and professional nurses. Caring is a hallmark of nursing and maybe the rationale why nursing has long enjoyed a high level of respect by the public [10]. However, the authors of this chapter noted that nursing is not the same anymore due to the MHCUs, particularly those who are admitted due to SUDs. It should also be noted that authors of this chapter share their experiences based on the South African context.

In spite of the above information, many studies show that caring for MHCUs who are diagnosed with SUD is challenging for the nurses and deemed demanding as nurses reported that these users are untrustworthy. This leaves the nurses emotionally and physically drained [1, 11]. Nurses caring for MHCUs who are diagnosed with SUDs experience frustration, anger, fear, burnout, occupational stress, emotional exhaustion, helplessness and demotivation [11]. Other nurses reported that MHCUs who are diagnosed with SUDs could be violent, aggressive and potentially threatening, thus providing a rationale for the negative views of some nurses toward caring for these MHCUs [1]. Health care professionals in general have negative attitudes toward MHCUs who are diagnosed with SUDs. Nurses are not excluded from this problem. This may lead to poor communication between the health care providers and MHCUs and this may taint the therapeutic alliance [1]. All these concerns show that a lot needs to be done in the area of mental health and SUDs. However, the authors of this chapter want to emphasise that nurses must respect the constitutional rights of these MHCs as enshrined in constitutions of many countries especially with regards to their rights to dignity and respect. On the other hand, it should be noted that most of the nurses are not coping when they care for MHCUs who are diagnosed with SUDs. The above discussion led to the following question:

What are the nurses’ coping strategies when caring for MHCUs who are diagnosed with SUDs? This is the question that prompted the authors to write this chapter.

Source: William A. Haseltine.

2. Clarification of key concepts

The key concepts used in this chapter are clarified below:

2.1 Coping

Coping is defined as a combination of thoughts and actions in order to deal with a threatening situation [12]. Coping can also be defined as activities in which people use a range of cognitive and behavioural strategies to deal with, moderate or endure, situations that are demanding or surpass their routine ways of dealing with these situations [13]. Information from the introduction shows that caring for MHCUs who are diagnosed with SUDs is demanding. Coping in this chapter refers to the actions or activities that the nurses do when they care for MHCUs who are diagnosed with SUDs. It is also clear from the introduction of this chapter that nurses from different countries are dealing with stressful situations when they care for MHCUs who are diagnosed with SUDs. As a result, authors of this chapter deemed it necessary to write this chapter in order to improve coping of the nurses who are caring for MHCUs diagnosed with SUDs. It should also be noted that nurses are regarded as backbones in the health care system in most countries.

2.2 Coping strategies

Coping strategies typically involve a conscious and direct approach to problems, in contrast to defence mechanisms [12]. In this chapter, coping strategies refer to a conscious and direct approach used by nurses of all categories when they care for MHCUs who are diagnosed and admitted due to SUDs.

2.3 Mental health care user (MHCUs)

Mental health care user (MHCUs) refers to a person who is receiving care, treatment and rehabilitation services or utilising the health care services at designated health establishments that are aimed at enhancing the mental health status of users, mentally ill prisoners and state patients. When the person concerned is under the age of 18 years, or incapable of making decisions, MHCU may include the prospective user, the user’s next of kin, or any person who is authorised by any law or court order to act on the behalf of that person, an executor of the diseased person’s estate or an administrator appointed in terms of the Mental Health Care Act [14]. The above definition shows that MHCUs do not only include the person who is diagnosed and admitted to mental health care institutions, it also includes other people who are using the mental health care services. For the purpose of this chapter, we define MHCUs as a person who is receiving care, treatment and rehabilitation services for SUDs.

2.4 A nurse

A nurse refers to a person registered in a category under Section 31(1) of the Nursing Act in order to practice nursing and or midwifery [15]. For the purpose of this chapter, a nurse refers to a person registered with the South African Nursing Council (SANC) to care for MHCUs diagnosed with SUD.

2.5 Substance use disorders (SUDs)

Substance Use Disorders (SUDs) For the purpose of this chapter, we define SUD as the misuse of, abuse of, or dependency on substances such as alcohol, cannabis, nyaope, cocaine, tobacco and other or unknown substances. When the MHCUs are admitted to mental health care institutions for care, treatment or rehabilitation services for SUDs, they are cared for by nurses who are not coping most of the time. This is the main focus of this chapter.

3. Methodology

A narrative literature review was followed in exploring and addressing the current literature on the nurses’ coping strategies when caring for MHCUs diagnosed with SUDs. Five (5) online databases were used to search for information on the nurses’ coping strategies when caring for MHCUs diagnosed with SUD namely, JSTOR, Google Scholar, Sabinet Online, African Journals and Science Direct. The following keywords were used to search for the relevant literature published between 2011 and 2022: coping, coping strategies, nurses, care, caring, mental health care users, psychiatric patients, substance abuse, substance-related disorders and substance use disorders.

4. Themes

The reviewed literature revealed that there are six (6) themes that the nurses use as their coping strategies when caring for MHCUs who are diagnosed with SUDs namely nurses’ resilience, peer support, management support, strengthening the multidisciplinary team (MDT) approach, open-door policy as well as education and training. The themes and sub-themes are given in the followingTable 1:

Themes	Sub-themes
4.1 Nurses’ resilience	4.1.1 Use of internal protective factors; 4.1.1.2 Use of External protective factors
4.2 Peer support	4.2.1 Importance of collegial support
4.3 Management support	4.3.1 Addressing nurse-to-patient ration; 4.3.2 Collaboration among employers, healthcare practitioners and researchers; 4.3.3 Empowerment of nurses with relevant skills
4.4 Strengthening the multidisciplinary team (MDT) approach	4.4.1 Benefits of multidisciplinary team approach; 4.4.2 Composition of multidisciplinary team
4.5 Open-door policy	4.5.1 Benefits of open-door policy
4.6 Education and training	4.6.1 Need for proper education and training; 4.6.2 Continuous workshops; 4.6.3 Involvement of Nursing Education Institutions in the fights against SUDs; 4.6.4 Family involvement

Table 1.

Themes and sub-themes.

4.1 Nurses’ resilience

It is clear from the introduction of this chapter that nurses deal with challenges in their working environment, especially those that are working at mental health establishments, or those who are caring for MHCUs who are diagnosed with SUDs. In this case, we strongly believe that nurses need to strengthen their resilience. Nurses who manage to cope and in some instances even grow in the face of omnipresent stressful experiences are described as resilient [16]. Resilience refers to a person’s capacity to withstand or recover quickly from difficult conditions [16]. The same study also refers to resilience as qualities of both the individual (internal protective factors) and the environment (external protective factors) that could support positive development [16]. We also have a strong view that nurses should use both the internal and external protective factors of resilience in order to cope when caring for MHCUs who are diagnosed with SUDs. Resilience can also be defined as the ability of people to adjust to unfavourable conditions in a positive way, and bounce back from hardships and overcome negative life experiences [17]. It is clear from the information, particularly in the introduction that nurses caring for MHCUs who are diagnosed with SUDs are working in unfavourable conditions. However, they should be able to view that situation in a positive way and overcome their negative life experiences of MHCUs diagnosed with SUDs. Most of the nurses when they care for MHCUs who are diagnosed with SUDs feel angry, demotivated and dissatisfied. This resulted in some of the nurses choosing to leave South Africa in search of greener pastures [18]. Based on the above information, nurses need the opportunity to develop resilient attributes in their different specialist areas [18], particularly in the area of mental health and SUDs. Coping skills increase resilience [12].

4.2 Peer support

Peer support has been mentioned in several studies as nurses’ coping strategy when caring for MHCUs diagnosed with SUD [1, 11]. Workplace support provided by peers or colleagues and the organisation is of major importance in the direct delivery of nursing care as a lack of teamwork can compromise patient care [18]. However, it should also be noted that relying on support from outside the workplace can also play an important role in the ability of nurses to cope [18], particularly when they care for MHCUs who are diagnosed with SUDs. Having collegial support from other nurses and interprofessional team members is recommended to manage uncertainty [1]. A qualitative study recently conducted in the NWP found that nurses do not collaborate with one another and as a result, they are unable to deliver quality care to MHCUs diagnosed with SUD. The above information highlights the gap that, it is imperative that nurses have role support which includes the presence of supportive, knowledgeable colleagues with whom to collaborate and gain expertise in practice [1].

4.3 Management support

Management support is one of the strategies that nurses use when caring for MHCUs diagnosed with SUDs as shown in several studies [1, 11, 19]. Participants of a qualitative study that was conducted in 2016 in the NWP of SA indicated that it would be good if the nurses were supported and motivated by their own management [11]. Nurses mentioned in a study conducted in New Jersey that they have no problem of caring for MHCUs diagnosed with SUDs for as long as the MHCU load or nurse-to-patient ratio is not too much because these MHCUs can be a handful at times [1]. This shows that the sooner the management supports the nurses by addressing the issue of nurse-to-patient ratio, the better the client outcome and the nurses’ improved coping. Strengthening the prevention and treatment initiatives for addressing SUDs requires direct effort and partnership from employers (management), healthcare practitioners and researchers [19]. Managers and supervisors should create learning opportunities with the sole purpose of empowering nurses with relevant skills in providing care to mental health care users [18]. Health care practitioners should work collaboratively with the management of the mental health care institutions where they are working. The researchers should conduct more research that is aimed at assisting the nurses to cope better when they care for MHCUs who are diagnosed with SUDs.

4.4 Strengthening the multidisciplinary team (MDT) approach

Several studies mentioned strengthening the multidisciplinary team (MDT) approach as one of the strategies used by nurses who are caring for MHCUs diagnosed with SUDs [1, 8]. Nurses in collaboration with other disciplines have collective power to achieve more [10]. Two people are better off than one. Multidisciplinary team (MDT) approach is effective in caring for MHCUs who are diagnosed with SUDs. MDT approach consists of nurses, psychiatrists, pharmacists and dieticians who play a unique role in treating MHCUs who are diagnosed with SUDs [8]. For the purpose of this chapter, we suggest that the word mental health care practitioners be used to refer to MDT. According to the Mental Health Care Act 17 of 2002, mental health care practitioners also include psychologists, social workers and occupational therapists, who have been trained to provide the prescribed mental health care, treatment and rehabilitation services [14], including the care of MHCUs who are diagnosed with SUDs. Both collaboration and support with nurses and interprofessional colleagues will help manage the challenges in care and possibly mitigate the uncertainties in caring for this increasingly common patient population [1].

4.5 Open-door policy

Open-door policy is mentioned in the literature as one of the effective strategies used by the nurses who are caring for MHCUs diagnosed with SUDs. The practice of restricting the freedom of MHCUs who are diagnosed with SUDs by locking the doors of mental health care units is highly questionable [20] because everyone has the right to freedom of movement [21]. All MHCUs especially those who are diagnosed with SUDs are also protected by this right. The introduction of an open-door ward policy can reduce coercive measures like unnecessary seclusions, involuntary care, treatment and rehabilitation services, as well as incidents of aggression [20]. As a result, authors of this chapter advocate for open-door policy for all MHCUs who are diagnosed with SUDs. This will be in line with Section 21(1) of the Constitution of the Republic of South Africa (RSA) which states that “everyone has the right to freedom of movement. However, it should be noted that the MHCUs who are violent, aggressive, suicidal or homicidal, meaning those who are dangerous to themselves, or other people may be admitted involuntarily or be secluded. This is normally done after prescription by the medical doctor. The main reason for admitting these MHCUs is to protect them and other people such as families and health care practitioners. In this case, it does not mean that the MHCU’s rights are violated, this is done to protect them.

4.6 Education and training

Many studies show that education and training play a major role for the nurses who are caring for MHCUs diagnosed with SUDs [1, 6, 11]. However, literature shows that some nurses do not have the necessary training and education for proper care, treatment and rehabilitation services for MHCUs who are diagnosed with SUDs. For instance, the nurses mentioned in a qualitative study that was conducted in the North West Province (NWP) of South Africa that they were taught at the university or the colleges how to care for, treat and rehabilitate MHCUs who are diagnosed with SUDs. However, the nurses maintained that caring, treating and rehabilitating an MHCU diagnosed with SUDs was not dealt with in greater detail [11]. The authors of this chapter are in agreement with this statement because substance use is presented like any other topic. There is no emphasis on it. Knowledge, skills and experience play a role in the nurses’ ability to cope while providing mental health care [18]. Continuous workshops should be done for the nurses to help them deal effectively with the addicted MHCUs [12].

Another important study was conducted by two scientists from Kean University in New Jersey. The findings of the study indicated that nurses reported a lack of knowledge specific to mental disorders and SUD issues and reflected a disconnect in their ability to care for MHCUs with both physiological and psychiatric disorders [1]. The same study continues to mention that for the nurses to cope effectively with the MHCUs who are diagnosed with SUDs, nursing education programs should be created to assist nurses in developing skills in articulating and managing their uncertainty and to use evidence to guide practice [1]. This means that Nursing Education Institutions (NEIs) should also be part of the fight against SUDs.

A mixed methods study was conducted in Nigeria on the Forex Index and Substance Abuse among Psychiatric Patients. The findings of the study indicate that the staff in mental health care institutions including the mental health nurses should be trained on techniques of screening and detecting the use of psychoactive substances as well as on how to successfully rehabilitate MHCUs who are diagnosed with SUDs [6]. Education focusing on assessment, prevention and interventions to prevent violence and aggression, should be addressed in educational offerings, both in academia and in the clinical environment [1]. In addition, when the nurses are properly educated and trained on how to care, treat and rehabilitate MHCUs who are diagnosed with SUDs, they will be able to teach MHCUs about the dangers of substance abuse, including but not limited to the psychological and physical effects; the damage to relationships and family lives; and the impact on meeting basic needs such as holding down a job. These nurses who are well trained will also educate the MHCUs regarding treatment options, including those they can use on either an inpatient or outpatient basis and those they can use to stay substance-free long-term. The nurses might also educate MHCU’s family members about what to expect from the rehabilitation process and how they can support their loved one’s attempt to conquer addiction to the substances.

5. Conclusion

Caring for MHCUs who are diagnosed with SUD is challenging and demanding for the nurses as nurses reported that these users are untrustworthy. This leaves the nurses emotionally and physically drained. However, there is no documented literature on the nurses’ coping strategies when caring for MHCUs diagnosed with SUDS, hence we strongly believe that this chapter is interesting and adds important literature in the field of psychiatry and mental health nursing science. Further studies should be done on the coping strategies of nurses caring for MHCUs diagnosed with SUDs. These studies should follow different methodologies such as quantitative, qualitative mixed and multi-methods, or different reviews. Different reviews can be systematic, integrated, comprehensive and scoping reviews. This chapter showed that nurses need to strengthen their resilience, they also need peer and management support, multidisciplinary team (MDT) approach, open-door policy, as well as education and training to be able to cope when caring for MHCUs diagnosed with SUDs. Nurses should specifically be trained at under and postgraduate levels on the provision of quality mental health care, treatment and rehabilitation services, management of SUDs as well as dual diagnosis. It is important for NEIs to consider development of postgraduate programs on the Management of Substance Use Disorders (SUD).

Acknowledgments

Authors acknowledge the authors of all books, articles and Acts used in this chapter.

Conflict of interest

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this chapter.

Thanks

Thanks to the NWU librarians for assisting us with the literature search.