Perception of nursing care for dependents
of psychoactive substances in the light of social learning
Castillo Zamora Luz Victoria 1
Rodríguez Núñez Yolanda 2
Cajachagua Castro Mayela 3
1 Doctora en Enfermería, docente Universidad Peruana Unión, enfermera Hospital Nacional Hermilio Valdizán, Lima Perú
2 Doctora en Enfermería. Docente investigadora de la EP de Enfermería de la Universidad Católica Los Ángeles-Chimbote
3 Doctora en Educación, docente principal e investigadora Universidad Peruana Unión, Lima Perú
Victoria CLZ, Yolanda CM & Mayela CC. (2018) Perception of nursing care for dependents
rehabilitation of psychoactive substances in the light of social learning
Journal of Psychosocial Rehabilitation. Vol 22 (1) 93-100
objectives were to analyze the perception of care provided by the nurse
dependent on psychoactive in the light of social care learning and
performing with cognitive behavioral model during the rehabilitation
process substances people. It corresponds to the qualitative approach,
descriptive-exploratory type. Study subjects were five nurses working
in a Rehabilitation Center in Lima, Peru. Technique semistructured
interviews and Hermenéutica technique for analysis was used. Two
categories are unveiled: The conception of nursing care, which is based
on support, concern, support and involvement, factors contributing to a
change of lifestyle. The second category is the providing nursing care
applying social skills within the framework of cognitive behavioral
model. The perception of care that provide dependent on psychoactive
substances person is basis for recognizing that its presence through
its essence, way of being and personal experience ensure a permanent
and individualized holistic care where self-help skills are applied and
mutual aid rehabilitation based on social learning approach.
Keywords: Psychoactive substance dependent person, Holistic care, Rehabilitation, Nursing care
Misuse of drugs is a major obstacle to the integral
development of people and of society at the local, regional and global levels,
since it harms the personal and family environment of people who opt for the
use of psychoactive substances, because their lives are appear cracked with few
opportunities to escape this disease, due to its chronicity (Comisión
Nacional para el Desarrollo y Vida sin Drogas, 2012). That is why drug abuse disorders are currently
one of the most important public health problems. Substance abuse leads to
physical, psychological and social harm, both to the person consuming the drug
and for others; it has become a complex problem, not only for the health
sector, but for society(Espada, S.,
Rodriguez, 2012), (Cueva, 2012).
Dependence is considered a multifactorial health
problem, which can and should be treated. According to Burrone et al.
(2010), since the 1990s effective interventions to
counter this problem have been identified; however, the development of research
on the implications of substance abuse and dependence have been scarce. In that
las Naciones Unidas Contra la Droga y el Delito., 2002), States that the person with substance
dependence has difficulty communicating, (need of social skills, managing
emotions, self-control, etc.). In addition, other problems are often added on such
as a deteriorating physical condition.
In order to increase awareness of this dependence
and its influence on society, the Office of the United Nations Office on Drugs
and Crime reports that five percent of the world's population between 15 and 64
years old consumed an illicit substance during 2012. In addition, about 27
million problem drug users were registered(Unites
Nations Office on Drugs ans Crime (UNODC), 2014). Moreover, another World Report reports that
drug use continues to cause considerable damage, which is reflected in the loss
of the valuable lives and productive years of many people. In 2012 worldwide a
total of 183,000 deaths were reported related to this problem. This figure
corresponds to a mortality rate of 40.0 deaths per million in the population
between 15 and 64 years of age. Although this calculation is less than 2011,
there are still gaps in the provision of services, since in recent years only
one in six people consuming problematic drugs in the world had access to drug
Nations Office on Drugs and Crime, 2014). For its part, (United
Nations Office on Drugs and Crime, 2014) reported that drug abuse is one of the
twenty major risk factors to health worldwide and one of the ten most important
in developed countries. Problems arising from this consumption contribute to
the development of other health problems such as HIV/AIDS, tuberculosis,
suicide, death by overdose, etc.
To understand the importance of drug use in Peru,
some data that reveal the situation of Peruvian households should be reviewed.
The National Commission for Development and Life without Drugs (DEVIDA) conducted
research which indicates that there has been an increase in consumption between
2006 and 2012. The prevalence per year increased by fifty percent and current
usage has almost doubled, therefore the demand for treatment in the health
system increased by twenty percent between 2006 and 2010 (Comisión Nacional para el
Desarrollo y Vida Sin Drogas - (DEVIDA), 2012).
According to the statistical report of the Hermilio
Valdizán Hospital (Valdizan,
2013), an institution specializing in Mental Health and
Psychiatry belonging to Peru´s Ministry of Health (MOH) in 2013, 2,762 patients
were treated at outpatient clinics for behavior issues due to multiple drug
use. For the period 2012, an increase in the number of patients who sought care
treatment and rehabilitation due to substance abuse and dependence was
A Rehabilitation Center is an institution specializing
in addictive behavior which attends to people who are dependent on psychoactive
substances based on the principles of the Therapeutic Community (TC), harmoniously
engaging with the theories of learning and Cognitive Behavioral Therapy Program.
The goal of rehabilitation is abstinence in the
short/medium term, the elimination of addictive behavior, prevention of
substance use, the restructuring of the patient´s personal, family and social
situation, promoting change in their lifestyle and the restoration of adequate
levels of health (Bobes, J.,
Homes, M. & Gutierrez, 2015),(Aroca, C.,
Bellver, Ma C. & Alba, 2012). All diseases with psychiatric components
have cognitive and behavioral components, thus alterations and changes to either
the cognitive or behavioral functions, or both, are part of the process to
promote recovery (Lau, 2017). Cognitive behavioral therapies guide the
patient to develop strategies which allow for emotional regulation and
management of compulsive consumption (Keegan, 2012). To facilitate the rehabilitation process,
one approach is the restructuring of beliefs (Binnie, 2015). In accordance with(Beck, A.,
Wright, F., Newman, C. & Liese, 1999)cognitive techniques treat drug-related
beliefs and automatic thoughts that contribute to the impulses and cravings
while behavioral techniques focus on actions that interact causally with
cognitive processes. It is a theory that reinforces and prevents relapses
achieved through reinforcement(Fernández, C.
& Llorente del Pozo, 2006). Thus cognitive behavioral therapy
facilitates functional cognitive rehabilitation which can be focused on the
recovery of an optimized occupational functioning such as self-care, work or
leisure management.(Pedrero-Pérez, E., Rojo-Mota, G. Ruiz-Sánchez De León,
J., Llanero-Luque, M. & Puerta-García, 2011).
In accordance with Molina, J.,
Hernandez, D., Sanz, E. & Clar, F. (2012), nurses occupy a privileged place in the
care of drug addicts by the nature of their profession and knowledge that influence
the quality of patient care. It is in this context, that of the importance of
the nurse providing care for dependents of psychoactive substances, where it
becomes important for the development and implementation of the various
activities of the patient during the rehabilitation period. Therefore, the
nurse becomes a motivator to make the process of adaptation of the dependent
person become more effective, which ultimately leads to promote a change of
lifestyle without drugs, considering the promotional preventive aspect(Díaz, 2010), (Gonzáles-Suárez,
M., Duarte-Climents, 2014).
This research study plays an important role by
incorporating data on the problem because few studies have been conducted in
this area in Peru, South America, with the nurse being a part of the
interdisciplinary team which is prepared to observe, evaluate, guide and care for
dependents, using cognitive behavioral techniques necessary for success in
rehabilitation during treatment.
This issue of care has weaknesses related to the
role that a nurse has in the care of dependents on psychoactive substances,
this is evidenced by the lack of a comprehensive program or clear definition of
the profile of the nurse in the rehabilitation process of an addictive behavior.
Therefore, the present research work raises the question: How is the care that
a nurse provides for dependents of psychoactive substances in a Rehabilitation
Center? Faced with this reality, the following research objectives are
proposed: analyze the conceptions that the nurse has
about the care provided to people dependent on psychoactive substances in the
light of the social learning model and analyze the care provided to people
dependent on psychoactive substances with the cognitive behavioral model, in
the perception of the nurses themselves.
research study was conducted using a qualitative approach and the descriptive-exploratory
model. The sample consisted of five nurses who work at the Rehabilitation
Center: four women and one man. For data analysis, the model of hermeneutics
was used, which in this case is considered to be the art of providing means to
reach an understanding of the object of study.
collecting information, a semi-structured interview was used, following (Hernández, R. Fernández, C.
& Baptista, 2010) the interview as a process through which the
researcher seeks information contained in the statements of the participants,
who in this case are nurses who care for dependents of psychoactive substances.
Interviews were conducted at the place where nurses
provide care and lasted an average of 40 minutes. They were made privately,
recorded, transcribed and then read exhaustively. Then, the information
obtained from each interview was analyzed, identifying, analyzing and
categorizing the information collected.
The process of collecting and analyzing information
was performed simultaneously with the collection of individual information of
each participant. After the interview, the transcript of the interviews was wade
and was followed by analysis and interpretation, selecting meaningful
expressions that reflected the care provided by nurses thus determining the
categories of study.
regard to quality control for the data, the necessary steps to evaluate and
constantly improve confidence were followed, and it was further shown that the
information obtained was true and met the objectives. For scientific rigor, the
data collected was compared with the answers given by the nurses. The answers
were given voluntarily and were authorized.
is worth mentioning that there were no preconceived categories for this
research study. The categories were determined from the analysis of the interviews.
Their development took into account the recommendations provided by the
hospital ethics committee which oversees the Rehabilitation Center, through
informed consent, regulated in the Code of Ethics for nursing in Peru (Law
This research study was subject to truth and fidelity,
thus the participants were asked to sign an informed consent document. To
ensure the privacy of participants, the ethical principle of anonymity was
taken into account, which occurs when any researcher cannot tie the data with
the subject in which the three ethical principles of Belmont (Hungler, B.
P. & Polit, 2005) have been considered. The research subjects
were not exposed to situations in which they could have been harmed by the
secrets revealed during the recordings; they were confidential and used only
for research purposes.
Therefore, each subject voluntarily decided to
participate or not in this research study. Additionally, they received complete
and clear information about the investigation to be carried out.
categories of analysis were identified, which are presented from the transcriptions
of the nurses obtained in the interviews:
I: This category contains the concept of care including support, concern and accompaniment
with involvement for a change of lifestyle through the cognitive behavioral
model. In that sense, the nurses commented:
Care is to be with the patient, accompanying him throughout the process of
behavioral change, reinforcing adaptive behaviors ... when performing
activities according to the rules for the therapeutic community such as:
punctual and responsible ... with our way of being, we are also behavioral
models for them ... they can be prepared to live in society E2.
I provide care in an integral way, I see the resident (user) with difficulties
in different areas ... we are there to guide him ... to do whatever possible so
he can develop his adaptive capacities ... in his whole process of behavioral
change ... E3.
care is support, seeking that he learn and be able to adapt to the program in
the various activities and thus strengthen his biopsychosocial capabilities to
make him a functional person E1.
"... the first thing I do when I get on
duty is concern myself with knowing the biopsychosocial and spiritual situation
of a resident, that assessment is immediate and according to where he is
lacking I motivate him to present behavioral changes to improve his lifestyle
care is being involved … in the various activities performed by the patient to
understand the different difficulties presented and be able to intervene to
change their consumption behaviors into adaptive behavior, one seeks to achieve
that he organize himself in his daily activities looking for a biopsychosocial
balance helping to strengthen self-control, to do that I provide individualized
care ... considering that our behavior can influence a patient’s learning E4.
for me, care is to lead him to the point where he can perform the different activities
that the program contains and know that I'm there to see his behavior and
strengthen his adaptive behaviors ... and so he can prepare to rejoin society,
II. This category refers to nurse care from their social skills for dependents
on psychoactive substances using cognitive behavioral model. The comments from
the nurses about this category are as follows:
Giving nursing care
"... The Center has a therapeutic
program, patient care is complex ... one seeks for the patient to feel welcome,
understood, self-help and mutual aid and which gives the advantage of being
abstinent from the Center ... during the whole day. From six in the morning, when
you get up, until we sleep we are with him in his various activities,
monitoring, in psychotherapeutic care, which provides individualized care E5.
"... when they present their withdrawals,
interaction plays an important role, I accompany him throughout this process and
it is seen as a mutual help and he knows that we are there to listen and manage
his drug treatment, thus decreasing his withdrawal symptoms E2.
we use communication at all times, it is a tool for us because the relationship
with the patient is achieved through communication and through it we can
encourage social skills, which they really need E3.
I provide care considering assertive communication as one of the
characteristics of the patients is they are manipulative; we seek that they realize
what they are doing E4.
We apply cognitive behavioral theory at all times, and it is pleasant both for the
patient and for us, we communicate with affection, make them feel throughout
the whole process of change that they can count on us at every turn ... we
apply our care with assertive communication ... E2.
"... communication with the patient is continuous,
providing different behaviors which are be presented and supporting him to achieve
his goals to change E5.
Regarding the first category, we can say that, for
nurses in the Rehabilitation Center, the conception of care is to help people
who are dependent on psychoactive substances to adapt to the rehabilitation
program and coexistence in the Therapeutic Community. This is done by applying reinforcement
of the person’s capabilities in his training of adaptive behaviors, such as
self-control, thus considering a comprehensive form of care.
Social Cognitive Theory is used, which holds that observation and
given through models close to their environment. At the same time, they
changes in the systems of misconceptions, so it is important to
self-management, where their self-efficacy expectations can improve
situations of non-consumption (Bandura, 1983). One goal of this theory
is the development
of self-assessment and self-reinforcing, which develops during
continuous care(Bayrón, 2012). In this regard, the testimony of nurses
this first category coincide with care by psycho-education, drug
control for psychoactive substances and reinforcement of adaptive
Such care is continuous twenty-four hours a day and is the
the nurse to maintain its integrity and well-being at every moment of
stay, thus they identify consumer behavior as slang, demotivation and
drug use, which are not permitted within the process of change.
1980)mentioned in his theory that the nurse is as an
external force acting to preserve the organization and integration of behavior at
an optimum level using regulatory mechanisms, an approach that corresponds to the
care nurses provide to persons dependent on psychoactive substances, where the
nurse applies personal expertise in promoting and/or redressing the imbalance
of the dependent person so he can cope in a more adaptive way and continue his
A nurse who accompanies a dependent on psychoactive
substances can show his true self, that is, let him be, so he can have the
opportunity to be part of his own change, he becomes what he is, a person who
can be happy without drugs, developing the full potential of their being,
leaving his former life and incorporating new knowledge and acquiring a new
lifestyle without drugs, because in the process he learns to develop those
capabilities and potentials which he has as a human being.
With regard to the second category, care performed
by nurses are part of the cognitive behavioral model, using as a basis the
Social Learning Theory, which indicates that nurses provide care using their
social skills and become a learning model for the dependent person in
rehabilitation (Bandura, A.,
& Walters, 1974).
According to Bandura (1987), behavioral techniques are useful to produce
changes in the lifestyle of the person, so that the nurse is aware of the
behavior of discriminative stimuli of the dependent person to prevent relapse
of consumption. Therefore, the role of the nurse is important because it will provide
support, remembering that all this is subject to movement and readjustment based
on the patient’s needs to seek his own change.
It is also important to consider the theory of
behavioral system presented by (Johnson,
1980) where the nurse helps facilitate effective
behavioral functioning in the dependent person before, during and after
rehabilitation. This is where the nurse intervenes to preserve the organization
of the conduct of the dependent person when he feels under stress or the desire
for consumption, by promoting regulatory mechanisms.
Also, according to (Miotto, 2016), the critical-holistic view is part of the
interaction and the balance between internal and external components. This is
further defined as part of a dynamic integration process which therefore sees
human beings as open systems that interact with the environment and for that
reason, external factors will favor if a person stops or falls back into
That's why the nurse, in order to provide help,
develops a repertoire of skills, both social and emotional skills, where new
experiences are required regarding suffering, people's lives and learning new
ways of coping with situations of withdrawal. The therapeutic relationship is,
for a nurse, a learning and personal growth experience.
Nurse care in people with withdrawal consists in
assisting to maintain an open and assertive interaction. Accompany the
dependent person in his situation of pain, anguish, anxiety and understand
what's going on. That way, the patient finds his potential and is motivated to
seek within himself his freedom with capabilities that can make a comprehensive
change, finding harmony in mind, body and soul.
Finally, the dependent person receives from the
nurse a form of individualized teaching where he learns to value the personal
side, such as his time, friends, family and work, which is given through the
interaction between nurse and dependent person using assertive and effective
communication. This approach aims to achieve a significant change in the
process of rehabilitation of people with drug problems which gravely afflict
intervention of the nursing staff plays a key role in the process of care and
rehabilitation of people dependent on psychoactive substances. Their task is to
unify the functions and assistance activities from a focus on holistic care.
Nurse care for the person dependent on psychoactive
substances in rehabilitation is holistic, integrating all of the biopsychosocial
areas. Through it the relationship with the nurse provides support and
guidance, which sheds light aimed at achieving a new lifestyle. Therefore,
nurses involve their own ways of being and personal experience; care being a
major factor in the rehabilitation of addictive behavior, thus making up for withdrawal.
In the process of rehabilitation, nursing care uses
the cognitive behavioral model. In that sense, it also employs theories of social learning that not
only means learning the different stages and structure, but of unlearning and
reorganizing mental systems in order to make the dependent person relearn new
healthy behaviors for life.
It requires a new
understanding of treatment quality where nurses are transmitting significant
holistic care, as noted by Dorothy Johnson, who argues that nurses through the
promotion of regulatory mechanisms and other resources, are an important
external force which acts in order to preserve the organization of behavior of
the person, so one can help dependent people when they feel subjected to consumption
Concerning care from a viewpoint of assertive communication
and affection for the dependent person during the process of changing,
communication skills and the possible inclusion of third parties significantly
improve the prognosis of treatment, so that fostering the therapeutic link
between them is part of the job of the nurse. This helps avoid aggressive
confrontations, whether physical or verbal and moreover increase motivation for
the treatment in question.
In addition, the nurses as part of their role, take
a proactive attitude towards the situation of pain, anguish and anxiety in
withdrawal symptoms that befall the person dependent on psychoactive substances.
To do this, the put their interpersonal skills, scientific knowledge and
systematic work methods into practice. They also serve as a facilitator of this
process, using empathy and listening, evaluating in this regard the signs and
symptoms of the dependent person.
Finally, this study demonstrated the need to have
evidence of the care and achievements such as: registers, protocols and
processes of care which would allow nurses to provide quality comprehensive
care to people who are dependent on psychoactive substances, also bearing in
mind that this scenario is complex, multidisciplinary and multifactorial.
Undoubtedly, nurses play an important role during the process of care and
rehabilitation. Its nature also lies in how much the nurse is committed and
involved in the process of change and/or rehabilitation.
On the other hand, it is recommended that the Center
for Rehabilitation under study be decentralized and become an independent
institute, so that it can foster the promotion, prevention, and not only those
activities directed at treatment or rehabilitation, but also the recovery or
prevention which is one of the most challenging phases for the whole society
steeped in this very serious health problem.
Finally, the Rehabilitation Center can improve
their vigilance with regard to rehabilitation, which can lead to reduced demand
and prompt attention of dependency. This would require the application of the
system of reference and counter-reference in order to facilitate a care
network, as they are two inseparable and essential components of an effective
policy on reducing demand for drugs while providing access to quality services
that have continuity over time, as warranted by this chronic problem.
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