The International Journal of Psychosocial Rehabilitation
Perception of nursing care for dependents rehabilitation
of psychoactive substances in the light of social learning

Castillo Zamora Luz Victoria
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

 International Journal of Psychosocial Rehabilitation. Vol 22 (1) 93-100


The 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 sense,(Oficina de 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 treatment(United 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 observed.

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.

The 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.

In 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.

With 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.

It 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 22315).

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.


Two categories of analysis were identified, which are presented from the transcriptions of the nurses obtained in the interviews:
Category 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 E5.

"... 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, E5.

Category 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.

Therapeutic nurse-user communication
"... 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.

Applying CBT
"... 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.

Bandura’s Social Cognitive Theory is used, which holds that observation and imitation is given through models close to their environment. At the same time, they can produce changes in the systems of misconceptions, so it is important to emphasize self-management, where their self-efficacy expectations can improve future 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 in this first category coincide with care by psycho-education, drug control, toxicology control for psychoactive substances and reinforcement of adaptive behaviors. Such care is continuous twenty-four hours a day and is the responsibility of the nurse to maintain its integrity and well-being at every moment of their stay, thus they identify consumer behavior as slang, demotivation and talks about drug use, which are not permitted within the process of change.

Likewise, (Johnson, 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 rehabilitation.

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 consumption.

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 our society.

The 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 behavior.

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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