I am alone: the experience of nurses delivering care to alcohol and drug users

Abstracts

The objective of this study was to determine the experience of nurses who care for drug-dependent patients at a medical service of a public hospital in Chile. This is a qualitative study of phenomenological trajectory according to Martin Heidegger’s framework. The study question was, What is the experience of taking care of drug-dependent patients admitted to your service? Nurses’ reports were based on the concept of situated phenomenon reference by Joel Martins After analyzing the interviews, we identified three themes that expressed this phenomenon: speaking about the drug-dependent patient, taking care of patients in an adverse environment, and dispelling the fear of care. This study shows the need to train health care professionals on dealing with alcohol- and drug-dependent patients in order to overcome prejudices and improve care delivered to these patients.

Nursing care; Alcoholism; Street drugs; Phenomenology

El propósito de este estudio es comprender cómo es ser enfermera vivenciando el cuidado de pacientes drogodependientes que ingresan al Servicio de Medicina de un hospital público de Chile. Se opta por un estudio de tipo cualitativo, de trayectoria fenomenológica, según el referencial de Martín Heidegger. La pregunta orientadora fue: ¿Cómo es cuidar a pacientes drogodependientes que ingresan en tu servicio? Los discursos de las enfermeras fueron interpretados bajo el referencial de Fenómeno Situado de Joel Martins. Después del análisis de las entrevistas, se identificó 3 temas que expresan el fenómeno: hablando del paciente drogodependiente, cuidando al paciente en un medio adverso, superando el miedo para cuidar. El estudio muestra la necesidad de capacitar al personal de salud en dependencia en alcohol y drogas para superar los preconceptos y mejorar el cuidado de estos pacientes.

Atención de enfermería; Alcoholismo; Drogas ilícitas; Fenomenología

O objetivo do estudo é comprender como é ser enfermeira vivenciando o cuidado de pacientes usuários de drogas que ingressam em um hospital público do Chile. Trata-se de estudo qualitativo, de trajetória fenomenológica, segundo o referencial de Martin Heidegger. A pergunta orientadora foi: como é cuidar de pacientes usuários de drogas que ingressam no serviço? Os discursos das enfermeiras foram interpretados com base no referencial do fenômeno situado de Joel Martins. Depois da análise das entrevistas, foram identificados três temas que expressam o fenômeno: falando do paciente usuários de drogas, cuidando do paciente em um meio adverso e superando o medo para cuidar. O estudo mostra a necessidade de capacitar o pessoal da saúde sobre o uso de drogas e álcool para superar o preconceito e melhorar o cuidado a esses pacientes.

Cuidados de enfermagem; Alcoolismo; Drogas ilícitas; Fenomenologia

INTRODUCTION

The increase in drug consumption is causing negative effects in all areas of human development and is generating high costs due to the damage to health, economic, and social spheres ^{( 1 )} . A study conducted in Latin America identified Chile as the country with the highest consumption of cannabis and alcohol in the region and with the second highest prevalence of cocaine consumption ^{( 2 )} . It is estimated that 246,132 persons are drug abusers. Of these, 25.1% in the past year were cannabis consumers in the last year compared with 43.8% coca paste and 22.7% cocaine users. Concerning Approximately 23% of the population reported consuming alcohol two or three times a week; 14.4% of men age 19 to 25 years reported alcohol abuse ^{( 3 )} .

A study of disease burden and attributed burden conducted in Chile in 2007 showed that alcohol dependence is the fourth leading cause of loss of years of life ^{( 4 )} . Other studies have correlated alcohol consumption with cancer, infarction, strokes, liver problems, neuropsychiatric disorders, accidents and traumatic events; such accidents and events are seen more in the young population ^{( 5 )} .

Given this scenario in Chile, some public health efforts have sought to reduce the problematic consumption of drugs. Examples include the National Strategy for Drugs and Alcohol, the National Plan for Mental Health and Psychiatry, and the approval of law 20580, which changes the alcohol levels permitted for drivers. Such efforts helped reduce deaths and violence associated with alcohol and drug consumption ^{( 6 )} .

In 2000 the model of mental health care, in consonance with changes performed in others countries in Latin America, changed the structure of care. Care should no longer be restricted to medical offices and hospitals but rather be expanded to include the care delivered by people close to the patient; this guaranteed continuity of care at different levels and ensured access to health promotion and protection measures ^{( 6 )} . In this model, patients in mental health and drug programs would be participants in the network, and, as a result, would have access to connected services to address needs for any stage of their health and disease process.

Despite these changes, studies indicated that investments in human resources are still low. In addition, evidence suggests that hospital and service networks are resistant to change the model. Training and development plans that enable continued participation in a network are also lacking. For this reason, some studies have indicated that rights to access and care did not resound in general population or in health professionals responsible for the care of those who sought such services ^{( 7 - 8 )} . In addition, without a doubt, these changes pose new challenges for nursing professionals.

Other countries similar to Chile lack knowledge of clinical management of patients dependent on alcohol and drugs. Management of these vulnerable patients remains focused on physical demands and often does not consider their psychological and emotional needs ^{( 9 - 10 )} .

Some health care workers have a negative attitude towards the patient and the evolution of his or her clinical features ^{( 11 - 13 )} . Although this is an important subject, few studies have addressed it ^{( 14 - 15 )} . A review of the literature on this subject showed that beliefs and actions of nursing professionals, assistants, and managers concerning drug-dependent people and drugs differ according to personal factors and experiences. The review emphasized the lack of instruments to measure attitudes. We believe that training professionals to improve quality of care is important and that qualitative studies to further investigate this topic are needed ^{( 16 )} .

In Chile, we found no studies that approached this issue among nursing professionals with the aim of understanding the reality of services and observing concrete problems from this point of view. Therefore, this study aimed to understand how nurses provide care for drug-dependent patients who sought clinical services at a general hospital in Chile. Briefly, we attempted to determine how nurses deliver care to drug users admitted to clinical services, how nurses intersubjectively relate with drug users seeking assistance, and what these professionals needs in order to provide high-quality care for these patients.

METHOD

This investigation sought to understand nurses’ experience from their own perspective. We used Martin Heidegger’s phenomenology, a model pertinent because it seeks, without prejudice or theories, to investigate, comprehend, and interpret the nurse who delivers care as a concrete experience and as a conscious individual. Hence, in this study we sought to attribute meaning, according to the nurses’ view of the world, according to their customs, knowledge, and values intersubjectively experienced with others ^{( 17 )} .

Our study included six nurses working on the medical service of a public hospital in Chile, who were responsible for the care of psychoactive substance users. Data was collected by phenomenological interviews using the following open question: What is the experience of taking care of psychoactive drugs users? Interviews were conducted between January and February 2012.

Nurses were asked to freely share their experience on the subject so that reports were spontaneous. Before the interviews, formal authorizations were obtained from the health service director, hospital director, and vice-director of care from the same hospital. This study was approved by the Ethical Committee of the Facultad de Medicina de la Universidad de Valparaíso, No. 18 and protocol No. 29/2011 ^{( 18 )} .

All participants signed the consent form. Interviews were conducted at a single session; therefore, the nurses’ point of view was expressed spontaneously. Discourses were numbered from 1 to 6, preceded by the letter I (for interview ): I1, I2, and so on ^{( 18 )} . In earlier phenomenological quality research, the total number of nurses to be interviewed could not be determined before the study. In our study, interviews of six nurses were enough to answer the study question. Interviews were conducted at a clinical service or a place indicated by the participant and at a time that was convenient for the participants. Interviews were recorded, transcribed, and then reviewed with respondents to verify whether their thoughts were accurately represented.

In this context and in agreement with other researchers who conducted interviews, we selected a qualitative analysis of situated phenomenon ^{( 19 )} . To situate the phenomenon in the nurses’ own world, phenomenologically speaking, means to place their thoughts in parentheses that, in phenomenology, are known as epoke ; this means suspension of beliefs and values regarding the existence of the phenomenon in question. After that, we attempted to describe the findings as precisely as possible, leaving aside any hypothesis, presupposition, or theory, searching exclusively for what is shown. For this reason, discourses were analyzed by applying trajectory moments of situated phenomenon: description, reduction, and comprehension ^{( 19 )} .

As the investigators became familiar with descriptions by the repetitive readings of the content, some significant units appeared to be associated with the investigators’ views on systematizing the experience of individuals’ way of life in relation to the essence of the phenomenon. The phenomenology reduction is the decision to suspend (put in parentheses or remove from access) beliefs and values on the existence of the phenomenon in question. The goal is not to deny but to comprehend and explain individuals’ spontaneous affirmations.

Our study attempted to clarify the discourses or bring into light the significant points, seeking their essence and showing what they really are. When descriptions converged (i.e., when repetitions were found in discourses), it was possible to affirm that the phenomenon was shown and the essential expression of means and discourse was clarified ^{( 19 )} . At that moment, the researchers’ main concern was to understand individuals’ thoughts related to the proposed question and what the situation meant to them.

Nomothetic analysis ^{( 19 )} was carried out only after the end of the analysis of each discourse. A global analysis was developed to make generalizations from the phenomenon in question. We also found convergence and divergence among units in different discourses; individual details of each unit were also revealed. Convergences characterized the general structure of the phenomenon, and divergences and idiosyncrasies indicated individual perceptions.

After we analyzed the phenomenon, the results were the meanings given by nurses on their experience with providing care for psychoactive substance consumers at a public hospital in Chile.

RESULTS

All nurses participating in this study were women aged 25 to 45 years who had more than 1 year of experience in the service and were responsible for patient care.

From the participants’ experience, the phenomenon of caring for drug-dependent patient was revealed. This experience involves three important aspects: 1) speaking about the drug-dependent patient; 2) taking care of patients in an adverse environment; and 3) dispelling the fear of care.

Speaking about the drug-dependent patient

Nurses on the service have a clear idea of the situation of drug-dependent people who seek care. Nurses describe users as difficult to deal with; responsible for affecting the dynamic of the unit; undesirable; and possessing complex physical, mental, and spiritual problems.

The number of drug dependent patient has increased (…) associated with disease (…) such as hypertensive crisis, trauma, or shock (…) and stab wounds; psychiatric drug-dependent patients are also referred to our service (I2).

Nurses have perceived a increase in the number of patients who seek care on the service because of alcohol and drug abuse; this perception is particularly seen with regard to the increase in psychiatric disease among young people.

...Nowadays it is more frequent. There is easy access to (…) drugs and alcohol, there is more psychiatric disease among young people, (…), as well as suicide attempts, with a depressive, obsessive component and…other psychiatric conditions… (I3).

In general, users begin to consume drugs because of the influence of friends or because of family or affective problems, and as time passes their drug use increases. Dependents justify the consumption as way to forget their problem , avoid reality, and reduce distress.

... People justify drinking beer very day because it feels good. Manufacturers encourage young people to consume alcohol, by using, for example, beautiful women in beer advertisements, so what we see more and more is damage to the liver, and people perceive it as normal. on holidays it seems that people need to drink alcohol. For me, the zero tolerance law sounds great (I2).

Nurses often associate drug consumption with patients at high social risk, such as homeless people. Health care workers often stigmatize drug-dependent patients. They view the drug-dependent as people who just want to enjoy the moment, and who put little effort into treatment of drug dependence. All nurses reported that they experienced this situation:

…We receive patients from all types of socioeconomic status…when the patient is admitted for hepatic damage or digestive hemorrhage, physicians and also nurses stigmatize him or her. We think, it’s his or her fault to be in that situation, that the person sought it. In my opinion, we should think about this differently (I6).

The most complex situation affecting nurses and the health care team is the clinical management of alcohol and drug deprivation syndrome, which occurs when the patient is admitted. Patients become aggressive, and sometimes it is necessary to restrain them physically and use sedatives.

… when we see that deprivation syndrome begin, the patient becomes agitated, which compromises his or her general health status, the cycle, and all organic parts. Therefore, psychiatric treatment needs to be supplemented with internal medicine services… (I4).

Taking care of patients in an adverse environment

Nurses affirm that the medical service is not prepared to manage psychoactive drugs users because, among other needs, the staff lacks training.

The service is not prepared for this, (…) I don´t know if I´m prepared to manage these patients; there is no training (…) (I1).

In this scenario, nurses become exhausted, feel alone, and do not receive support from their coworkers or hospital administrators. Therefore, they became responsible for the patients’ care without the support of physicians or psychiatrics who could prescribe sedation or contain patients’ aggressiveness. In addition, there are few men on the staff who could help. The lack of training for specialized nurses in the care for drug-dependents patient constitutes a source of anxiety and stress.

(..)Because there´s no physician, we are alone. There is not even one doctor who could indicate what we should administer to the patient (I1).

Nurses also report that hospital infrastructure is inadequate to receive alcohol- and drug-dependent patients. In addition, hospitals lack dedicated rooms for dependent patients, and therefore these patients are mixed with nonusers. In fact, there were attempts to organize care in special rooms, and the new head of the service indicated that specific beds were assigned for such patients.

…there is a lack of training, tools, and actions from health intuitions in relation to these patients. The government must also respond and give us qualified professionals, specific rooms, and guarantees on provision of medicines that will be needed (I3).

There are no protocols for the care of drug-dependent patients or for psychiatric patients with deprivation syndrome. Nurses believe that a practice protocol is needed, particularly because the number of cases has increased. They also reported that some of them took responsibility for revising such practices, but the work was not finished.

A protocol is needed. I believe that this gap should be addressed. A protocol should exist because there are many patients who seek the service, especially the medical service. There are men, women. Most of them are adolescents. The service lacks a protocol (I4).

Nurses often have problems dealing with such patients and their families because nurses are shocked and do not understand the reality of drug consumers; the consumers need of inclusion.. Nurses receive complaints because some drug users shout at night, attack the staff, and put them in risky situations. These situations represent an additional workload. At this point, it is important to control sources of physical or psychiatric aggression to decrease interpersonal conflicts and empower social skills in the care process.

(…) Patients also complain. We received letters (…) complaining (…) that patients were exposed (I1).

In this context, it is emphasized that a support network at the hospital is not organized to enable post-discharge specialized treatment of drug-dependent patients. If someone wants treatment for drug addiction, the hospital does not offer support. Specialized centers for users are not enough, and the ones that do exist lack vacancies and medicines. More centers for support are needed, along with awareness and calls to action to help caregivers lose their fear of substance users, humanize their care, and increase their understanding of the situation.

The health service lacks support to improve or increase quotas. It is necessary to improve and enlarge interventions so that there is room for hospitalization in the morning. El Salvador has this service, but quotas are scarce (I2).

However, nurses thought that the service should address this issue in an interdisciplinary manner in order to increase staffing and inputs that could improve patient safety with regard to medicine administration and registers.

… I believe that more inclusive centers are lacking for this kind of patient; (…) we could include them in the society, know them better, approach them without fear. We should not feel scared. We must know how to treat them because they are human beings as we are. These patients need to be understood. I think the population also lacks this understanding (I5).

Dispelling the fear of care

Nurses find delivering care for alcohol and drug users to be complex and because they do not feel psychologically prepared to face such situations. They are used to managing other types of disease.

This is complex; we are used to managing chronic patients, diabetic patients with pneumonia, and other types of diseases (I6).

Nurses feel uncertain when caring for patients with abstinence syndrome because they to know how it will present and what will happen; they suffer as they anticipate the results of the situation. They fear the uncontrollable strength of some patients and the need to medicate and restrain them, especially because doing so can cause more damage to the patients. Therefore, these professionals create care strategies that do not harm the patient. For nurses, sedation is not acceptable because it also leads to intoxication, and they know that the doses will need to be reduced.

when patients arrive and become agitated, we feel scared because they lose they tempers, they want to attack everyone. I feel scared. First I denied and thought: an alcoholic and drug-dependent patient was admitted, how am I going to manage it? But when the patient became stable, the emotional part appears: How to support them, how to reinsert them into society, especially when they are young (I4).

In the first contact with patients, nurses report feeling scared, and they tend to deny the person because to deliver care to them implies a greater workload; it also requires an adaptation of nursing care. They are afraid to sustain an aggressive attack from patients with the deprivation syndrome. This conflict of values could explain why nurses should be compassionate and express solidarity with the patient but yet feel frustrated, angry, and unwilling to help. At the second contact with patients, the nurse attempts to place himself or herself in the patient’s and family’s situation, to connect with them and understand their way of life. After that, the nurse ends up offering emotional support, calming the patients and families, and clarifying their doubts.

(…)in the relationship between nurse-patient, you put yourself in the other person’s shoes. You could never say: This situation will never happen in my family (I6).

Communication with patients is difficult, exhausting, and tiring because they are aggressive. When the family is together, family members complain and do not want to take care of the patient. Nurses think these patients should receive the same support as others patients. They should help and adapt to them. They should interact well with the patient, with the staff, and other patients in the room. Nurses see themselves at an difficult situation that causes stress and workload.

(…) So, you feel that you are the boss with this double workload. I want to calm down my team and also the patients, they need to rest, and there is also the risk to cause more harm to patients, so I end up at this crossroad (…) It feels like I’m carrying the whole world on my shoulders (…) the patients should be contained, I administer a diazepam and he/she calms down (I2)

Nurses feel that help provided by procedures and other professionals for management of patients is not enough.

To the nurse it is difficult, (…) the paramedic is the one who often assists more with the patient. All caregivers do not want the patient to bother them, they want them not to move, so you need to keep the patient sedated (I2).

When young patients are admitted, nurses attempt to understand why they take drugs. Nurses become worried and feel distressed to think about the future of patients and professionals who use drugs. They want to help the patients to become aware that they need take care of themselves, but patients normally return to drugs.

When I, personally, receive young patients in my service who attempted suicide, I used to ask them why they ended up consuming other types of drugs. It is like that — you and the patients are very close. They usually tell about their personal life, problems at home; sometimes their family doesn’t look unstructured (I4).

Such situations affect nurses because they have their own family problems. In addition, they tend to imagine how this situation is for the patients’ families and for the patients themselves. Therefore, nurses tend to explain the situation to each other and discuss what can be done to help, even without adequate tools. Nurses believe that they should be sensible and more aware about the drug consumers situation in order to be able to help.

We should talk about, support, and analyze these situations because this is only way to go forward and explain them to others (I3)

DISCUSSION

In response to the question of what it is like to be a nurse and take care of drug-dependent patients in a public hospital in Chile, the participants’ discourses provided significant insights. First, the discourses described caring for drug-dependent patients and characteristics that distinguished them from others patients. Second, they reflected the challenges that nurses and caregivers face in an adverse environment that led them to feel but also to find measures to overcome such adversities.

In this sense, Heidegger’s concept of Dasein is being – in the world ; it refers to someone who is not alone. Dasein-with ( being with be ) is constituted as a form of relation. The being is a construct for relationship, feeling, thinking, acting, and living with others in a shared world. This coexistence with others enables conditions for understanding the experience of others and for seeing them as they are by their gestures, way of being, and language ^{( 19 )} .

In this study, nurses were insecure about delivering care to alcohol- and drug-dependent patients. The first aspect of care revealed by the interviews – speaking about the drug-dependent patient – showed the displeasure associated with loss of control and authority ^{( 18 )} . The nurses experienced this because they were in an uncertain situation that provoked distress and fear ^{( 18 )} . The fear coexists with the other person in a situation where nurses should share themselves fully and spontaneously.

There are many ways in which nurses are involved in the world. One concerns the nurses’ total immersion in daily activities, without notice of their existence, when the work is done as part of a routine because they have learned it in their culture. So, for example, when nurses are in the hospital, they are responsible for delivering care to stable adult patients who are routinely admitted to their service. Another way to be in the world is to be conscious of your existence. When an incident happens, nurses become conscious of all details of their existence that were not perceived before. This is evident when, for example, they are providing care for patients for whom communication is difficult, and they therefore must adapt to a situation (that is, a world) – different from their own lives. In such a circumstance the work is limited by several difficulties, including those resulting from public service administration. Nurses also face difficulties in acquiring knowledge on how to face situations and deal with any associated complexity. Such difficulties end up changing the dynamic of their daily work when they are delivering care to drug-dependent patients in an adverse environment, the second aspect of nursing care revealed in this study.

These difficulties were also addressed in a review of the literature on this topic, which concluded that the greater the knowledge deficit, the greater will be professionals’ negative attitudes ^{( 10 )} . In addition to lack of knowledge is a lack of infrastructure and protocols at the hospital for the care of patients with deprivation syndrome.

Nurses by their side and professional dimension involve, on a particular manner, their own experience. This perspective could be easily seen in their reports concerning the professional development and experience acquired with care delivery for drug-dependent patients. To be situated implies that the person has a past, a present, and a future and that all aspects of a person’s life influences the current situation. Therefore, taking care of drug-dependent patients in the present must consider the meanings from the past and is also enriched by anticipation of the future ^{( 17 )} .

Heidegger also developed the care concept of being — worrying about others within the world. This perspective of care has two meanings, and they pose the possibility of conflict ^{( 17 )} . According to this author, care leads to interest or to take care of someone, addressing genuine worry about others. Thus, delivering care to drug users lets them show their real selves. In this way they became what they really are, developing all potentialities of being ^{( 17 )} .

Therefore, nurses can be involved in care, knowing that they can help others grow at their own pace and leave the drug dependency, establishing a relationship of convenience and interaction. This agrees with other studies showing that professionals show a more sensible attitude when they know the history and life experience of others who are close them ^{( 20 )} .

In other instances, nursing care was provided in a merely technical (that is, inauthentic) way. In other words, the patient’s needs were viewed in a functional manner by the service or professionals. Patients were physically restrained or sedated because doing so favored the function of the service or the team. This leads us to think that drug users were treated as something that needed care and their wishes were totally ignored. In this sense, the user is an object of interest, not of care service, ^{( 17 )} and, as a consequence, the patient is unable to realize all his or her potentialities.

In this context, nurses in this study sought to dispel their fear at the second contact with patients. This third aspect of care revealed by our study shows that the nurses put themselves on the side of the patients and attempted to understand this relationship; they switched from technical care to being-with care ^{( 21 )} . However, the nurses clearly indicated personal and professional barriers related to the organizational culture of the service and the lack of adequate structure. These deficiencies make it difficult for nurses to overcome obstacles in practice and to offer authentic and humanized care that considers drug users as real persons in the nursing care process.

CONCLUSION

Since the implementation of the mental health plan in Chile, the admission of drug-dependent patients at a general hospital in this country is becoming more common. This increase generates several difficulties. Nurses find themselves working in an adverse environment, characterized by the lack of necessary infrastructure, lack of specialized training for human resources, and problems with multidisciplinary work that generate a variety of feelings. The main feelings generated are impotence and value conflicts, worry that patients will be harmed and their health problem will worsen, fear of dealing with patients’ differences and searching for options to deliver high-quality care, and frustration in dealing with both substance abusers and their families.

This study showed that the care of drug users demands that nurses develop new skills to solve concrete and sometimes complex problems that occur in daily care. In addition to technical abilities, these include the ability to solve problems; being proactive; creativity; and effective communication skills with patients, families, and the health team. In addition, nurses should accept diversity and always work in teams.

For this reason, it is fundamental to strengthen future generations of professionals by using models of community mental health that empower interdisciplinary work, provide education on ethics, and enable professionals to explain human phenomena according to other perspectives.

It is necessary to produce more evidence that will enable professionals to deliver better care for this groups of patients. In this multifactorial scenario, phenomenology is presented as a view that could help improve understanding of the phenomenon of addiction; it could also allow better understanding of nurses’ personal concerns. Therefore, when nurses know themselves and their role in caregiving better, they the others (that is, the drug users), as human beings who face a complex health problem that deserves care. These patients need attention from health professionals, not only for detoxification but also in seeking a mutual therapeutic relationship that will help them begin on the pathway of recovery from the dependence.

Therefore, more studies are needed on the process of care in an internal health service and on tools that will allow nursing professionals to do their work more satisfactorily. Urgent education of the population and families of drugs users on the inclusion of alcohol and drug users in the general health system is important. With the partnership of this population, it is possible to decrease the exclusion of and prejudice against persons with alcohol and drug dependence in society, which may result in greater attention toward and positive actions in favor of this group.

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Publication Dates

• Publication in this collection
  01 Dec 2013

History

• Received
  23 July 2012
• Accepted
  25 Aug 2013