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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 172-178

Nursing care needs assessment of persons with substance use disorder: A qualitative case study approach


1 Ph.D Scholar, Department of Psychiatric Nursing, Lokopriyo Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam, India
2 Professor & Head, Department of Psychiatric Nursing, Lokopriyo Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam, India

Date of Submission11-Aug-2021
Date of Decision07-Dec-2022
Date of Acceptance12-Dec-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Ms. L Iris Devi
Department of Psychiatric Nursing, Lokopriyo Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_77_21

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  Abstract 

Substance use is a major concern in many parts of the world. It affects people across all strata and classes. This study uses a qualitative case study approach to gain an in-depth understanding of the needs of patients with substance use disorder (SUD) and to synthesise the outcome from each of the cases. Five cases of inpatients admitted with diagnosis of SUD in a tertiary mental healthcare institute were selected through purposive sampling technique, and data were collected through observations, interviews and documents. Participants were the patients and their caregiver. Individual cases were analysed and their needs were identified in categories and finally the identified common needs were organised into broader themes. The themes that emerged were grouped into biological, physical health, social, familial, disease-related and psychological needs. These findings can be put to use to give effective care to patients with SUD and further interventions can be designed with these specific aspects in mind.

Keywords: Case study research, needs assessment, nursing needs, patients, substance use disorder


How to cite this article:
Devi L I, Baruah A. Nursing care needs assessment of persons with substance use disorder: A qualitative case study approach. Indian J Cont Nsg Edn 2022;23:172-8

How to cite this URL:
Devi L I, Baruah A. Nursing care needs assessment of persons with substance use disorder: A qualitative case study approach. Indian J Cont Nsg Edn [serial online] 2022 [cited 2023 Feb 3];23:172-8. Available from: https://www.ijcne.org/text.asp?2022/23/2/172/366610


  Introduction Top


Substance use is a disorder which is prevalent in all age groups and across all genders. A substantial number of people in India use psychoactive substances, and it is most common in adult men.[1] Substance use disorders (SUDs) are related to an increased risk in the morbidity and mortality status of an individual if left untreated. As per the WHO Global Health Estimates in 2015, the percentage of deaths due to alcohol use disorder (AUD) was 0.2% and due to drug use disorders (DUD) was 0.3%. In India, the disability-adjusted life year for AUD is 0.3% and DUD is 0.4%, respectively.[2] Substance use affects the individual, family, society and the nation leading to loss of productivity, violence, crimes, increased healthcare expenditure, significant costs to the society and other social outcomes.[3],[4]

Addiction affects the pathways of the brain which makes it difficult to stop the drug use behaviour.[5] A person's recovery plan depends on the person's specific needs which has to be addressed in a holistic manner.[6]

This study uses a nursing assessment approach to gather data. Needs assessment refers to process of determining the individual needs and functioning at initial phase of treatment to clarify the issues to be addressed in the treatment of individuals.[7]

Nursing theorists argue that patients would have a better outcome if they had a more holistic assessment of their needs.[8] On defining need, the perspectives of the needs felt by the patient and family members might differ from the actual care to be provided in a setting.[9]

This study uses a case study methodology which is used when a holistic in-depth investigation is needed. It is useful in bringing out the information from the perspectives of the participants by using multiple sources of data.[10]

A qualitative study of what the patient and the family members experience and what they say they need may help to gain an in-depth understanding of the needs of the patients, and it will help to develop appropriate interventions and support services. This qualitative case study aimed to understand the nursing needs of patients with SUD.


  Methods Top


The present study has an explorative and descriptive research design and is a single-case study with embedded units. A single case was chosen, i.e., SUD, and each patient comprised the units of the case. The goal was to first explore the general and unique needs of each patient and then synthesise the outcome by comparing each of the case's needs. The setting is a tertiary care hospital located in the northeastern region of India which caters to most of the patients with mental health problems. It has a fully functional de-addiction ward with regular OPD services.

Participants were the individuals admitted with a diagnosis of SUD according to the International Classification of Disease (ICD) 10 criteria (F10 to F19) and their family members. Primarily, the patients were selected and it included all males as there are no admission facilities available for the female patients and also the proportion of females consuming substances is less in this part of the country as per the report published by the Ministry of Social Justice and Empowerment in 2019.[1] A total of five patients were included in the study and their age ranged from 19 years to 45 years. A maximum variation purposive sampling technique was applied to include individuals admitted with diverse aspects and types of substance use. Patients who were using substances for more than 6 months and diagnosed with SUD as per ICD 10 criteria and who could speak, understand and read English/Assamese and admitted for inpatient treatment were included. Patients having a Brief Psychiatric Rating Scale (BPRS) score more than 30 and those having major medical comorbidity were excluded from the study.

The family members acting as the primary caregivers included in the study were life partner (3), mother (1) and brother (1) who were free from any major medical or psychiatric comorbidity.

Data collection procedure

Data were collected between April and June 2021. Information on new admissions was gathered from the Medical Records Department room, and selections of the patients were done. The patients and the family members were then approached, and consent was taken for the study.

The primary sources of data were as follows: (1) documents (such as the notes in the patients' file by the various professionals, the nurses' report book, Nursing Rounds Book and the nurses' observation notes); (2) interviews with key informants (patients and the family members who were present during the stay of the patient in the hospital); and (3) observations (direct ward observations by the researcher, the duty nurses' observation gathered through nurses' observation sheet and the observations of the family member which was again collected through informal or formal interviews with the family members.

The patients were observed from the time of admission to the day of discharge regularly. Unstructured interviews with the patient and family members were conducted using open-ended questions. An average on 2–3 sessions of interview with the family member and 6–8 sessions of interview of varying lengths were conducted with the patient depending on the problems that could be identified. Simultaneously appropriate nursing interventions were provided based on the problem. Discussions were open ended and followed the previous related topics. Rapport was established with the participants, BPRS was applied and mental status examination was done to rule out any psychotic symptoms. Interviews were done whenever it was feasible for the participants and they were ready to provide information, providing ample time to share their experiences and problems. Each interview lasted for 45 min to 1 h. Field notes and reflective journals were kept after each interaction. At the end of each interview, the researcher summarised the content to ensure that the participant's perspectives were correctly stated and comprehended.

Ethical considerations

Permission was obtained from the institute's authority to conduct the study. Ethical clearance was obtained from the Institutional Ethics Committee. All the participants were provided with a participant information sheet including details of the study, and informed consent was obtained from the participants, i.e., patient and the family member. The participants were explained on the confidentiality of their information and also informed that they were free to withdraw from the study at any point of time if they wished to withdraw.

Information related to patients and family members on matters related to substance use can be ethically sensitive, so care is taken that matters which are sensitive are not revealed here. In this article, all identifying information has been concealed.

Analysis

The analysis consisted of a descriptive and an exploratory phase and followed the general principles outlined by Yin.[11] The descriptive phase was used to achieve a basic understanding of the data, and an analytical technique was used to get a coherent understanding of the findings.

Data analysis involved reading through all the data with emphasis on identifying concepts that related to specific aspects of problems faced by the patient and family members and needs which were expressed or unexpressed but which could be enhanced. Concepts were first identified within each case and then similar concepts were grouped under a theme. In the similar way between cases, themes were identified through constant comparison method.

Data were coded inductively, and the codes were later sorted into broader themes.

Validity of the findings was established by triangulation of data from different sources (documents, interview, observations, etc.) and by gathering information from various participants' family members and patients. The findings which emerged were also verified for accuracy from the participants.


  Results Top


The themes that emerged were grouped into biological, physical health, social, familial, disease-related and psychological needs [Figure 1].
Figure 1: Needs of persons with substance use disorder

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Theme 1: Biological needs

Patients with SUD experience various problems, and one of them was related to the biological needs of the individual. Under biological needs, there were two subthemes, i.e., sleep disturbances and poor appetite that emerged specifically.

Sleep disturbances

Patients with mental illness mostly experience problems in their sleep, and the case is not differentiated in an individual with SUD. Patients experienced disturbed sleep while they were admitted in the hospital in the initial phase of detoxification as a part of the withdrawal symptoms. They also experienced sleep disturbances before being admitted when they had been taking the substances at home and also at times when they would not be able to take their desired dose. Patients who had stopped substance use and had abstained from taking substance also reported sleep problems and indicated it as a reason for substance use relapse.

'When I did not take heroin I could not sleep but when I take it I can sleep nicely' (P2).

Poor appetite

The problem in nutritional domain was experienced by all the patients, with all the patients presenting with a history of poor appetite and decreased food intake at home. Patients experienced lack of appetite in the initial days of hospital stay which improved later during the stay. Most of the patients who reported alcohol use had been engaging in taking alcohol and skipping meals or eating meals untimely. This was mostly due to the intoxication and also due to the fullness sensation experienced after drinking alcohol and having no time for food. In the case of participant 3 (P3), he stayed alone and had no family members to look after his eating habits. For other patients with heroin or multiple substance use, poor eating habits were present where they would be intoxicated or return home late and skip meals due to the intoxication. The patients who had alcohol use had elevated levels of liver enzyme and associated problems with liver which further might have caused the appetite issues.

Theme 2: Physical health

Infectious disease

Patients with substance use had their physical health status affected due to the engagement in substance use. They were more prone to infectious diseases; two of the patients who were admitted with multiple substance use and heroin use had hepatitis C reactive status. These patients had a history of needle sharing with their friends apart from participant 1 (P1) who used opioid through chasing method. Patients sharing needles also remain at high risk for other infections such as HIV.

Poor health status

The health status of the patients was also found to be poor with complaints of loss of weight mostly due to inadequate food intake before admission. Many of the patients were also thin and emaciated.

Risk for chronic health conditions

Apart from the infectious diseases which two of the patients had, some others, especially those using alcohol, had conditions of liver, namely, fatty liver, organomegaly, gastritis and derangements of the blood profile like increase in GGT, SGOT, bilirubin, low haemoglobin, etc.

Theme 3: Disease related

There were also a number of needs identified related to the disease process such as withdrawal, craving of substances, poor knowledge about the disease process, relapses and poor self-control and increased intake of substance when staying alone.

Withdrawal

Problems of withdrawal were experienced by all the patients in various forms related to the specific substances taken like patients with alcohol use experienced forgetfulness, pain in the extremities, decreased sleep, etc., Similarly, patients with heroin use experienced body aches, decreased sleep, poor appetite, etc., These withdrawals were experienced during the hospital stay and also when the patient previously tried to abstain from substances by themselves.

'Previously when he did not take alcohol for 1 day he went out to the market and fell down… he lost consciousness' (P3).

Craving

Craving for the primary substances was experienced during the initial days of hospitalisation by all the patients; participant 5 (P5) was also heard discussing about heroin with other inmates by his wife. During the later part, most of them reported no cravings for the primary substance but experienced craving for tobacco with instances where P3 was found by his wife consuming tobacco in hiding and participant 2 (P2) stated that he would use tobacco even after discharge.

Poor knowledge on the disease

All participants had poor knowledge on the disease process with initial history of not knowing about the long-term effects of substance and starting substance use and also there was delay in help-seeking. Patients (P1, P2 and P3) had a history of switching to other substances in trying to quit a primary substance.

Relapse and poor self-control

Majority of the patients tried to abstain from substances due to various reasons such as desire to leave substances, health condition and family pressure but relapsed due to various problems such as sleep disturbances, stress and poor self-control and also in a social situation where peers offered substance.

Increase of substance + intake on staying alone

P3 and participant 4 (P4) reported an increase in the amount of substance intake when they stayed alone and amount decreased when they stayed with their families.

Theme 4: Psychological needs

Few of the subthemes identified were tension and stress, substance use for coping, irritability and hiding use from family

Tension and stress

P1 and P4 experienced stressor related to their family responsibilities and work, P4 regarding issues with his previous wife leaving him and son not staying with him. The wife of P4 also stated that the patient was unable to move on and not accepting of what had happened.

'He doesn't try to understand things or his mistakes done and commits it again. He has a habit of taking alcohol and mostly thinks about his son who stays with the previous wife' (P4).

Substance use for coping

Substances were also used as a form of coping and escaping from the situation at hand by few patients (P1 and P4). Substance use increased after fights with girlfriend to relieve the tension (P1) and also to relieve the life stressor experienced and to escape from it (P4). 'if I dint take alcohol these tensions use to come, if I close my eyes it comes more if I open my eyes its less, I take too much stress' 'I started taking substances because of my girlfriend and powder because of the sleep problem' (P1).

Irritability

Patients displayed anger and irritability frequently on intoxication where they would quarrel with the family members on frequent nagging by them. P2, on not getting money for substance use, would quarrel with his mother and on one instance inflicted self-harm. In case of P4 due to the anger on his ex-wife, broke household items such as almirah and TV and demolished the house built by him under the intoxication effect.

'If I take tablet (nitrazepam) I cannot control my mind; in case of heroin I can control, if I take tablet (nitrazepam) I get angry fast and want to say things' (P2).

Hiding use from the family

Most of them experienced various emotions such as embarrassment, shame, guilt and hopelessness and would hide their substance use from family. They tried various techniques such as denying the substance use, returning home late, switching to vodka or other substances which would not emit any odour.

'The person who takes alcohol has no respect, my wife's and my father in law's status get hurt when I am name called' (P3).

Theme 5: Familial needs

A person with an illness and their family are interdependent with each affecting the other. The subthemes identified were burnout and stress of the family members, poor bonding with the family, frequent quarrels and caregiver burden.

Burnout and stress of family members

Most of the caregivers after engaging with the individual taking substance for a long time expressed anger and frustration after their repeated attempts to deter the patient from taking substances. The wife of P3 was frustrated with this cycle of admissions and relapses. The mother of P2 was frustrated and stressed out with all the efforts made and the chaos due to the substance use at home and at times uttered curses. Most of the caregivers would frequently nag the patients and also would give critical comments.

'If he drinks he doesn't get to hear good words from me' 'what I say he doesn't do that' (wife of P3).

Poor bonding with family

Most of the family members stated that the patient would be so engaged to take his substance that spending time with the family became a secondary activity. They would spend less time with their wife and children and also the interaction was poor. 'even if I go to his quarter we don't get to spend quality time together' (wife of P3).

Frequent quarrels

There would also be frequent quarrels of the individual and the family members (sister or brother etc.) with regard to substance use. Furthermore, the patients would be scolded by their family members when they caught the patient taking substances.

Caregiver burden

The caregivers were stressed at their homes and also during the initial stages of the hospitalisation as they could not get rest. The mother of P2 could not get rest for 3 days due to the condition of the patient and the frequent threats of self-harm and attempts which were done in the disoriented state which required for the caregiver to be vigilant. The wife of P5 could not rest due to the aches caused by withdrawal which the patient experienced and so she would spend time massaging his legs and hands. The caregivers also at times had to go in search for the patient to their adda (place of gathering) to bring them back home.

Theme 6: Social needs

The participants with substance use have various social needs and substance use effected their social functioning.

Lack of interest in work

Most of the patients had problems related to their work. The reasons stated include feeling lazy and lacking interest do any work. P1 avoided going to work as others would come to know of his substance use.

'Because of this my situation got worse, I don't have interest to sit in the shop, I have no interest to entertain the customers, and family members are also tensed because of me' (P1).

In the case of P4, he expressed that he would engage in substance use throughout the day and would be lazy to go for his work. He would go and drive his rickshaw for a few hours because of the persistent nagging of his wife to work and even then, would take a share of income for purchasing substances. A meagre amount was handed over to his wife for household expenses. Other patients also had similar problems where during substance use their productivity of work decreased and they had less interest to work. They mostly would work a minimum to earn money for purchase of substances. P3 in contrast expressed that his intake of substances would increase when he had less workload and the use decreased when he was busy at work.

Stigma from the society

Some of the patients tried to hide their use of substance from others in their workplace; P3 had a feeling of shame when he would go to his adda (place of gathering) in the morning and would close the windows of the vehicle. Furthermore, he had experienced some unwelcome expression from his friends and relatives due to his substance use behaviour. 'I don't prefer walking while going in the mornings, I go in an auto, shut the windows or people would be saying he has come again' (P3).

'I had to keep it a secret from others, and my home was feasible for it and people would come to know, so I stopped going to work' (P1).


  Discussion Top


The range of themes that emerged from the assessment illustrates diverse experiences and the various problems the participants face in the long run with substance use. Each case was unique but had some commonalities which emerged as themes. The strength of using a qualitative case study method for this study was that it allowed for a detailed exploration of each individual participant's perspectives and their needs. The results of this study not only show one face of the phenomenon, but also it explores the problem in hand through the various aspects to get a clearer perspective of the issue. The study findings are also in line with and supported by the biopsychosocial model of health.

In this study, patients expressed problems in their sleep and having difficulty sleeping during the stage of detoxification and before hospitalisation. This is supported by a study done by Tripathi where a substantial proportion of male patients had problems in sleep who were on maintenance with buprenorphine.[12] Nurses need to pay attention to the sleep quality in drug users as these may play a role in the recovery process. Magnée et al. also found sleep quality in persons with substance use to be poor.[13] As sleep problem was expressed as a cause of relapse, it is vital to address sleep-related issues in those who are trying to abstain from drug or alcohol use.

Patients had poor appetite and less amount of food intake. Persons using drugs often consider taking drugs to be more important than any other activity and so they spend less time thinking or enjoying having meals which results in skipping meals.[14] Poor appetite apart from intoxication and drug use might also be related to other causes such as having a health condition, poverty and side effects of drugs which is reported in the study by Neale et al.[14] The findings indicate the need for meeting the nutritional need with appropriate dietary planning and improving eating habits for these patients.

Substance use affected the physical health with patients having hepatitis reactive status, loss of weight, issues like fatty liver or organomegaly, etc., A study conducted in London also found that 76% of patients seeking treatment for substance use had at least one physical health problem on admission and the most common were gastrointestinal and liver diseases.[15] Infection control, therefore, becomes a mandate. Substance users, in the course of treatment and follow-up, need to be assessed and treated for potential infections that they are at risk.

All the patients experienced problems of withdrawal and craving. Previous studies also found that many people who were on opioid substitution experienced pain while on maintenance phase and were more likely to report opioid craving.[16],[17] Many of the patients in the present study also craved for tobacco which was assumed as a less harmful substance and also stated that they would take it after discharge. Switching of substances was also seen in the past when patients tried to stop the primary substance of abuse. Findings in a study by Shapira et al.'s study also showed that majority of the participants substituted their preferred substance due to the availability, curiosity, improved or less adverse effects, self-medication and managing of withdrawal symptoms.[18]

Majority of the patients had tried to abstain from the substance use in the past but relapsed later due to various issues such as problem in the sleep, having poor self-control and due to craving, peer pressure associated with craving and due to the family stressors faced. Seyedfatemi et al. found that clients experience multiple psychological, social and behavioural problems which can affect the relapse process and lead to drug re-use or prevention.[19]

It was seen that intake of the substance increased when patients stayed alone and decreased when they were with their family. Many of the participants also tried to hide the use of substance from their families. Bachman et al. also hypothesised that drug use was unchanged when persons using drugs stayed with families and it increased when living in other arrangement involving fewer adults.[20] The presence of family members therefore had a mitigating effect on substance use. This point needs to be considered when counselling family on substance use treatment.

Patients also felt irritability and increased anger mostly when intoxicated. Similar studies also show that most of the family members reported verbal and emotional aggression, physical violence and property damage which were mostly due to substance use.[21]

Substance use affected the families where there would be frequent quarrels with family members regarding substance use, poor bonding amongst the members and spending less time with family. Mc Cann et al. found that anger and aggression often affect the social interactions and disturb family dynamics with times where the children often assume the caregiver role.[21] Furthermore, in this study, the caregivers felt frustrated and burdened due to the repeated relapses and the events leading to hospitalisation. Previous studies also showed that caregivers reported moderate or severe burden.[22],[23] Furthermore, in the initial days of hospitalisation, some of the caregivers could not get rest and sleep due to the condition of the patient. These findings are consistent with a study conducted in India where family members of patients with substance use experienced high levels of stress.[24] In the social and work functioning, patients were mostly engaged in using substances and being intoxicated that they ignored their responsibilities and did not go for work. Can and Tanrıverdi also found an intermediate level of social functioning in patients with SUD.[25]


  Conclusion Top


The study explored the nursing needs of patients with SUD using a qualitative case study approach. The study helped to gain an in-depth understanding of the needs from the perspectives of both patients and their family members. The results were categorised into six themes such as biological needs, physical health needs, disease-related, psychological, familial and social needs. The patient as well as the family members who also suffer from distress needs care. Recovery of a person with substance use can be successful when their overall needs are met and caregivers are thriving and support the patients. These findings can be implemented in daily practice; nursing personnel can provide care to patients with substance use focusing on these specific aspects. Further, interventional studies can be designed with these aspects in mind to see the outcome for both patients and their families.

Limitations

The participants were recruited from a single tertiary care setting of a specific geographical area, thus this study can help in formulation of a basic understanding of the needs of this group of patients. The study is also limited to the male population who have SUD as there were no females admitted with SUD. A study on both the genders will be essential to have broader understanding across genders. Patients with cannabis use disorder were not admitted during the course of the study.

Acknowledgement

The researchers would like to acknowledge the participants of the study for their participation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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