Inpatient Substance User's Care And Treatment: Innovative Guiding .

Inpatient substance user’s care and treatment: innovative guidingPrinciples for nursesbyGRACE TSHILIDZI RAVHURASubmitted in accordance with the full requirementsFor the degree ofDOCTOR OF PHILOSOPHYin the subjectNURSINGat theUNIVERSITY OF SOUTH AFRICASUPERVISOR: Prof O N MAKHUBELA-NKONDOJanuary 2020

DECLARATIONI Grace Tshilidzi Ravhura, Student Number: 34092412, declare that:INPATIENT SUBSTANCE USERS’ CARE AND TREATMENT: INNOVATIVEGUIDING PRINCIPLES FOR NURSESis my own work, and that all the sources that I have used or quoted have been indicatedand acknowledge by means of complete references, and that this work has not beensubmitted before for any other degree at any other institution.Signature: Date: January 2020ii

ABSTRACTSubstances use is an increasing national concern. Various forms of harmful disordershave also been noted as posing a national health crisis. Against this background, the aimof the study was to explore, identify, describe and analyse inpatient substance addictionand its disorders, and to propose a relevant framework of principles to guide and improvenursing care in this regard.The study adopted a combined mixed-methods research approach involving qualitative,quantitative, using convergent research design in order to maximise both the efficacy ofthe methods and sources of data collection and their concurrent analysis, as well as theeventual findings of the study, which was conducted at three substance addictiontreatment centres in Gauteng Province.The quantitative aspect of the study was facilitated by means of a comprehensive reviewand analysis of admission records belonging to 244 substance addicted inpatients at oneof the selected three treatment centres. The quantitative variables reflected in theadmission records represented the entire range of sociodemographic, help seeking,substance abuse history, family support, and medical and psychological characteristicsof substance abusers. On the other hand, the study’s qualitative aspect was facilitated bymeans of three (3) unstructured in-depth focus groups with selected nurses providingcare to inpatient people addicted to substances. An investigation of 5 (five) inpatienttreatment programmes at the self-same three treatment centres complemented thequalitative aspect of the study.For the majority cases of occurrence/ frequency at the treatment centre from which 244admission records were obtained, the quantitative findings revealed, among others, thatthe majority of inpatients (n 224, 91.8%) were Blacks; single (n 223, 90%); at secondaryschool (n 207, 84.8%); unemployed (n 232, 95.1%); with the heroin as the most abusedsubstance by 88.9% (n 217) inpatients followed by cannabis (n 205, 83.6%). The mostcritical of these variables was that the majority of the inpatients (n 74, 30.5%) were thosewho had been substance abusing for 7-10 years. The implication is most young peoplewere the most at-risk group as they started substance abuse during the adolescent stagesof their live, which increased the chances of progressing to substance abuse disordersand poor mental health.iii

Meanwhile, the qualitative findings derived from the focus group discussions with thenurses and the five treatment programmes yielded five focal themes and associatedmultiple sub-categories. These principal/global themes are: psychological and emotionalimpediments to inpatient care; attitudes of patients’ relatives; quality of care by nurses tosupport inpatients; nurses’ attitudes; and challenges experienced by nurses. Collectively,both the quantitative and qualitative findings indicate that substance abuse disorder is acomplex and multifaceted physiological and psychosocial challenge for both the sufferersand society as a whole. For its management and treatment, nurses should be adequatelytrained, and multi-professional teams should be part of a concerted and dedicated effortto provide care and eradicate the problem convincingly.The study envisages that its recommendations will contribute towards effective policydevelopment and implementation based on a viable framework of inmate substanceabuse guidelines to innovatively guide nursing care and management of substance abusetreatment centres. Such innovation should incorporate continuing professionaldevelopment guidelines for different categories of nurses to enhance their skills and alsoimprove knowledge on mental health implications as well.Key words: guiding principles, inpatients, treatment, socio-Demographic, Addictionnursing, Substance Use Disorder, Substance Use care and treatmentiv

DEDICATIONThis work is dedicated with love and appreciation to the following: All those who need love, the orphaned, and the indigent widows, sons and daughtersof love for availing themselves to help others; and to those who always look aroundto find someone in need of help and avail their help. May God bless them richly! In memory of my late mother, Mukanangalwo Josephinah Nepfumbada, for doing herbest to ensure that my brothers and I went to school supported only by her disabilitygrant and some money from the jerseys she knit and sold. Whenever I face thechallenges of life, I always remember her courage. Despite her physical challenges,she always pulled through. May her soul rest in peace!v

ACKNOWLEDGEMENTSFirst and foremost, I thank Almighty God for making it possible for me to complete thisstudy. His joy has always been my strength.I also express my sincere appreciation to the following people for helping and supportingme directly and indirectly: My supervisor, Professor O.N. Makhubela-Nkondo, for her encouragement,motivation, guidance and not giving up on me during hard times. The Gauteng Department of Social Development (GDSD) and all participants, fortheir co-operation and allowing me to conduct the study at their facilities. Dr TJ Mkhonto, for editing my thesis. Ms Refilwe Matatiele, for her assistance with Turnitin registration and other libraryrelated matters, and the late Cathy Lekganyane for her library skills. Dr Surge for helping with qualitative data analysis. My husband, Thanyani Gerson Ravhura, for his continuous support, and for alwaysbeing the wind beneath my wings. My children Ronewa, Thanyani, Gundo and Mukonazwothe, for their understandingand support, and for allowing me to accomplish my goal and remain their role model.I will never forget the back and leg massages I continuously received after longperiods of fieldwork-related travelling, and during my research report writing. I haveset a standard they can look up to. My grandmother, Mrs Nyamukamadi Annah Khubana and my mother in law MrsSophia Mpfunzeni Ravhura for their prayers and encouragement. My family and brothers, Tshenani and Mulalo. I will always be grateful to theirunwavering support, prayers and encouragement. My aunts and uncles for their prayers, support and encouragement My colleagues: Nneke Ramaloko for her IT expertise, and Brenda Ramabu for herdata capturing assistance. Their immeasurable support was not in vain. Professor Mavhandu-Mudzusi for all the indefatigable motherly support. Dr Kisaka for her advice and teachings. My brothers Fholisani and Phathutshedzo, for driving me and assisting with therequisite logistical preparations during the data collection.vi

LIST OF ACRONYMSAIDSAcquired Immune Deficiency SyndromeAPAAmerican Psychiatric AssociationARVAntiretroviralCBICognitive Behaviour InterventionCBTCognitive Behaviour TherapyCMContingency ManagementCNSCentral Nervous SystemDSM-VDiagnostic Statistical Manual of Mental Disorder 5th editionDSDDepartment of Social DevelopmentDUDsDrug Use DisordersEMCDAEuropean Monitoring Centre for Drugs and AddictionFTFamily TherapyGSTGeneral Systems TheoryHIVHuman Immune VirusHOIHead of InstitutionICD 10International Classification of DiseaseINBRInternational Narcotics Board ReportMDTMultidisciplinary teamMECMember of Executive CommitteeMETMotivational Enhancement TherapyMIMotivational InterviewMMMixed MethodsNHANational Health ActNIDANational Institute on Drug AbuseRHTRefusal of Hospital TreatmentOSTOpioids substance TherapyQOLQuality of LifeSASubstance Abuser/sSACENDU South African Epidemiology Network on Drug UseSADHSSouth African Demographic and Health SurveySASHSSouth African Stress and Health SurveySBIRTScreening Brief Intervention and Referral to TreatmentSIDSubstance Induced DisorderSIMDSubstance Induced Mental DisorderSRDSubstance Related DisorderSTIsSexually Transmitted InfectionsSUDSubstance Use DisorderTBTuberculosisTSFTwelve Step FacilityUNISAUniversity of South AfricaUNODCUnited Nations Office on Drugs and CrimeWDRWorld Drug ReportWHOWorld Health Organisationvii

ContentsDECLARATION . iiABSTRACT . iiiDEDICATION.vACKNOWLEDGEMENTS . viLIST OF ACRONYMS . viiCHAPTER ONE: OVERVIEW OF THE STUDY .11.1 INTRODUCTION AND BACKGROUND .11.1.1 Magnitude of Substance Abuse and Required Responses .21.2 STATEMENT OF THE RESEARCH PROBLEM .41.3 RATIONALE AND SIGNIFICANCE OF THE STUDY .51.4 RESEARCH AIM/ PURPOSE AND OBJECTIVES.61.4.1 Research Aim/ Purpose . 61.4.2 Research Objectives . 71.4.3 Research Questions. 71.5 DEFINITION OF KEY CONCEPTS . 71.6 THEORETICAL PERSPECTIVES . 91.6.1 Selected Theories . 101.7 RESEARCH DESIGN AND METHODS . 111.7.1 Merging of Quantitative and Qualitative Research . 111.8 DATA COLLECTION AND ANALYSIS . 111.9 THE SAMPLING CONTEXT . 131.10 ETHICAL CONSIDERATIONS . 141.10.1 Permissions and Approvals . 141.10.2 Voluntary Participation . 141.10.3 Informed Consent. 151.10.4 Privacy, Confidentiality and Anonymity . 151.10.5 Autonomy. 161.10.6 Beneficence . 161.11 SCOPE OF THE STUDY . 161.12 LAYOUT OF CHAPTERS . 171.13 CONCLUSION . 19CHAPTER TWO: LITERATURE REVIEW . 202.1 INTRODUCTION . 202.2 MANIFESTATION OF SUBSTANCE USE AND ADDICTION . 212.2.1 The Extent/ Magnitude of Substance Addiction . 212.2.2 Stages of Substance Addiction . 232.2.2.1 Experimentation. 232.2.2.2 Recreational. 242.2.2.3 Harmful use . 242.3 SUBSTANCE RELATED DISORDER . 242.3.1 Substance Use Disorder . 252.3.1.1 Severity of substance use disorder . 262.3.2 Substance Induced Disorder . 272.4 A GLOBAL PERSPECTIVE OF SUBSTANCE ABUSE . 282.4.1 Effects of Substance Use Disorder . 29viii

2.4.1.1 Biological effects. 292.4.1.2 Psychological effects . 302.4.1.3 Social effects . 312.4.1.4 Effects on the individual . 312.4.1.5 Effects on the family . 312.4.1.6 Effects on society . 322.5 TREATMENT OF SUBSTANCE USE DISORDER . 322.5.1 Treatment of Biological/ Biomedical Symptoms . 342.5.2 Treatment of Psychological Symptoms . 352.5.3 Treatment of Social Symptoms . 352.5.4 Treatment of Spiritual Symptoms . 352.6 INPATIENT SUBSTANCE USE DISORDER TREATMENT . 362.6.1 International Standards of Inpatient SUD Treatment . 362.6.2 Treating Factors of Substance Use Disorder. 372.6.2.1 Treatment setting . 372.6.2.2 Intensity and duration of treatment . 372.6.2.3 Methods of treatment provision . 382.6.2.4 Components of treatment . 382.6.3 The Inpatient Treatment Process . 382.6.3.1 Intake and screening . 392.6.3.2 Assessment . 402.6.3.3 Treatment plan . 402.6.3.4 Treatment modalities . 412.7 SUBSTANCE USE IN THE SOUTH AFRICAN CONTEXT . 422.8 NURSING AND SUBSTANCE ADDICTION . 442.8.1 Nursing Care . 452.8.2 Holistic Nursing in Substance use . 482.8.2.1 The systems context of nursing . 492.8.3 The South African Nursing Council Perspective on Caring for Substance useInpatients . 502.9 CONCLUSION . 52CHAPTER THREE: THEORETICAL FRAMEWORK . 533.1 INTRODUCTION . 533.2 AETIOLOGICAL MODELS AND THEORIES OF ADDICTION . 533.2.1 General Systems Theory . 543.2.2 Physiological/ Biological Theories . 553.2.2.1 Biological perspectives . 563.2.3 Psychological Theories . 563.2.3.1 Psychological perspectives . 573.2.4 Socio-Cultural and Environmental Theories . 573.2.4.1 Social perspectives . 583.2.5 The Spiritual Theories . 583.2.5.1 Spiritual perspective . 593.2.6 Bio-Psychosocial Spiritual Model . 593.2.7 Reflective Choice Model . 613.3 CONCLUSION . 61CHAPTER FOUR: RESEARCH DESIGN AND METHODS . 624.1 INTRODUCTION . 62ix