**4. Themes**

The reviewed literature revealed that there are six (6) themes that the nurses use as their coping strategies when caring for MHCUs who are diagnosed with SUDs namely nurses' resilience, peer support, management support, strengthening the multidisciplinary team (MDT) approach, open-door policy as well as education and training. The themes and sub-themes are given in the following **Table 1**:


**Table 1.** *Themes and sub-themes.*

### **4.1 Nurses' resilience**

It is clear from the introduction of this chapter that nurses deal with challenges in their working environment, especially those that are working at mental health establishments, or those who are caring for MHCUs who are diagnosed with SUDs. In this case, we strongly believe that nurses need to strengthen their resilience. Nurses who manage to cope and in some instances even grow in the face of omnipresent stressful experiences are described as resilient [16]. Resilience refers to a person's capacity to withstand or recover quickly from difficult conditions [16]. The same study also refers to resilience as qualities of both the individual (internal protective factors) and the environment (external protective factors) that could support positive development [16]. We also have a strong view that nurses should use both the internal and external protective factors of resilience in order to cope when caring for MHCUs who are diagnosed with SUDs. Resilience can also be defined as the ability of people to adjust to unfavourable conditions in a positive way, and bounce back from hardships and overcome negative life experiences [17]. It is clear from the information, particularly in the introduction that nurses caring for MHCUs who are diagnosed with SUDs are working in unfavourable conditions. However, they should be able to view that situation in a positive way and overcome their negative life experiences of MHCUs diagnosed with SUDs. Most of the nurses when they care for MHCUs who are diagnosed with SUDs feel angry, demotivated and dissatisfied. This resulted in some of the nurses choosing to leave South Africa in search of greener pastures [18]. Based on the above information, nurses need the opportunity to develop resilient attributes in their different specialist areas [18], particularly in the area of mental health and SUDs. Coping skills increase resilience [12].

#### **4.2 Peer support**

Peer support has been mentioned in several studies as nurses' coping strategy when caring for MHCUs diagnosed with SUD [1, 11]. Workplace support provided by peers or colleagues and the organisation is of major importance in the direct delivery of nursing care as a lack of teamwork can compromise patient care [18]. However, it should also be noted that relying on support from outside the workplace can also play an important role in the ability of nurses to cope [18], particularly when they care for MHCUs who are diagnosed with SUDs. Having collegial support from other nurses and interprofessional team members is recommended to manage uncertainty [1]. A qualitative study recently conducted in the NWP found that nurses do not collaborate with one another and as a result, they are unable to deliver quality care to MHCUs diagnosed with SUD. The above information highlights the gap that, it is imperative that nurses have role support which includes the presence of supportive, knowledgeable colleagues with whom to collaborate and gain expertise in practice [1].

#### **4.3 Management support**

Management support is one of the strategies that nurses use when caring for MHCUs diagnosed with SUDs as shown in several studies [1, 11, 19]. Participants of a qualitative study that was conducted in 2016 in the NWP of SA indicated that it would be good if the nurses were supported and motivated by their own management [11]. Nurses mentioned in a study conducted in New Jersey that they have no problem of

### *Nurses' Coping Strategies When Caring for Mental Health Care Users Diagnosed with Substance… DOI: http://dx.doi.org/10.5772/intechopen.107034*

caring for MHCUs diagnosed with SUDs for as long as the MHCU load or nurse-topatient ratio is not too much because these MHCUs can be a handful at times [1]. This shows that the sooner the management supports the nurses by addressing the issue of nurse-to-patient ratio, the better the client outcome and the nurses' improved coping. Strengthening the prevention and treatment initiatives for addressing SUDs requires direct effort and partnership from employers (management), healthcare practitioners and researchers [19]. Managers and supervisors should create learning opportunities with the sole purpose of empowering nurses with relevant skills in providing care to mental health care users [18]. Health care practitioners should work collaboratively with the management of the mental health care institutions where they are working. The researchers should conduct more research that is aimed at assisting the nurses to cope better when they care for MHCUs who are diagnosed with SUDs.

#### **4.4 Strengthening the multidisciplinary team (MDT) approach**

Several studies mentioned strengthening the multidisciplinary team (MDT) approach as one of the strategies used by nurses who are caring for MHCUs diagnosed with SUDs [1, 8]. Nurses in collaboration with other disciplines have collective power to achieve more [10]. Two people are better off than one. Multidisciplinary team (MDT) approach is effective in caring for MHCUs who are diagnosed with SUDs. MDT approach consists of nurses, psychiatrists, pharmacists and dieticians who play a unique role in treating MHCUs who are diagnosed with SUDs [8]. For the purpose of this chapter, we suggest that the word mental health care practitioners be used to refer to MDT. According to the Mental Health Care Act 17 of 2002, mental health care practitioners also include psychologists, social workers and occupational therapists, who have been trained to provide the prescribed mental health care, treatment and rehabilitation services [14], including the care of MHCUs who are diagnosed with SUDs. Both collaboration and support with nurses and interprofessional colleagues will help manage the challenges in care and possibly mitigate the uncertainties in caring for this increasingly common patient population [1].

#### **4.5 Open-door policy**

Open-door policy is mentioned in the literature as one of the effective strategies used by the nurses who are caring for MHCUs diagnosed with SUDs. The practice of restricting the freedom of MHCUs who are diagnosed with SUDs by locking the doors of mental health care units is highly questionable [20] because everyone has the right to freedom of movement [21]. All MHCUs especially those who are diagnosed with SUDs are also protected by this right. The introduction of an open-door ward policy can reduce coercive measures like unnecessary seclusions, involuntary care, treatment and rehabilitation services, as well as incidents of aggression [20]. As a result, authors of this chapter advocate for open-door policy for all MHCUs who are diagnosed with SUDs. This will be in line with Section 21(1) of the Constitution of the Republic of South Africa (RSA) which states that "everyone has the right to freedom of movement. However, it should be noted that the MHCUs who are violent, aggressive, suicidal or homicidal, meaning those who are dangerous to themselves, or other people may be admitted involuntarily or be secluded. This is normally done after prescription by the medical doctor. The main reason for admitting these MHCUs is to protect them and other people such as families and health care practitioners. In this case, it does not mean that the MHCU's rights are violated, this is done to protect them.

#### **4.6 Education and training**

Many studies show that education and training play a major role for the nurses who are caring for MHCUs diagnosed with SUDs [1, 6, 11]. However, literature shows that some nurses do not have the necessary training and education for proper care, treatment and rehabilitation services for MHCUs who are diagnosed with SUDs. For instance, the nurses mentioned in a qualitative study that was conducted in the North West Province (NWP) of South Africa that they were taught at the university or the colleges how to care for, treat and rehabilitate MHCUs who are diagnosed with SUDs. However, the nurses maintained that caring, treating and rehabilitating an MHCU diagnosed with SUDs was not dealt with in greater detail [11]. The authors of this chapter are in agreement with this statement because substance use is presented like any other topic. There is no emphasis on it. Knowledge, skills and experience play a role in the nurses' ability to cope while providing mental health care [18]. Continuous workshops should be done for the nurses to help them deal effectively with the addicted MHCUs [12].

Another important study was conducted by two scientists from Kean University in New Jersey. The findings of the study indicated that nurses reported a lack of knowledge specific to mental disorders and SUD issues and reflected a disconnect in their ability to care for MHCUs with both physiological and psychiatric disorders [1]. The same study continues to mention that for the nurses to cope effectively with the MHCUs who are diagnosed with SUDs, nursing education programs should be created to assist nurses in developing skills in articulating and managing their uncertainty and to use evidence to guide practice [1]. This means that Nursing Education Institutions (NEIs) should also be part of the fight against SUDs.

A mixed methods study was conducted in Nigeria on the *Forex Index and Substance Abuse among Psychiatric Patients*. The findings of the study indicate that the staff in mental health care institutions including the mental health nurses should be trained on techniques of screening and detecting the use of psychoactive substances as well as on how to successfully rehabilitate MHCUs who are diagnosed with SUDs [6]. Education focusing on assessment, prevention and interventions to prevent violence and aggression, should be addressed in educational offerings, both in academia and in the clinical environment [1]. In addition, when the nurses are properly educated and trained on how to care, treat and rehabilitate MHCUs who are diagnosed with SUDs, they will be able to teach MHCUs about the dangers of substance abuse, including but not limited to the psychological and physical effects; the damage to relationships and family lives; and the impact on meeting basic needs such as holding down a job. These nurses who are well trained will also educate the MHCUs regarding treatment options, including those they can use on either an inpatient or outpatient basis and those they can use to stay substance-free long-term. The nurses might also educate MHCU's family members about what to expect from the rehabilitation process and how they can support their loved one's attempt to conquer addiction to the substances.
