Jun 01, 2013
By Charlene Chu, RN, H.B.Sc., HBScN , Ashley Galang, RN, Bscn

Hospital Nurses' Attitudes toward Patients with a History of Illicit Drug Use

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Illicit drug use refers to regular, long-term illicit consumption of either prescription or non-prescription drugs, such as opiates and narcotics, including the injection of opioids, amphetamines or cocaine (Degenhardt, Hall, Warner-Smith, & Lynskey, 2004). Health-care professionals’ attitudes toward both illicit drugs and the people who use them affect their approach to providing care (Brener, Von Hippel, Kippax, & Preacher, 2010; van Boekel, Brouwers, van Weeghel, & Garretsen, 2013). Patients with a history of illicit drug use require complex care, including frequent hospital admission, as illicit drug use is often associated with various comorbidities, including HIV and hepatitis C infection or mental illness (Fischer et al., 2005). Furthermore, these patients are likely to have been exposed to violence, crime and the sex trade (Kerr & Palepu, 2001), and their mortality rate is increased (Degenhardt et al., 2004). However, despite the established presence of illicit drug use in Canada, studies describing the attitudes of Canadian health-care professionals toward patients with illicit drug use are lacking. Specifically, there is a lack of research focusing on registered nurses in general internal medicine, who frequently work with this population. A baseline understanding of nurses’ attitudes toward patients with illicit drug use may indicate both the quality of the nurse-patient relationship formed and the quality of care provided, as well as identifying aspects of the nursing role that could be enhanced.

Negative attitudes toward patients with a history of illicit drug use can adversely affect the therapeutic nurse-patient relationship, resulting in suboptimal patient care. We examined registered nurses’ attitudes toward patients with illicit drug use (e.g., non-prescription use of opioids and narcotics, use of illicit drugs) admitted to the general internal medicine unit of an urban hospital and attempted to identify nurse-specific and environmental factors influencing these attitudes. The results indicated that nurses had a neutral attitude toward working with patients with a history of illicit drug use, but respondents also had low motivation and role support (i.e., perception of receiving support to fulfil one’s professional role) related to caring for this high-risk population. The authors suggest greater use of organizational tools, such as protocols, consult services and in-services, to address nurses’ clinical concerns and support therapeutic nurse-patient relationships and thereby enhance care delivery.

Nurses routinely provide 24-hour care to patients in hospital. The staff RN role is typically fulfilled at the bedside, where nurses are in frequent contact with patients who use illicit drugs who are seeking health care (Natan, Beyil, & Neta, 2009) and where they face complex clinical and personal situations that require a high level of clinical competence, expertise and skill (Ford, Bammer, & Becker, 2009). The attitudes of health-care professionals working with patients who misuse drugs and other substances have been shown to constitute an important predictor of their willingness to engage with those patients (van Boekel et al., 2013). Conversely, perceptions of discrimination on the part of nursing staff among patients undergoing treatment for drug addiction constituted a significant predictor of whether the patients completed treatment (Brener, von Hippel, von Hippel, Resnick, & Treloar, 2010).

Previous studies have indicated that health-care professionals in general hold a negative view of patients with current or past illicit drug use (Happell & Taylor, 2001; Howard & Chung, 2000), which can contribute to suboptimal care (van Boekel et al., 2013). Furthermore, there is evidence to suggest that nurses have a more negative attitude than other health-care professionals (Howard & Chung).

Several variables may contribute to nurses’ attitudes in this area. In one study, nurses considered the clinical management of patients with drug addiction difficult (Natan et al., 2009), which contributed to their overall negative attitudes. Additional factors, such as anxiety, discomfort and the perception that the patients can control their illicit drug use, have been associated with negative attitudes among health-care professionals who care for patients with a history of illicit drug use (van Boekel et al., 2013), whereas nurses who expressed determination to provide high-quality care to patients with drug addiction had more positive attitudes (Natan et al.). Contextual factors and organizational support, such as policies and procedures related to providing therapeutic and unbiased care, can also play a role in nurses’ attitudes toward patients with illicit drug use (Albery et al., 2003; Ford et al., 2009; National Centre for Education and Training on Addiction [NCETA], 2006).

Negative attitudes can significantly affect the therapeutic nurse-patient relationship, by negatively influencing the provision of care to patients with illicit drug use (Kelleher, 2007). For example, mismanagement and undertreatment of pain are compounded by knowledge deficits and poor attitudes among health-care providers (Portenoy et al., 1997). Similarly, among patients receiving methadone maintenance therapy, perceived discrimination on the part of health-care staff was a major barrier to seeking medical help, both for their substance abuse and for treatment of general and chronic conditions (Nyamathi et al., 2007). Conversely, positive encounters within the health-care system can motivate these patients to seek ongoing medical assessment and treatment for their drug dependency and other health problems (Gorman & Morris, 1991). These patients are seeking non-judgmental and empathetic care, which is crucial in fostering health-seeking behaviours to address acute and chronic health conditions (Nyamathi et al.). As such, it is vital that these patients maintain contact with the health-care system to address their multiple medical comorbidities and mitigate their risk of additional health problems.

Stigmatizing attitudes of health-care professionals toward people with unhealthy drug use are negatively associated with patient empowerment (van Boekel et al., 2013) and can affect treatment outcomes (Brener, von Hippel, von Hippel, et al., 2010). Researchers in various countries, including Brazil, Thailand and the U.K., have reported negative attitudes toward individuals with drug use problems among health-care professionals, such as nurses and physicians (Chan & Reidpath, 2007; McLaughlin, McKenna, Leslie, Moore, & Robinson, 2006; Ronzani, Higgins-Biddle, & Furtado, 2009). Yet to date, there is a lack of research from Canada describing the attitudes of RNs who frequently work with this population. The purpose of this study was to describe the attitudes of RNs toward patients with illicit drug use in a large urban general internal medicine unit and to identify the factors contributing to these attitudes. Identification of existing attitudes will in turn help in identifying gaps in practice, education and research.

Methods
This prospective, cross-sectional survey study was performed in the general internal medicine unit at St. Michael’s Hospital, in Toronto, a major university-affiliated urban hospital. All full-time and part-time RNs employed on the unit were invited to participate. The study investigators, although members of this cohort, did not participate.

Survey instrument. On the basis of Cartwright’s (1980) measure of therapeutic attitudes, we defined therapeutic attitude as a health-care provider’s attitude toward his or her therapeutic role with the patient. Therapeutic attitude is multi-faceted and is shaped by many factors, including demographic influences (e.g., age, gender, setting), commitment to the role (motivation, professional self-esteem) and sense of fulfilment in the role (role adequacy and legitimacy), as well as external variables, such as role support (Cartwright).

To determine nurses’ therapeutic attitude, we used the Drug and Drug Problems Perceptions Questionnaire (DDPPQ) (Watson, Maclaren, & Kerr, 2007), a tool originally developed to measure the attitudes of mental health professionals toward working with “drug users” (defined for our study participants as “patients with a history of illicit drug use”). The pencil-and-paper tool consisted of 20 closed-ended statements. Respondents were asked to indicate the extent of their agreement with each statement or item on a seven-point Likert scale anchored by 1 = strongly agree and 7 = strongly disagree. The questionnaire was divided into five subscales:

  1. job satisfaction (four statements)
  2. role-specific self-esteem, including motivation, work satisfaction and task-specific self-esteem (four statements)
  3. role adequacy, “the sense that an individual has sufficient knowledge of the causes and effects of drug use to enable them to carry out their professional role and to give appropriate information and advice over the short and longer term” (Watson et al., p. 213) (seven statements)
  4. role legitimacy, “the extent to which people regard particular aspects of their work as being their responsibility” (Watson et al., p. 207) (two items)
  5. role support, “the perception that practitioners can access advice readily to help them perform their role effectively” (Watson et al., p. 213) (three items)

With regard to the last of these subscales, the presence of role support enhances nurses’ motivation to work with patients who have illicit drug use, as well as the nurses’ expectations of satisfaction and professional self-esteem when engaging with such patients in the course of therapeutic activity (Watson et al., 2007). According to Ford et al. (2009), role support is related to the availability of colleagues who can help the nurse to formulate a response to personal and clinical issues related to patient care, a key factor in determining therapeutic attitude.

The DDPPQ is considered valid and reliable (Hohman, Finnegan, & Clapp, 2008; Watson et al., 2007). Permission to use this tool was obtained from the primary author of the original study. Demographic data (age, sex, ethnicity, education level) and other factors previously associated with nurses’ attitudes (interest in working with drug users, religion, primary work pattern [day or night shift]) were also collected to allow testing for correlations with DDPPQ scores.

Data collection. The study was advertised in the unit’s newsletter, on posters and through the unit’s electronic mailing list. We also hosted a series of information sessions for both day shift and night shift staff. Three biweekly mail-outs of the survey were completed in fall 2011, coinciding with the distribution of pay stubs. The unit’s administrative assistant distributed the surveys and maintained the master list linking each survey to a participant via a unique identifier. Nurses were instructed to return surveys (whether or not they had completed the questionnaire) to anonymous drop-off boxes in the unit’s nursing stations.

Ethics.Ethics approval for the study was obtained from the St. Michael’s Hospital research ethics board. An information letter was attached to the front of each survey detailing the purpose, methods and potential harms and benefits of the study. Respondents were informed that participation in the study was voluntary. Consent to participate was implied by completion and return of the survey. No identifying information was collected, to maintain participants’ privacy and confidentiality. The survey responses were entered into a password-protected database on a password-protected computer in a locked room. Only the research team had access to the data collected.

Data analysis.Two members of the research team independently entered the data into Excel spreadsheets. Inter-rater reliability of data entry was determined, and any discrepancies identified were addressed by checking the corresponding paper survey. In accordance with instructions for the DDPPQ, participants’ ratings for some statements were reversed, to ensure that a low numeric score on any statement indicated a positive attitude, and a high numeric score indicated a negative attitude. Then, the data were transferred into SAS version 9.1 software for analysis. A numeric value for the primary variable, the respondent’s overall attitude, was calculated from the Likert-scale scores on the DDPPQ. Descriptive statistics (either mean [standard deviation] or median [interquartile range]) were calculated as appropriate for the overall scale and the subscales. Relationships between selected demographic characteristics (sex, age, marital status, religion, ethnicity, education, experience, work schedule) and scores on the DDPPQ were tested with the chi-square or Pearson correlation test and regression analysis, as appropriate. Statistical significance was defined as p < 0.05, to accept a five per cent chance of type I error.

Results
Of the 102 potential respondents, 73 returned a partially or fully completed survey (72% response rate). Inter-rater reliability was high (98%), and all discrepancies in data entry were corrected by examining the original surveys. Of the 73 returned surveys, 59 (81%) had complete demographic information and 44 (60%) had complete DDPPQ responses.

Among the respondents providing demographic information, most were women (53/59 or 90%), and the mean age was relatively low (34.8 years [SD 10.3 years]). The mean duration of nursing experience was 9.3 years overall (SD 9.1 years; range <1 year to 36 years) and 4.1 years on the general internal medicine unit (SD 2.2 years; range 1 month to 25 years). Most respondents (52/59 or 88%) had a baccalaureate in nursing or nursing science. The mean DDPPQ score was 62.6 (SD 15.6), where the maximum possible score was 140 (20 items × 7, the highest per-item numeric score). This score indicates that respondents’ attitudes toward “drug users” were essentially neutral. Furthermore, none of the demographic or other variables were significantly correlated with the DDPPQ score. Notably, the mean scores for motivation (one item; part of the role-specific self-esteem subscale) and for the role support subscale (three items) were relatively high, indicating attitudinal factors with a negative effect on the overall DDPPQ score.

Discussion
Contrary to existing literature, the nurses in the study sample (from a general internal medicine unit) had neutral attitudes toward patients with illicit drug use. This result may be related to the history of this specific hospital setting, which is both academically affiliated and known for its commitment to the care of inner city clients. These attributes may attract nursing staff with similar values (O’Reilly, Chatman, & Caldwell, 1991; Vandenberghe, 1999). In addition, constant exposure to patients with illicit drug use on the study unit may have heightened nurses’ level of confidence and comfort in working with this often-marginalized population, with a resultant increase in empathy and compassion. Alternatively, nurses with no particular attitude toward illicit drug use may have been drawn to the academically affiliated practice environment of the organization.

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Respondents reported low levels of role support for their work with this patient population, a finding consistent with existing literature. Generalist nurses in hospital wards have previously reported struggling to provide care to this patient group, citing inadequate educational preparation (Happell & Taylor, 1999) and poor role support in this clinical work, among other reasons. It would be advantageous for organizations to acknowledge that formal nursing education often fails to provide adequate training for the care of this population (McLaughlin et al., 2006; Rassool & Rawaf, 2008) and to proactively address this deficit by providing supplemental drug and alcohol workplace education and training to minimize misconceptions, stigma and negative attitudes (Kelleher & Cotter, 2009; NCETA, 2006). However, evidence indicates that in order for workplace education to effectively modify the therapeutic attitudes of generalist nurses, support from workplace colleagues to engender empathetic therapeutic attitudes and nurse-patient relationships (i.e., role support) is also necessary (Ford et al., 2009). Furthermore, the development of standard protocols for the identification, management and treatment of patients with illicit drug use (for example, guidelines for documentation and assessment to ensure unbiased treatment) can provide role support to benefit both the nurse and the patient (Kelleher & Cotter, 2009). Other protocols regarding interventions related to illicit drug use can further minimize misunderstandings by communicating an explicit message that highlights the importance of providing equitable, unbiased and high-quality care to all patients, regardless of their personal and medical history.

Further research is needed to address important aspects of this topic. Adding new services, such as an interdisciplinary team of expert clinicians (including nurses) who can act as a drug and alcohol consultation service for nursing staff, has been shown to improve nurses’ attitudes, confidence and perceived knowledge when working with patients with illicit drug use (Happell & Taylor, 2001). However, interventional research regarding the implementation and evaluation of drug and alcohol consult teams in the Canadian health-care system is needed to assess the utility of such a resource in this country. Given that the prevalence of illicit drug use is strongly influenced by regional factors, such as the local economy, health-care system and drug culture, research in various health-care and geographic settings is essential to accurately and comprehensively describe attitudes toward those who use illicit drugs. Lastly, the DDPPQ was initially developed for use with mental health professionals; as such, more research is warranted to develop a measurement instrument that is specific and appropriate for assessing other health-care professionals’ attitudes toward illicit drug use.

Despite the high response rate, some limitations of the current study should be noted. There may have been a response bias because of the sensitive nature of this topic. The sample was limited to the nursing staff of a single general internal medicine unit in Toronto, which limits the generalizability of these findings to other settings. Finally, although the DDPPQ is valid and reliable, it may not have captured the depth and breadth of nursing work in the general internal medicine setting.

Conclusion
Patients with illicit drug use represent a vulnerable population that continues to account for a large number of admissions to general internal medicine units. However, baseline information about nurses’ attitudes toward these patients is lacking for many Canadian cities. The study reported here has begun to address this knowledge gap by describing the attitudes of general internal medicine nurses at a hospital in Toronto. The results indicate that the nurses had neither a positive nor a negative attitude toward patients with illicit drug use, although their scores for individual statements indicated low motivation to work with these patients and a need for more role support. These results suggest a potential need for organizational interventions to support nurses in their work with this clinically challenging patient population. Interventions to increase role support can enable nurses to fulfil their professional role and may thereby positively influence nurses’ attitudes toward patients with a history of illicit drug use. In turn, such positive attitudes will facilitate an appropriate nurse-patient relationship to ensure that this population receives health care that is equitable and empathetic.


ACKNOWLEDGMENT
The authors gratefully acknowledge Caridad Sinajon for her help during data collection, Fran Banfield-Collis for her administrative support, Mary Murphy for her managerial support, Orla Smith for her guidance, the St. Michael’s Research Advancing Practice Program for funding this research opportunity, and all the nurses who responded to the survey.

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Charlene Chu, RN, H.B.Sc., HBScN, is a Phd Candidate In The Lawrence S. Bloomberg Faculty of Nursing and the Institute of Aging at the University of Toronto. She is also a Staff Nurse at St. Michael’s Hospital, Toronto.
Ashley Galang, RN, Bscn, is a Staff Nurse at St. Michael’s Hospital.
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