Critical to this issue of patient care quality and safety is the rising incidence of comorbid drug and alcohol abuse among hospitalized patients.1 The World Health Organization reported that there were 2 billion alcohol users and 185 million drug users worldwide in the general population.2 Consequently, there has been a substantial rise in the addiction disorders in the hospitalized population with an estimate that 20% to 50% of hospitalized patients manifest addiction disorders.3 A paucity of research has been conducted on the perceptions of nurses who provide care to hospitalized patients with substance abuse/dependence.3 With the incidence of illicit substance abuse/dependence on the rise1 and the presence of unknown addictions being a frequently identified issue in contemporary nursing practice,4 there exists the need to further explore nurses’ perceptions regarding caring for this challenging patient population as systems and processes are developed to support safe and quality care delivery.
The purpose of this exploratory research was to investigate RN perceptions of caring for hospitalized medical-surgical patients with the comorbid conditions of substance abuse/dependence.
Lovi and Barr5 conducted a phenomenological study to explore the experiences of RNs working in a substance abuse unit. In interviews with 6 nurses, the following major themes emerged: inappropriate judgment, advocacy, and need for further education. A key finding was that nurses believed that despite how commonplace patients with substance abuse/dependence are, stigma directed toward this population remains.5 Nurses reported instances of “inappropriate judgment such as falsely blaming patients with abuse/dependence on missing or damaged items or the belief that because abuse/dependency was self-inflicted these patients should not receive hospital care.5(p171) Despite stigma being reflected through their interviews, nurses acknowledged the importance of their role as patient advocates and in the delivery of effective care and interventions, privacy, and safety. Nurses in the study also conveyed disappointment in their identified lack of knowledge regarding the role of nurses in dealing with substance abuse/dependence, “as well as the ongoing attitudes that sustain the stereotypical image of people with dependence and how they act.”5(p172)
Ford et al6 conducted a large-scale multivariate study to investigate the determinants of nurses’ therapeutic attitude to patients who abused drugs and to examine effective strategies for workforce development. One thousand six hundred five nurses completed a modified form of the Alcohol and Alcohol Problems Perception Questionnaire7 to measure therapeutic attitude, the Disapproval of Drug Use Scale8 to assess nurses’ attitudes to illicit drugs, personal characteristics (age, sex, educational level, religious affiliation, church attendance, and personal use of substances), and the professional practice factors of basic role requirements and workplace factors. Basic role requirements consisted of 3 components: role support, the number of hours of drug and alcohol education and how recently nurses received this training, and 3rd, experiences with this patient population.6(p2454-2455) Role support was operationalized by 3 items6: the assessment of nurses’ perceptions of having supportive others to confer with regarding patient difficulties and clarification of professional responsibilities and determination of the best practice for this complex population. Workplace factors referred to nurses’ practice group, years of experience, current work status, and whether nurses practiced in the private or public sector.6 The majority of nurses were female, employed in medical-surgical settings, baccalaureate prepared or higher, Christian, and involved in direct patient care in the public sector.6 Nurses reported that their drug and alcohol education was scarce, with “only 22% reporting workplace education in the preceding 12 months.”6(p2467) Nurses’ personal characteristics were not associated with therapeutic attitude, and while nurses’ attitudes to illicit drugs were related to therapeutic attitude, it did not account for a significant proportion of variance (<1%) in therapeutic attitude.6 Therapeutic attitude was conceptually defined as the nurses’ intention to engage with the patient.6,7
In this same study,6 multivariate regression analysis revealed that 53% of the variance in nurses’ therapeutic attitudes was explained by the professional practice factors of role requirement and workplace factors. The most important factor identified was role support. In this study, nurses conveyed that having someone to collaborate with, including the generation of a plan of patient care, was the strongest factor related to therapeutic attitude; yet in this study, 44% of the nurses reported not having role support.6 Drug and alcohol education alone was not associated with therapeutic attitude. However, when 10 hours of drug and alcohol education was combined with role support, the authors reported “an impact on therapeutic attitude of 17.2%.”6(p2460) A model of hypothetical workforce initiatives incorporating both education and role support was then developed. Ford et al6 concluded that in order to help nurses improve care for patients with substance abuse/dependence, attention should focus on the professional preparation and support of nurses.
In a follow-up study using the same sample, Ford et al4 concluded that providing better alcohol and drug education alone to nurses was not enough to improve nurses’ attitudes toward patients who abuse alcohol and use illicit drugs. Ford4 reported that “Only in the presence of moderate to high levels of role support can workplace drug and alcohol education facilitate nurses’ therapeutic attitude.”4(p116)
Using an inductive approach to learn more about how nurses perceive working with medical-surgical patients with the comorbid condition of substance abuse/dependence, a qualitative approach using subjective data from a descriptive, nonexperimental study investigating nurses’ attitudes toward suicide in hospitalized patients9 was used in this study. Recognizing that patient comorbidities with substance abuse/dependence substantially increased suicide risk in physically ill patients,10 2 additional qualitative questions were posed and are being reported. Because of the exploratory nature of this investigation, research questions were identified from gaps in the literature regarding nurses’ perceptions of caring for patients with physical illness and concomitant substance abuse/dependence. Nurse experts and advanced practice nurses in adult health provided content validity to the following questions: (1) What are your thoughts and feelings about working with patients with substance abuse and/or dependence issues in the hospital settings? (2) How does caring for a patient with substance abuse/dependence influence your nursing care provided to hospitalized patients?
After receiving institutional review board approval from the academic institution and the community medical center in which the study was conducted, using a convenience sample, the subjective data of nurse participants (n = 24) practicing on 5 inpatient units were collected. The units consisted of 3 adult medical-surgical units, a neurological-orthopedic unit, and an oncology unit of a community medical center located in the northeast corridor of the United States. No specific addiction unit or service existed within this community medical center. Identification of substance abuse/dependence was either identified by patient history or medical records or undetected at time of admission.
During a routine staff meeting, the study was introduced to potential nurse participants by the co–principal investigator, and a letter of introduction provided an explanation regarding the purpose and nature of the study, voluntary provisions, confidentiality, and right to withdraw at any point during the conduct of the study. Potential nurse participants were informed that completion of the data collection instruments would take approximately 15 minutes. Using an implied consent form, data were confidential, no names were used, and only the principal investigators had access to the data. Although no names were used, the study was confidential and not anonymous because of the possibility that demographic information might enable the principal investigator to identify nurse participants based on their clinical demographic information provided, such as age, ethnicity, unit worked, and so on. The co–principal investigator was available to answer any questions and to provide a debriefing if necessary. After introduction of the study, nurse participants were provided privacy in a staff conference room and were instructed to return the completed questionnaires in a secure sealed envelope to the nurse investigator. Twenty-four nurses practicing on inpatient units responded to the 2 research questions in writing, providing details regarding their perceptions of caring for patients with substance abuse/dependence.
The nurses responding to the questions in this study were predominantly female (96%; n = 23), baccalaureate prepared (83%; n = 20), with an additional 4 nurses holding an associate degrees or a diploma in nursing. The racial background of participants was relatively homogeneous with predominantly white nurses (n = 17), and the remainder of nurses were of Asian (21%; n = 5) or American Indian or Alaska native descent (8%; n = 2). The ages of nurse participants were varied, with 10 nurses ranging from 20 and 40 years of age, 6 nurses between 41 and 50 years of age, and 8 nurses between 51 and 55 years of age. The majority of nurses held substantial experience ranging from 11 to 30 years of experience (75%; n = 18), 3 nurses had 6 to 10 years of experience, and only 3 nurses with less than 5 years of nursing experience.
Although data saturation was not used to determine sample size because the original study used a descriptive, correlational design, substantial responses yielded similar patterns. Constant comparative analysis via coding of categories was used for the generation of common patterns or themes. To support the credibility of the themes generated, nurse experts in research methodology and clinical practice were given access to the subjective statements and shared their interpretation of findings with consensus reached regarding the patterns identified in this study. The 4 patterns identified in response to the 1st question were as follows: ethical duty of care, negative perceptions of caring for patients with substance abuse/dependence, need for education, and sympathetic concern for working with patients with substance abuse (Table 1). The 1st theme, ethical duty of care, was identified and conceptually defined as the delivery of nursing services using advocacy, compassion, and understanding to provide equitable care without regard to the nature of a patient’s health problems. The following statement from 1 participant exemplifies the ethical duty of care:
Substance abuse, as in any other medical illness, is a disease, and patients undergoing or diagnosed with the disease are deserving of optimal care and treatment.
The 2nd theme identified in response to the question, “What are your thoughts and feelings about working with patients with substance abuse/dependence issues?” was negative perceptions toward caring for patients with substance abuse/dependence. This theme represented the majority of responses regarding nurses’ perceptions in working with this population. The following statements and those identified in Table 1 clearly articulate nurses’ negative perceptions and opinioned difficulties in providing care to patients with substance abuse/dependence. Statements reflected intolerance, anger, and the demand of patients with substance abuse/dependence necessitating greater attention and nursing care:
I have no tolerance for substance abuse patients. They are manipulative and needy and drug seeking and take time away from other patients who are really physically sick and dependent on my nursing care.
Working with patients who abuse drugs and alcohol makes me very angry.
In addition, a key element in this theme was the nurses’ perception of being manipulated or distrusting of these patients, as expressed in their statements:
As a healthcare provider, you always have to have your guard up because substance abuse patients are very good at manipulating people and events to their benefit.
I find these patients are manipulative and require frequent monitoring.
Another identified challenge to the provision of care contributing to nurses’ negative perceptions toward this patient population pertained to safety. Safety was a paramount nursing concern. Statements of fear and apprehension and reporting a need to protect themselves from physical harm were stated. Nurses reported that patients could be aggressive and potentially threatening, thus providing a rationale for the negative views of some nurses toward caring for these patients. For example:
As for ETOH abuse, I tend not to bother them much, since I am afraid of sudden outbursts.
When I have patients with substance abuse, it increases my stress because there are more safety issues to worry about, and patients can be aggressive.
I do not feel comfortable working with these patients.
However, despite being cognizant of the obvious and potential safety hazards and risks for harm, patient care and their ethical duty of care remained a primary concern. Nurses perceived an element of danger in carrying out professional responsibilities. Despite these safety concerns, nurses’ professional responsibility and accountability prevailed in the delivery of comprehensive, holistic patient care. One nurse cited:
Nurses inherently, as part of their role, take on responsibilities in light of safety hazards; it is 2nd nature.
Importantly, safety issues pertained not only to nurses themselves but also to their patients.
Sometimes giving nursing care is challenging. If your patient is intoxicated or under the influence, he/she has trouble being logical or remembering safety instructions. I find these patients often need a 1:1 watch for safety reasons, and when that isn’t available, it is challenging. It is hard to be attentive to your other patients and aware that your patient who is under the influence could climb out of bed and fall.
Although less prominent, the theme, need for education, was identified by several nurses. Nurses reported that caring for patients with substance abuse/dependence, as well as general psychiatric disorders, reflected a specialized body of knowledge, for which they were unprepared and lacking in knowledge. They also described the need for additional supportive services for themselves as well as their patients from highly specialized psychiatric and substance abuse/dependence professionals. The following statement and those in Table 2 highlight these concerns:
I don’t have enough training in this area to be comfortable taking care of these patients.
These statements are consistent with the literature, albeit scant, substantiating a described lack of preparation and knowledge on the part of nurses, in dealing with patients with substance abuse/dependence.
The last theme identified from the question, “What are your thoughts and feelings about working with patients with substance abuse/dependence issues?” deals with nurses possessing sympathetic concerns for their patients and family members. Unlike empathy, characterized by feelings with an individual, expressions of sympathy were evident by nurses, conveying how they felt concern for their patients and families facing substance abuse/dependence (Table 1).
Responses to the 2nd question in this study, “How does caring for patients with substance abuse/dependence influence your nursing care?” revealed the similar themes of ethical duty of care and negative perceptions toward caring for patients with substance abuse/dependence (Table 2). In addition to nurses’ ability to remain professional and to adhere to the ethical duty of care despite appropriate concerns, nurses’ responses to the 2nd question revealed highly similar responses to the 1st question. Negative perceptions toward patients with substance abuse/dependence in regard to recidivism and mistrust were noted. For example, nurses stated:
It can be very frustrating because we see these patients over and over again. We put a lot of time and effort into their care, and they frequently come back in the same situation.
It is really hard to believe them sometimes; hard to know if they are telling the whole story.
However, the additional theme of incongruence in assessment of pain and need of analgesics emanated from the voices of these nurses, reflecting the dissonance between their professional assessment and the patient’s requests and/or demands for analgesia or medical orders (Table 2). Furthermore, exposure to patients with substance abuse/dependence may influence how nurses viewed pain management, not only for individual patients, but also for all patients in general. The following quote exemplifies this perception:
Seeing people with narcotic addiction has affected my view of patients who really are in pain and in need of pain medication for relief. Now I question anyone who constantly asks for pain medication.
In addition, nurses conveyed their ambiguity in assessment of pain and need for analgesics because of suspicions regarding the truth of their patients’ pain and how nurses’ actions may impact substance abuse/dependence issues in patients. One nurse stated:
It sometimes makes me more suspicious of their needs for pain medication. It makes me feel like I am contributing to the problem.
Many of the themes identified in this study are consistent with the scarce but growing literature on the issues and challenges that nurses increasingly face with the increasing incidence of alcohol and drug abuse/dependence in hospitalized patients on medical-surgical units.
As seen in the subjective data of nurses in this investigation, 2 open-ended questions soliciting perceptions about caring for patients with substance abuse/dependence yielded poignant portrayals of the daily experiences of nurses in practice. These statements represented a broad category of challenges of care and addressed many aspects involved in their care, such as fear, safety, frustration, lack of education, and the perception of being manipulated.
Safety was an appropriate concern for nurses as reported in this study. According to the International Council of Nurses,11 nurses face more dangers than either policemen or prison guards. While a culture of safety has been well established for patients, further attention to protecting and instituting safety measures for nursing personnel is warranted.
Caring for patients with substance abuse/dependence is challenging for nurses and deemed taxing as nurses reported that these patients were demanding and untrustworthy. Nurses frequently described being manipulated. In addition, some nurses reported a sense of futility in providing care to recidivist patients at the expense of caring for other patients. These findings are consistent with a systematic review12 identifying that, in general, healthcare personnel possess negative attitudes toward patients with substance abuse/dependence issues due to the perception of these patients as manipulative, rude, aggressive, and unsafe.
Although manipulation, defined as patient behaviors that attempt to influence or control others to obtain one’s own selfish gain13 was frequently cited by nurses in this study, evidence of the delivery of compassionate, professional care was expressed through statements of nurses’ ethical duty to care. The nurses in the sample reported that they feel they were serving as a patient advocate and were providing objective, nonjudgmental provider care. These findings are consistent with the literature identifying that advocacy for patients with substance abuse/dependence problems remained a priority for nurses.5
A strong theme expressed was the incongruence in assessment of pain and pain management. Nurses expressed a disparity between their own professional assessment of patient needs, particularly when determining need for analgesia versus prescribed orders and patient demands. Nurses reported acquiescing to patient demands and possibly contributing to further patient dependency, despite their nursing judgment. The discrepancy between acknowledging pain as whatever a person says it is and a nurse’s observation of pain as different from the patient’s reporting represents a moral conflict. Unresolved, this conflict can contribute to moral distress in nursing and compromised patient care by enabling further patient dependence.
Quandaries in care for the patient with a substance abuse/dependence problem may be viewed by nurses as “navigating the ethical gray area of practice” and represent uncertainty in patient care situations.14(pp149,152)
Having collegial support with other nurses and interprofessional team members is recommended to manage uncertainty and “nursing education programs should be created to assist nurses in developing skills in articulating and managing their uncertainty”14(p156) and to use evidence to guide practice.
Nurses in this study identified the need for additional education in knowledge and supportive services in the provision of comprehensive, holistic care to this patient population. Nurses reported a lack of knowledge specific to psychiatric disorders and substance abuse/dependence issues and reflected a disconnect in their ability to care for patients with both physiological and psychiatric disorders.
Ford et al4 identified that education alone is not sufficient to improve nurses’ attitudes toward patients with substance abuse/dependence. Along with education, it is essential that nurses have role support, including the presence of supportive, knowledgeable others with whom to collaborate and to gain expertise in practice. 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.
Qualitative inquiry revealed multiple challenges in the provision of care, yet professionalism prevailed. Nurses expressed negative attitudes in challenges in care with patients with substance abuse/dependence and specifically issues of safety, fear, manipulation, quandaries of care, and need for education. Consistent with the existing literature, findings support the need for enhanced educational provisions to nurses, both in basic educational preparation and continuing educational offerings, as well as the development and/or enhancement of supportive collegial networks in the practice setting.
Given the focus of safety as reported both in the literature and in this study, nurse administrators can facilitate an enhanced milieu of safety through the provision of several measures. Consistent available role supportive services such as mental health professionals working in collaboration with nurses can provide the essential teamwork needed to comprehensively assess, manage, and provide excellence in care in addressing the complex needs of this increasing patient population in medical-surgical settings. Having a supportive interprofessional team provides the opportunity to explore ethical quandaries in care and formulate expert care based on collegial consensus and evidence. Importantly, the presence of educated security to provide substantial protection for nurses and other health professionals as well as for other patients and families should be visible and readily accessible for nursing staff on medical-surgical units, as well as other units in healthcare facilities.
Additional educational opportunities to enhance knowledge of best practices regarding the complex needs of the medical-surgical patient with the comorbid condition of substance abuse/dependence are needed. Education focusing on assessment, prevention, and interventions to prevent aggression and violence, content on state-of-the-art nursing and medical management, including pain management, and specific procedures (similar to a code) to alert health professionals and security to a potential imminently dangerous situation should be addressed in educational offerings, both in academia and in the clinical arena. The development of a debriefing policy may assist nursing staff to process the experience following a violent episode. These measures may reassure staff, reduce their fear, and ultimately improve the care to these patients.
Additional research is needed to more fully understand the complex challenges in care that nurses face in daily practice with patients with substance abuse/dependence disorders. Further research is needed to determine the efficacy of enhanced education and workplace collegial support networks on nurses’ attitudes toward patients with comorbid substance abuse/dependence.
The authors thank Maureen A. Schneider, PhD candidate, MSN, MBA, RN, senior vice president of Clinical Program Development, and chief nursing officer, and Kathleen Cummins, MS, RN, APN, ACNS-BC, vice president of Nursing Operations, for their support of this research initiative.