Substance abuse is a global human crisis and a major public health issue.1 According to the World Drug Report 2019, globally 35 million people suffer from drug use disorders who require substance use disorder treatment.2 Geographically, Iran is located near 2 significant growing narcotics areas Pakistan and Afghanistan and drug trafficking represents a major problem for the Islamic Republic of Iran.3 Many studies have shown that substance abuse problem has been increasing year by year in Iran.4 Also numerous research studies in Iran have documented the high prevalence of addiction and substance use disorders among hospitalized patients.5,6 Nurses are the backbone of health care service to delivering quality care to patients with substance abuse. These patients need comprehensive and special nursing care with a combination of poor physical health, psychological issues, and social vulnerability, in addition to drug-related problems.7 A multidisciplinary treatment team with a long-term approach to care is necessary for recovering the health status and well-being of patients with substance abuse; however, in many countries, treatments and caring for these patients in the hospital remains focused on the physical needs and usually does not consider their psychological and social demands.8 According to studies providing quality nursing care for this particular patient group is affected by many barriers and patients usually face numerous challenges to receiving effective care.9,10 Nursing studies explain a wide range of nurses’ feelings and attitudes toward patients with substance abuse such as nervousness, intolerance, stress, frustration, and exhaustion. Commonly there is stigma and strong negative perceptions that are associated with substance abuse. It is not only the general public who carries a negative attitude about people with substance abuse, but health care professionals also hold a negative feeling toward people with illegal substance, opium, or alcohol dependence.11 Nurses, together with other health care providers who care for this patient group, practice based on knowledge, beliefs and attitudes, about substance abuse.12 Sometimes patients hospitalized with substance abuse not only suffer from the disease itself, but also from nurses’ prejudice and discrimination.13 In a study patients said that nurses’ attitudes and behaviors lead them to feel worthless.14 In another study nurses said that they do not work closely with a patient with illicit drug use.15 Nurses have more face-to-face connections with patients suffering from substance abuse than any other health professional,16 so they are in a special situation to improve the health and affect the recovery of this patient group in a positive way. In a country like Iran where there are many barriers and challenges in nursing care of patients with substance abuse, it is so important to identify the root causes of the problem. The first step in effective problem-solving is to be aware that barriers exist and view the problems as an opportunity for repair. So, this study aimed to determine the barriers faced by Iranian nurses in caring for patients with substance abuse.
MATERIALS AND METHODS
A qualitative research design of in-depth interviewing was used because the experience of the nurses about barriers and challenges in caring for patients with substance abuse could not be adequately quantified. A descriptive study using content analysis was conducted to achieve the purpose of the study. Content analysis is a method for knowledge generation and a vehicle for practice change. This is a systematic coding-and-categorizing method, which allowed researchers to construct inferences from interviewee’s talk by classification data according to meaningful similarities among units of analysis.17
Settings and Participants
Purposive sampling was used to recruit nurses at general hospitals affiliated to Babol University of Medical Sciences. Purposeful sampling was chosen to select nurses from different general hospitals’ wards with diverse job history to capture a wide range of perspectives. The inclusion criteria for participation were nurses who have experience of caring for patients with substance abuse and who were able to understand and speak Persian.
Face-to-face semistructured interviews and focus groups were conducted in the places comfortable for participants, September to January 2019. Five of the interviews took place in a researcher office and 23 interviews took place at a hospital office. Two focus groups took place in a nursing faculty meeting room outside of the faculty member meeting hours. The participants for individual interviews comprised 28 nurses. The interviews started with the backgrounds and demographic questions such as education, job history, age, and experiences in caring patients with substance abuse. Then data collection focused on the aim of the study with open-ended questions. The main explorative question in interviews was: From your experience, what are the barriers of caring for patients with substance abuse? The researcher probed interviewee’s response by using some questions, such as, Could you tell me more about your experience? Participant’s interviews were audio recorded and as soon as possible transcribed verbatim. Most interviews lasted about 40 minutes. Field notes were taken during all the interviews.
Focus groups can provide a broader range of information in qualitative research.18 To collect supplementary data, 2 focus groups were conducted, and the participants were 5 nurses in each group. In focus groups, a researcher as moderator clarified the goal of the study, encouraged conversations and interactions among participants and interjected probes. Other researchers managed the audio recording, took notes of transactions and behaviors during focus groups. Focus groups lasted between 50 and 60 minutes. After the 28th interview and second focus group there were no new data generated from the participants, so data saturation was determined and interviews were concluded. Choosing participants from various ages, level of education, experience of working as a nurse, and different hospital wards helped us to capture a wide range of perspectives and experiences.
The Granheim and Lundman method for qualitative content analysis was used to analyze data. At the first step audiotaped recordings were listened, interviews transcribed verbatim, and data reviewed multiple times to capture the sense of the whole, then the text was categorized into meaning units. In the next steps condensed meaning units were abstracted and labeled with codes. Codes were sorted into categories and subcategories based on their differences and similarities. In the end, themes were formulated as the statement of the underlying meaning or latent content of the text.19
Rigor and Trustworthiness
Lincoln and Guba’s20 trustworthiness criteria were applied in this study, including credibility, dependability, transferability, and confirmability. The credibility and confirmability of the data were sought using peer checking, member checking, and maximum variation sampling. An external audit was managed by an expert in qualitative data analysis. He checked all phases of the analysis process and his comments were discussed.
This study was approved by the Ethics Committee of Babol University of Medical Sciences. The ethical code of our study is “MUBABOL.HARI.REC.1396.104.” Participants were informed about the aim of the study. Participation in the study was voluntary and the participants signed an informed consent form. Also all participants were guaranteed confidentiality and anonymity. The data of the study were stored safely besides data access being limited just to the researchers.
In all, 38 nurses of 25 to 48 years of age who they had a mean of age of 35.2 years participated in the study. According to nurses working in Iran, most participants (n=23) were women. All participants worked full-time. The working experience of the participant nurses ranged in number of years from 2 to 25 years. Regarding the level of education 30 participants held baccalaureate degrees, n=7 held masters’ degrees, and n=1 held PhD degrees. Three main themes emerged from the data analysis: “negative and stereotypical attitudes,” feelings of unease and worry,” and “insufficient knowledge and lack of preparation.”
Negative and Stereotypical Attitudes
Negative stereotypical attitudes and reluctance to care for patients with substance abuse were identified as the very important barriers among nurses and contribute to providing substandard nursing care for this particular patient group. The nurses clearly mentioned their negative attitudes toward the substance abuser, and they indicated that patients who use substance are unpleasant to work with. According to the participants’ viewpoints, their stigmatizing attitudes toward this patient group could negatively impact nursing care delivery, as well as may result in caring avoidance or disruption during relapse. Participants indicated that some of the nurses have stereotypical attitudes toward patients who use substance and treat them with authoritarianism.
Participants provided data about background and context factors that affected nurses’ attitude toward patients with substance abuse. Some contributing factors of their stereotypical attitude were identified and discussed in the interviews such as cultural background, academic education, and their own experiences of caring.
Participants believed that there is a stigma that is attached to the person who abuses substances and the general public has the tendency to stereotype and label this population group. Participant indicated that social influence plays a prominent role in their attitude formation. According to participants’ viewpoints, their negative attitude causes many challenges toward these patients such as poor nurse-patient relationships, intolerance and uncomfortable feelings, and injustice in providing care and punitive behaviors.
A participant stated:
In my point of view, the addicted person doesn’t respect to themselves. They pick the wrong path, so I blame substance abusers for their disorders. Actually, I can’t deliver compassionate care toward patients who are substance abuser.
Some nurses view the substance abuse through the lens of criminal activity. One participant explained:
I know the reality is that substance abuse or addiction is an illness and not a crime, but in the background of my mind addiction plays a role as a criminal activity. You know, I socialized in a country that its many people have a criminal view to a person who uses substances. Sometimes I have no tolerance for patients with substance abuse; this mindset leads me to provide substandard care toward them. I feel upset with myself for feeling that way.
Another participant described her experience:
Sometimes I ignore these patients because always they exaggerate pain levels to get opioids or analgesics. They make me angry; I prefer to take care other patients who are really sick. To be honest with you, last month a patient with substance abuse told me; you are always playing favorites between your patients; you don’t pay attention to me.
Feelings of Unease and Worry
When the participants were reporting their experiences about challenges faced by them toward caring for patients with substance abuse, it was found that their experiences were accompanied by feelings of concern, worry, and unease. Most of the participants have experienced unconventional and inappropriate behaviors from this patient group, and they had been feeling worry about these unsuitable behaviors. According to the participants they distance themselves from this patient group who provoke them. Participants indicated that the moral challenges they experience when providing care for patients with substance abuse lead to they being vigilant and cautious in these encounters. Also, they were very concerned about the patient’s infection with some of the infectious diseases such as human immunodeficiency virus and hepatitis. As a result, nurses indicated that they make shorter visits with more task-oriented approaches when caring for patients with substance abuse.
An experienced nurse said:
Sometimes the behavior of patients who use substance is intolerable, they are often angry and grumpy … actually, these behaviors cause distance between my patient and me, and make patient care harder.
A nurse stated:
I assume that all patients with substance abuse have a contagious disease unless proven otherwise … Always I put gloves on to take care of them, sometimes double gloves … I mean I concern about being in close contact with patients who suffered from addiction.
Other nurse indicated that:
Last year my coworker was pregnant and she just had a needle-stick exposure from a drug addict with HBsAg positive, it was terrible, she was obviously under a lot of stress. Since then, he has been caring for addicted patients with major stress. You know, um, this painful experience has a direct negative impact on quality of nursing care.
Some of the nurses in this study experienced different types of aggressive and violent behaviors during providing care toward the patient with substance abuse and they believed that concern about inappropriate behaviors from these patents is cause of an ineffective nurse-patient relationship.
The patients who use substances frequently exaggerate their pain to take some opium drug, if you don’t pay attention to them, they cannot control their anger and shout loudly. Oh. This behavior is boring … it’s a challenge for me. I can’t deal with them when get hysterical.
Insufficient Knowledge and Lack of Preparation
Patients with substance abuse have a complex and widespread physical and psychological need for nursing. Most of the participants believed that they were not well aware of addressing the health problems of the patient with substance abuse, specially its withdrawal or overdose phase. They felt that a few of them have had adequate educational preparation in substance use disorders and their insufficient knowledge of this field led to providing suboptimal care toward this patient group. Participants consistently said that lack of preparation and incompetency to care patients who use substance contributes to their powerlessness and low self-esteem toward caring of this patient group.
Moreover deficiencies in academic education were mentioned as an important cause of the insufficient knowledge of nurses in this field. There is no specialized course for providing care toward patients with substance abuse in the Iranian nursing bachelor’s education curricula and students have spent just 2 to 4 hours classes about this topic on psychiatric and mental health nursing course. Insufficient academic education was reported by almost all participants. A nurse indicated:
In the care of complex-needs patients, such as patient with substance abuse or addiction, we need to acquire a wide range of knowledge to be able to provide the appropriate level of care. Substance abuse is not a simple illness, like stomach ache; nurses should get information about the types of addictive substances, drugs, withdrawal symptoms, drug interactions, emotional support and etc. There was no sufficient training program regarding the caring of patients with substance abuse in our curriculum. We only spent 4 hours classes about substance abuse which is quite insufficient.
Some nurses believed lack of knowledge causes their lack of self-confidence and confusion in delivering care toward these patients. They feel that their knowledge was not enough to avoid uncertain situations. A nurse indicated:
Last week I had a patient with multiple trauma who was addicted to alcohol, I had no idea about drug interactions with alcohol … I encountered uncertain situations … honestly; I was terrified of doing something wrong.
Several nurses expressed concern about disconnection between their ability to care for patients with both physical and psychological disorders. A participant stated:
To tell you the truth, I have a deep need to learn about psychological support of these patients, usually when my addicted patients get agitated I just look for a drug to calm them down, yes, I always try to solve the problem immediately and just physically ….
In the first theme to emerge from the narratives, the main barrier faced by nurses in the care of patients with substance abuse was described. Participants felt that their negative and stereotypical attitudes affect the quality of care provided to patients with substance abuse. A systematic review article showed that nurses’ negative attitude toward patients with substance abuse is a common and global issue.21 Numerous studies have shown that prejudices against this patient group existed and many health care providers had a very negative attitude toward the patient with addiction or substance abuse.15,22,23 A study showed that stigmatization of these patient group causes nurses not giving much attention to the patient’s personality.24 Health care providers stereotype substance abusers in ways that preclude the feasibility of cares directed at addressing the problem of substance abuser.13 Most evidence indicated that negative attitude leads to suboptimal nursing care for these patients and health professionals commonly have feelings of frustration, unmotivated, and dissatisfaction when providing care to this particular patient group.25–27 Often substance abuse disorder is treated as a criminal and moral challenge instead of a health issue.28 Receiving respect from nurses is important because it helps patients with substance abuse to alleviate frustration, to feel safe and express ourselves, and also to promote positive patient outcomes. Negative attitudes of nurses can reduce the therapeutic nurse-patient relationship, endanger feeling of safety and self-esteem in patients, as well as subsequently influences nursing care outcomes.29 According to previous studies nurses who have more communication and contact with this patient group have declared more positive attitudes.30 This is in accordance with a theory in psychology named contact hypothesis, which states that prejudice and negative attitude between groups can be reduced if members of the groups contact with each other. Also, this hypothesis suggests that persons who have more experience with a stigmatized situation or who have more interaction are more willing to allow the existence of behavior that one does not necessarily agree with and have more positive attitudes with each other.31 Several studies have indicated that the work atmosphere and environmental condition seem to affect nurses’ attitudes toward patients with substance abuse. Some factors contribute to prevent negative attitude and increasing willingness to work with this group’s patient such as supportive atmosphere in work, possibilities to consult a supervisor and an expert, and contact with role models.7,30,32 Supportive environment increases feelings of empowerment and adaptability among nurses toward caring patients with substance abuse.21
Our study showed that nurses’ experience to care for this patient group was accompanied by feelings of unease and worry. They had a feeling of worry about patients with substance abuse who demonstrate unconventional and inappropriate behaviors or who are infected by contagious disease. This experience of nurses led to the having an avoidant approach in the delivery of care to patients with substance abuse. Our findings are in line with other studies, which has found that health care providers have an avoidant and the task-oriented approach when working with a substance abuser.33 Peckover and Chidlaw24 in a study indicated that health care providers experience challenges when they deliver care to patients with substance abuse, such as threats and manipulation and the health care staff struggle to give care to these patients. Skinner et al34 also found that the health care provider has a stigmatizing and stereotypical view of people who abuse substance with contagious diseases, such as acquired immunodeficiency syndrome. Other studies in this issue showed that nurses had less empathy and make shorter personal engagement when caring for patients with substance abuse compared with other patients.35,36
The data emerging from this study show that some factors such as insufficient knowledge and lack of preparedness to care patients with substance abuse contribute to nurses’ powerlessness and feeling low self-esteem in giving care to this particular patient group. In another study, nurses confessed that their knowledge of substance abuse is not enough and they lacked self-confidence in meeting patient needs related to substance abuse. Patients who abused substances identified the nurses’ lack of confidence and inadequate knowledge, and recognized that it negatively affected the care provided to them. According to the participants’ viewpoints nursing curriculum deficiencies on substance abuse–related issues is the root cause of lack of knowledge in nurses. Baccalaureate nursing curriculum has not kept pace with the increasing community health challenges related to substance abuse and the developing evidence base for cares.37 Similar findings in Brazil indicated that baccalaureate nursing students have received a limited instruction in substance abuse and addiction. The insufficient knowledge in this part of education curricula may be contributing toward negative or neutral attitudes.38 Today’s baccalaureate nursing students are the nurse staffs of tomorrow. Students need adequate education and learning opportunities to shape their professional attitudes and values. The findings suggest that modifying the nursing education curricula and enough specific education of nurse students were needed to promote the knowledge of them toward patients with substance abuse and to improve their attitude toward this patient group. Moreover, providing ongoing training for nurses can be a measure to address this challenge.
An enhanced understanding about the barriers faced by nurses in caring patients with substance abuse can be a crucial factor in promoting the quality of care presented to this particular patient group. This study highlights the need for more knowledge about patients with substance abuse among nurses, as well as promotional activities to improve the professional attitude, moral awareness, and human dignity in encounters with these patients regardless of their background. Also, there is a need for nurse administrators to enable nurses to provide better quality care for patients with substance abuse, through fostering a more resourceful and positive work atmosphere.
According to our finding, it seems necessary to change nurses’ negative attitude and stereotypes toward patients with substance abuse. It is important to note that attitude change is often a long-term process and requires quite a bit of work, time, and effort. Some measures to achieve this objective are as follows: providing ongoing training for nurses, informing nurses about their disruptive behavior, and the destructive effect of negative behaviors in providing care toward patients, counseling opportunities, and organizational support for nurses in working with this group, interprofessional education, encouraging nurses to focus attention on the patient’s right to receive care with no discrimination based on sex, nationality, type of disease, religion, race, and others. Another recommendation is to invite patients with substance abuse disorders who have negative experiences during hospitalization to express their experience and the destructive effect of health care provider’s negative attitude to them. Another suggestion for preventing negative attitude toward this population is by holding discussion groups for nurses aimed at identifying barriers, managing strategies, and supporting each other for work with substance abusers. Participants believed that defects of nursing curricula and baccalaureate nurse education program in substance abuse–related subjects are the root of their insufficient knowledge and low self-esteem to care for this patient group. The need for a plan to make education program reform based on specialized caring of this population is a top priority. Before the process of changing in baccalaureate nurse education and to make changes viable it is really important that the nurse educator be adequately prepared in substance-abuse subjects.
The authors acknowledge all the participants who helped us in this study.
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