Original Research: Nurses' Self-Assessed Knowledge, Attitudes, and Educational Needs Regarding Patients with Substance Use Disorder

Substance use disorder (SUD) can be defined as a chronic illness that “affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine,” and also includes substances such as alcohol, marijuana, and nicotine.1 Although the terms SUD and addiction are often used interchangeably, SUD is now the preferred scientific term. The four hallmarks of the disorder, according to the Diagnostic and Statistical Manual of Mood Disorders, Fifth Edition, Text Revision (DSM-5-TR), are impaired control over the substance or substances, physical dependence, social problems, and risky use behaviors.2, 3 Substance misuse is widespread. According to the National Center for Drug Abuse Statistics, 50% of Americans ages 12 years and older report having used illegal drugs at least once, with 13.5% reporting current use (within the past 30 days).4 Drug-involved overdose deaths have been rising dramatically, from over 70,000 such deaths in 2019 to nearly 92,000 in 20205; and provisional data indicate there were more than 107,000 such deaths in 2021.6, 7 The rise is due, in part, to the COVID-19 pandemic.8, 9

The 2016 report Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health, a first for that office, highlighted SUD's far-reaching effects not only on individuals and their families and colleagues, but also on health care workers, communities, and the nation.10 The report noted that SUD-related socioeconomic costs include higher health care costs, higher criminal justice system costs, and reduced productivity, and cited an annual financial toll of $193 billion. Though it can be daunting to consider the scope of the problem, it's also true that nurses are well positioned to positively influence the health and lives of patients with SUD.

People with SUD are likely to access primary care through the ED. From 2008 to 2017, the rate of ED visits by people ages 18 to 34 years with a primary diagnosis or primary complaint of substance use or dependence increased from 45.4 to 76 per 10,000 people.11 Furthermore, SUD is associated with higher rates of comorbidities such as cardiovascular disease; chronic kidney and lung illnesses; COVID-19; diabetes; hepatitis C; HIV/AIDS; hypertension; and mental health issues, including anxiety, depression, and posttraumatic stress disorder.12-14 A retrospective analysis of national data from 2014 to 2018 showed that one in 11 ED visits were by people with alcohol use disorder or SUD, many of whom had comorbidities.15 A general reluctance to seek health care often results in these patients presenting with more advanced illnesses, leading to higher rates of repeated ED visits and hospitalizations compared to patients without SUD.16

SUD is often viewed as an intentional choice rather than as a disease, making its stigmatization a national issue. It's concerning that nurses have been found to be more judgmental toward people with SUD than are other health care professionals.17 Negative attitudes toward people with SUD have ramifications for both their willingness to seek care and the provision of that care. Because people suffering from SUD often feel marginalized and stigmatized in health care settings, they are less likely to seek and have access to preventive health care.18

Understanding how nurses perceive SUD and patients with SUD is crucial to ensure the provision of evidence-based and patient-centered care.19 The quality of a provider's interpersonal skills and competence have been found to strongly influence patient satisfaction.20 Nurses' involvement in drug treatment and recovery programs is fundamental to patients' success.21, 22 Although prior studies have examined nurses' attitudes about caring for patients with SUD, to our knowledge this is the first to compare nurses' self-assessed knowledge and attitudes in hospital settings across the United States. Having a better understanding will help to support focused, effective interventions for nurses where these are most needed.

Study purpose. The primary purpose of this study was to explore hospital nurses' self-assessed knowledge and attitudes with regard to caring for patients who use substances (whether formally diagnosed with SUD or not) and who are hospitalized on selected units: medical–surgical units, ICUs, EDs, mental health units, and mother–baby units (including labor and delivery, postpartum care, neonatal ICUs, and newborn care). A secondary purpose was to determine the SUD-related educational preferences and needs of nurses who care for this patient population. Two research questions specifically guided this study:

What differences in nurses' self-assessed knowledge and attitudes toward caring for patients with SUD exist across practice settings? What are the educational and training needs of nurses who care for patients with SUD? METHODS

Study design. This study used an observational cross-sectional mixed-methods design in order to determine nurses' self-assessed knowledge and attitudes in caring for patients with actual or suspected SUD. Institutional review board approval from Purdue University Northwest and University of Massachusetts Dartmouth was obtained before participant recruitment and data collection began in January 2020.

Sample and setting. Participants were purposively recruited through the social networking platform Facebook (the authors joined a number of nurse- and nursing-related Facebook groups, including Nurses of Lancaster, ER Nurse Tribe, Nurses Playing Cards, and others). Although we originally planned to collect data for six months, data collection was terminated after three months, in March 2020, with the onset of the COVID-19 pandemic. Inclusion criteria were being a nurse and working in a hospital setting. We anticipated that by surveying nurses who work in clinical areas within hospitals, we would capture an overall sense of the relevant standards and culture, inclusive of various care modalities and levels of nursing education. Of the potential participants, those who were not working as nurses, not working in hospitals, or not providing direct patient care were excluded. Eligible participants were then directed to an online survey administered through Qualtrics.

Data collection. Participants were first asked to complete a demographic questionnaire that included open-ended questions about their prior SUD-related training, perceived educational needs and preferences, and experiences in caring for patients with SUD. Participants were then directed to complete the Drug and Drug Problems Perceptions Questionnaire (DDPPQ).23 The DDPPQ is a 20-item scale designed to measure the self-assessed knowledge and attitudes of professionals who work with people who use drugs. Each item is scored using a seven-point Likert scale (ranging from 1 = strongly disagree to 7 = strongly agree); scores for negatively worded items are reversed. Lower total scores indicate more positive perceptions of one's knowledge and attitudes, whereas higher scores indicate more negative perceptions. Although the DDPPQ has five components (role adequacy, role support, job satisfaction, role-related self-esteem, and role legitimacy),23 its questions can be categorized as covering two major areas: self-assessed knowledge and attitudes. In particular, the knowledge questions (KQs) focus on a respondent's sense of their working knowledge of SUD and its physical and psychological effects, its risk factors, and their counseling skills. The attitude questions (AQs) focus on the respondent's attitudes about caring for people with SUD, including feelings, beliefs, rights, responsibilities, and comfort levels.

Reliability of the DDPPQ has been established for use among health care professionals, with a Cronbach α coefficient of 0.87.23

Quantitative data analysis. The average DDPPQ score of participants in each group (groups were formed both by practice settings and by age groups) was calculated and an analysis of variance was performed to check whether there were significant differences across practice settings and age groups. A post hoc test, the Tukey HSD (honest significant difference) test, was used to make pairwise comparisons for the purpose of identifying the practice settings in which nurses had the most positive perceptions (as indicated by lower scores) about caring for patients with SUD. We also compared self-assessed KQ and AQ scores by age group to investigate how age affected participants' perceptions about caring for these patients. Significance was set at P ≤ 0.05.

Qualitative data analysis. The open-ended narrative responses were analyzed using a six-step approach to thematic analysis.24 The data were reviewed and discussed, line by line, by the research team, allowing the team to become immersed in the data. Each researcher then analyzed the data independently, using an inductive approach, to develop codes. After discussing and comparing the codes as a team, each researcher independently grouped the codes, using a color schema, into larger themes. The researchers then engaged in group discussions until consensus was reached on all themes.

RESULTS

Participant characteristics. A total of 872 nurses completed all aspects of the survey. Of those, 181 worked in outpatient settings (such as physician's offices) and were excluded. (In asking about unit of hospital employment, the survey included “other” as a response option since unit names can vary; thus, some nurses employed in outpatient settings were at first inadvertently included.) Only data from the remaining 691 nurses who reported practicing on various hospital units were included in our analysis. Of these nurses, 34% worked on medical–surgical units, 23% in ICUs, 21% in EDs, 13% in mother–baby units (including maternity and neonatal care units), and 8% in acute care mental health units. Most participants (94%) were female and nearly all (97%) were RNs. See Table 1 for more details on participant characteristics.

Table 1. - Participant Characteristics (N = 691) Characteristic n (%) Gender (n = 683)    Female 645 (94.4)    Male 37 (5.4)    Other 1 (0.1) Nursing license type (n = 689)    RN 671 (97.4)    LPN 18 (2.6) Nursing unit (n = 691)    ED 148 (21.4)    ICU 161 (23.3)    Medical–surgical 238 (34.4)    Mental health 52 (7.5)    Mother–baby 92 (13.3) Hospital type (n = 683)    University/teaching 200 (29.3)    Community 354 (51.8)    Critical access (designated) 26 (3.8)    Urban 50 (7.3)    Hospice 8 (1.2)    Other 45 (6.6) Age in years (n = 689)    20-25 84 (12.2)    26-42 306 (44.4)    43-54 180 (26.1)    55-73 119 (17.3) Race and ethnicity (n = 683)    American Indian or Alaskan Native 10 (1.5)    Asian 10 (1.5)    Hispanic, Latinx, or Spanish 38 (5.6)    Black or African American 26 (3.8)    Native Hawaiian or Pacific Islander 0 (0)    White (non-Hispanic) 564 (82.6)    Prefer not to answer 24 (3.5)    Other 11 (1.6) Highest educational level (n = 683)    Diploma 24 (3.5)    Associate degree 122 (17.9)    Bachelor's degree 394 (57.7)    Master's degree 114 (16.7)    Doctorate 29 (4.2)

Note: Totals of less than 691 reflect missing responses; percentages may not sum to 100% because of rounding.

Quantitative findings. Sixty-one percent of all participants reported caring for patients with SUD at least weekly. Of these, almost 80% reported caring for patients with SUD at least monthly. Only 2% of all participants reported never caring for this patient population. A majority (96%) reported receiving some training or education in SUD, with 63% receiving education through their undergraduate or graduate nursing programs, 47% receiving either mandatory or optional training provided through their workplaces, 67% reporting self-learning through reading or continuing education courses, and 2% responding “other” (respondents could choose more than one option). Only 4% reported receiving no training on SUD. Yet 99% of all participants indicated feeling a need for at least some additional training to improve their SUD-related knowledge and skills. Of the participants who wanted additional training, 66% indicated a preference for in-person training; and of those, 59% would prefer training by a mental health specialist or expert rather than by another nurse.

DDPPQ scores. The researchers first calculated participants' total DDPPQ scores and then categorized the DDPPQ questions as either KQs (those concerning one's self-perceived knowledge and skills related to drug use and use-related issues) or AQs (those concerning one's attitudes toward drug use and use-related issues). Cronbach α measures of reliability were 0.90 for the DDPPQ overall and 0.85 and 0.89 for the AQ and KQ subscales, respectively.

Looking at total DDPPQ scores by unit, nurses working on mental health units had significantly lower mean scores compared with nurses working on the other units. Looking at total DDPPQ scores by age group, a comparison of mean scores revealed a significant difference between the youngest participant group (20 to 25 years) and the oldest (55 to 73 years), indicating that the oldest nurses had significantly more positive attitudes than the youngest nurses. There were no other significant differences in nurses' total mean DDPPQ scores across other units or age groups.

KQ and AQ scores by unit. Overall, a comparison of participants' responses to the KQs and AQs revealed that nurses working on all units had consistently lower mean KQ scores and higher mean AQ scores, indicating that while they felt they understood or had a good working knowledge of SUD, their attitudes remained poor.

Pairwise comparisons of KQ scores by unit revealed that only the nurses working on mental health units had significantly lower mean KQ scores (that is, they had more positive self-appraisals of their knowledge) than nurses on other units. The nurses working in EDs had significantly lower mean KQ scores than those working on medical–surgical units. There were no other significant differences in mean KQ scores between nurses working on other units (see Table 2). Pairwise comparisons of AQ scores by unit showed that nurses working on mental health units had significantly lower mean AQ scores (that is, they had more favorable SUD-related attitudes) than nurses on other units. There were no other significant differences in mean AQ scores between nurses working on other units (see Table 3).

Table 2. - Pairwise Comparison of Mean KQ Scores on the DDPPQ, by Hospital Unit Hospital Unit Pairs Mean Difference (95% CI) P ED ICU 0.25 (−0.04 to 0.54) 0.13 Medical–surgical 0.31 (0.04 to 0.58) 0.02a Mental health −0.45 (−0.87 to −0.04) 0.02a Mother–baby 0.33 (−0.01 to 0. 67) 0.07 ICU Medical–surgical 0.06 (−0.20 to 0.32) 0.98 Mental health −0.71 (−1.12 to −0.30) < 0.001a Mother–baby 0.08 (−0.26 to 0.41) 0.97 Medical–surgical Mental health −0.77 (−1.16 to −0.37) < 0.001a Mother–baby 0.02 (−0.30 to 0.33) > 0.99 Mental health Mother–baby 0.78 (0.34 to 1.23) < 0.001a

DDPPQ = Drug and Drug Problems Perceptions Questionnaire; KQ = knowledge questions.

aSignificant findings.


Table 3. - Pairwise Comparison of Mean AQ Scores on the DDPPQ, by Hospital Unit Hospital Unit Pairs Mean Difference (95% CI) P ED ICU 0.04 (−0.23 to 0.31) > 0.99 Medical–surgical −0.02 (−0.26 to 0.23) > 0.99 Mental health −0.97 (−1.35 to −0.58) < 0.001a Mother–baby 0.07 (−0.24 to 0.39) 0.97 ICU Medical–surgical −0.05 (−0.30 to 0.19) 0.97 Mental health −1.01 (−1.38 to −0.63) < 0.001a Mother–baby 0.036 (−0.27 to 0.34) > 0.99 Medical–surgical Mental health −0.95 (−1.31 to −0.59) < 0.001a Mother–baby 0.09 (−0.20 to 0.38) 0.91 Mental health Mother–baby 1.04 (0.63 to 1.45) < 0.001a

AQ = attitude questions; DDPPQ = Drug and Drug Problems Perceptions Questionnaire.

aSignificant findings.

KQ and AQ scores by age group. There were no significance differences in mean KQ scores based on age group. But pairwise comparison of mean AQ scores revealed significant differences between the scores of the youngest (20 to 25 years) and oldest (55 to 73 years) nurses, as well as between the youngest nurses and those in the next youngest (26 to 42 years) age group (see Table 4). We further investigated correlations between mean KQ and AQ scores and found a moderate positive correlation for each age group.

Table 4. - Pairwise Comparison of Mean AQ Scores on the DDPPQ, by Age Group Age Group Pairs, yrs Mean Difference (95% CI) P 20-25 26-42 −0.29 (−0.58 to −0.01) 0.04a 43-54 −0.24 (−0.55 to 0.06) 0.17 55-73 −0.36 (−0.69 to −0.03) 0.02a 26-42 43-54 0.05 (−0.17 to 0.27) 0.93 55-73 −0.07 (−0.32 to 0.18) 0.90 43-54 55-73 −0.12 (−0.39 to 0.16) 0.68

AQ = attitude questions; DDPPQ = Drug and Drug Problems Perceptions Questionnaire.

aSignificant findings.

Qualitative findings. Four main themes emerged from the data: unmet needs, personal experiences inform care, personal beliefs inform perceptions, and judgmental attitudes.

Unmet needs. Participants consistently described needs for more education and training, as well as for more resources for themselves and their patients. They described wanting a better understanding of how their patients became dependent on substances. One nurse wrote, “There needs to be more training on this topic. People need a deeper [understanding of] how patients end up down this road.” Another wrote,

“There definitely needs to be more education for nurses on dealing with drug-addicted patients. Most of the time there's such a strong mental illness background or trauma/abuse pattern seen in that population. I think it would help caregivers to understand that more and they would be better caregivers for it. Less judgment.”

Participants also described having inadequate resources. They reported that patients needed “more” than what nurses could directly provide. One nurse wrote, “We need more mental health services, including substance abuse and aftercare resources.” Another stated that patients with substance use issues were “so often [discharged] without resources that could help them.”

Personal experiences inform care. Participants described how personal experiences, including their own or a family member's struggles with SUD, contributed significantly to their perceptions about caring for patients with SUD. Specifically, several nurses shared how these experiences helped them recognize the need for nonstigmatizing empathic nursing care. One nurse stated,

“I have been a nurse for 17 years, and in my past I have struggled with addiction myself and have watched my brother struggle with addiction. I feel if you have been through it, then you can help others get through it as well.”

Another wrote,

“My child has a [history] of drug abuse. I think it makes me more compassionate towards these patients and also have the ability to see them as not just a drug abuser.”

Personal beliefs inform perceptions. Participants reported that their personal beliefs about SUD inform the way they see “drug abusers.” It's notable, for example, that many nurses saw SUD not as a chronic illness, but as an intentional choice. Others wrote about how “the system” can cause people to become dependent on drugs and can perpetuate drug use. One nurse stated,

“I am very concerned that most treatment facilities that patients are referred to have just as many [illicit] drugs in them [as licit drugs]. We need to work to rid these facilities from allowing illicit drugs from coming in. It truly defeats the purpose.”

Another wrote,

“In the ICU . . . it is often difficult knowing if we are placing our patients into addiction by the continuous drips they are on while intubated. . . . No, I don't think the pain medication should be withheld . . . but are we creating an environment for dependency?”

Judgmental attitudes. Participants openly discussed being judgmental of patients with SUD. Their comments revealed their own judgmental attitudes as well as those they observed in other nurses. One nurse wrote, “I think if a mother [tests] positive [for] drugs and [her] baby tests positive, she should be charged with a crime.” Other comments included:

“[Patients with SUD] tend to be very rude and demanding and take up a majority of my time for irrelevant demands. It is frustrating working with this population because of this. I feel it takes time away from my other patients that want to get better.”

“Younger nurses with limited life experience seem to be more judgmental towards patients that have addiction issues.”

“Many of my colleagues are judgmental about this patient population.”

DISCUSSION

Given the significant increases in substance use and drug overdoses in the United States since the onset of the COVID-19 pandemic,9 it's imperative that nurses have the knowledge, skills, and attitudes required to provide effective care to people with SUD.

Nurses' attitudes. The results of this study indicate that, in general, U.S. nurses have negative attitudes about caring for patients with SUD, even when they report being knowledgeable about the disease. That said, the mental health nurses in our study held significantly more positive attitudes, a result that supports the findings of Pinikahana and colleagues, who determined that mental health professionals (including nurses) had positive attitudes toward patients with SUD.25 It's possible that having mental health training and experience in working with patients with SUD enables mental health nurses to view their patients more empathically than nurses working in other areas.

We found no significant differences in attitudes among the nurses in practice areas outside of mental health. This finding is unsurprising, given that researchers have often reported on nurses' negative attitudes toward patients with SUD.17, 26, 27 For example, in one study, medical–surgical nurses reported feeling manipulated by and distrustful of these patients.26 In other studies, nurses working in various practice settings indicated that they found it frustrating and emotionally draining to care for patients with SUD.17, 28 This may be especially true when patients exhibit challenging behaviors. A recent survey of providers working in a level 1 trauma center ED found that, regarding physical assaults by patients with SUD, nurses were assaulted more often than residents, attending physicians, or consultants.29

Our participants' responses to the open-ended questions revealed that many nurses had difficulty feeling empathy toward patients with SUD, a finding in keeping with results from other studies.30-32 Difficulty empathizing with such patients can occur when providers confuse a patient's undesirable behaviors with the underlying disease of addiction.33 Moreover, several of our study participants indicated feeling not only that their patients' drug use was an intentional choice, but also that the health care system perpetuates patients' dependency. As Chu and Galang have suggested, organizational interventions to improve role support could improve nurse–patient relationships and the overall provision of care to this population.34

A surprising finding was that compared with the youngest group of nurses, the oldest group had significantly better attitudes toward caring for patients with SUD. This may be related to the relative lack of experience of novice nurses, as indicated by some older participants' comments. The nursing workforce spans multiple generations, and like the general population it is aging. According to the most recent National Nursing Workforce Survey, the current median age of RNs is 52 years, with those ages 55 years and older accounting for almost 43% of the RN workforce.35 These “baby boomers” grew up during a cultural era that favored experimentation and was described by Kern as having “its sacraments in sex, drugs, and rock [and roll].”36 That background may be a contributing factor in the older nurses' generally less judgmental attitudes.

Similarly, older nurses may be more likely to have had personal experiences that fostered the development of empathy. Olsen argues that empathy is a cognitive structure that arises from experience and matures over time.37 In our study, participants' responses to the open-ended questions indicated that those who have personal experience with SUD, or have family members or friends who do, felt more empathy toward patients with SUD. One could argue that newer-to-practice nurses lack the empathic maturity to care for patients with SUD in a nonjudgmental way. It's concerning that as more baby boomers retire, younger, less experienced nurses will make up an increasing percentage of the workforce.38 Juxtapose this with the facts that during the current pandemic, SUD prevalence has increased,8 overdose deaths have risen dramatically,5 and people with SUD are at increased risk for COVID-19 and its adverse outcomes.14 These conditions could create a perfect storm whereby increasing numbers of patients presenting with SUD are being cared for by newer-to-practice nurses who have more negative attitudes than prior generations. In turn, this could contribute to worsening patient outcomes, as patients may be more reluctant to seek care from nurses with such attitudes.

It's important to consider how nurses' initial perceptions of patients with SUD are formed and whether negative attitudes can be mitigated, starting in nursing school. Nurse educators can greatly influence the crucial development of students' empathy and ability to provide nonjudgmental care.39 Such development can be impaired if an educator's negative attitudes are passed along to students, intentionally or unintentionally. This may be particularly applicable in the maternal–child setting. In a study of nursing students, Schuler and Horowitz found that those working in maternal–child settings had worse attitudes toward patients with SUD than those working in other practice settings, even after being mentored.40 In learning about the negative effect of maternal SUD on neonates, students may blame the mother unless special effort is made to help them develop empathy for her. A systematic review of SUD education in nursing schools concluded that nursing curricula had significant room for improvement in this area.41 In a study by Muzyk and colleagues, undergraduates from various health profession programs, including nursing, participated in an interprofessional SUD course that focused on personal bias, behavioral change, and recognition and treatment of SUD.42 The intervention not only significantly improved students' attitudes and behaviors toward patients with SUD, but also positively affected patients' willingness to seek follow-up care.

Nurses' educational needs. Additional SUD education or training in the hospital setting is often recommended as a means for improving nurses' attitudes toward patients with this disease.26, 29 Our findings indicate that, as with nursing students, the educational needs of practicing nurses are more complex than simply knowing the pathophysiology of SUD. Participants' responses to the open-ended questions made it clear that they desired a better understanding of the social, psychological, and interpersonal reasons people use substances. Similar to the findings of van Boekel and colleagues,43 the results of this study confirm that merely having knowledge about SUD doesn't mean having more positive attitudes toward these patients. Furthermore, our participants' responses to the open-ended questions support the findings of Dion and Griggs, who reported a need for empathy-based nursing education to improve nurses' negative perceptions of patients with SUD.44 It's also interesting that the participants in our study reported a preference for face-to-face training conducted by mental health specialists. Prior research has shown that employing immersive and experiential learning via various types of simulation can improve nurses' attitudes and empathic behaviors.45

Limitations. This study had some limitations. First, recruitment and data collection were stopped after three months as the COVID-19 pandemic set in. Thus our assessment lacks longitudinal data. Second, qualitative data was limited to written responses to open-ended questions. Conducting individual interviews or focus groups with at least some participants might have captured additional opinions and insights. The self-reported nature of survey questionnaires inherently leaves room for inaccuracies, since participants might answer in ways that seem socially acceptable or might be unable to accurately assess their own knowledge and attitudes. We also acknowledge that the demographic questionnaire lacked an option for LPNs to adequately report the education they received with regard to caring for patients who use substances or have SUD. Lastly, although every effort was made to reach a wide variety of nurses on Facebook, recruitment was limited to that social media platform. It's possible that Facebook algorithms may have restricted our access to specific groups of nurses.

CONCLUSIONS

The results of this study indicate that in general, hospital nurses have negative attitudes toward patients with SUD. Of our participants, the mental health nurses tended to have better attitudes than nurses on other units; and the oldest group of nurses tended to have better attitudes than the youngest group. The results also reaffirm the need for empathy-based nursing education for nurses who care for these patients. Participants reported a preference for face-to-face training by mental health specialists experienced in SUD. Given the increasing prevalence of SUD and the expected retirement of older nurses, it is urgent that we prioritize empathy-based nursing education, particularly for newer-to-practice nurses, in order to improve nurses' attitudes and ensure best care for patients with SUD.

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