Editor’s note: The author uses substance use disorder as a diagnostic term. However, some of the research he cites uses a different term, such as drug addiction or drug misuse. In those cases, to ensure an accurate description of the study, he retains the specific terminology of that study.
People with substance use disorders suffer not just from the disorder itself but also from discrimination. In a 2014 survey, more than half of respondents said treatment options for people with drug addiction (the survey’s term) aren’t effective—and nearly half opposed increasing government spending on treatment. What’s more, almost two-thirds believed discrimination toward people with drug addiction isn’t a serious problem and 43% opposed equivalent insurance benefits for drug addiction. The overwhelming majority (78%) said they wouldn’t work closely with someone with a drug addiction.
The survey highlights stigmas and stereotypes related to substance use disorders, as well biased attitudes toward people with these problems. (See Key facts about substance use.) Even many nurses and other healthcare professionals have negative attitudes, which may contribute to suboptimal care or create barriers to care.
Exploring nurses’ attitudes
Nurses see patients with substance use disorders in emergency departments (EDs) and many other settings. In 2009, almost 1 million visits to public nonfederal EDs involved use of an illicit drug; the total number of drug-related ED visits was estimated at 4.6 million.
Like the general public, many nurses think poorly of people with substance use disorder. Substance use can cause not only physical signs and symptoms but also behavioral dysregulation that may be beyond the person’s control.
Nursing literature describes a variety of nurses’ attitudes and feelings toward patients with substance use disorders, including:
• feelings of being manipulated by these patients
• frustration, futility, and disappointment related to patient relapse and recidivism.
A longitudinal review of the literature on nurses’ attitudes revealed many nurses across three decades believed treatment for substance use disorders was hopeless and “misusers” (the study authors’ term) were irresponsible. However, surveys from recent years showed nurses’ attitudes have improved over three decades, becoming more positive and less condemnatory. Also, younger respondents with more education are likely to be optimistic about the treatment of alcohol use disorders specifically. As the next generation of nurses enters the workforce, this is good news.
A fairly recent review from Australia showed that nurses’ attitudes toward patients with problem alcohol use improved over time. Study authors noted that “on average, the nurses had neutral to positive attitudes regarding alcohol problems, which is encouraging compared to the predominantly negative views uncovered by research from the 1980s and 1990s.”
But nurses’ perspectives on patients with substance use disorders aren’t defined by straightforward improvement. The picture is more complex, with dissonance between what nurses value and how they feel and behave. The authors of the longitudinal review cited above noted that although nurses’ attitudes improved over time, “a significant minority…continued to stereotype alcohol and drug misusers negatively.” Authors of the Australian review found consistent pessimism in a solid minority of nurses, including 14% who didn’t want to work with patients who are “drinkers” and 12.5% who found little reward in working with people with alcohol problems. (See Vicious cycle: Knowledge deficit, poor care, escalating demands.)
Even in the context of negative perceptions of patients with substance use disorders, nurses can simultaneously feel sympathetic concern and an ethical duty to care for them. They may experience their ambivalent feelings as internal struggles, feeling frustrated even as they strive to understand patient suffering and focus on patient strengths and the possibility of a better future.
Why nurses have negative feelings, and what can be done
Nurses consistently say lack of knowledge or competence in caring for patients with substance use disorders contributes to their negative feelings, including powerlessness and anxiety. A 2014 qualitative study found nurses believed they lacked knowledge of substance abuse and dependence, which caused “a disconnect in their ability to care for patients with both physiologic and psychiatric disorders.” This knowledge deficit can perpetuate suboptimal care, and nurses recognize this.
One thing is clear: Nurses must become more knowledgeable about substance use disorders to care for patients effectively. Few have had adequate, if any, educational preparation in substance use disorders. Yet education can lead not just to more effective care but also to improved attitudes. In one comparative study, undergraduate nurses received 16 hours of substance- use education that included theory, epidemiology, identification of alcohol-related harms, and nursing-care elements (such as patient education, counseling, brief interventions, and motivational interviewing). This education led to greater knowledge and improved attitudes toward working with patientswho had alcohol problems— specifically in students’ ability to help them. It also increased their personal and professional satisfaction in this work. Other studies show that even brief educational programs that focus on treating substance use disorders can improve nurses’ knowledge, confidence, and attitudes.
But education alone isn’t enough. Nurses also need support. A 2014 study of hospital-based medicalsurgical nurses who’d received 10 hours of drug and alcohol education plus role support found they had better therapeutic attitudes when working with patients who had substance use disorders. The strongest factor related to this improvement was having someone to collaborate with in creating the plan of care.
A cross-sectional survey of generalist nurses in Australia found role support was the strongest driver of nurses’ therapeutic attitude and that workplace educationon illicit drug use was useful only when combined with role support. Other studies identify education, training, and support as key factors in improving providers’ attitudes toward patients with substance use disorders.
Of course, other healthcare professionals also need more than just education to improve their attitudes and to reduce patient stigmatization. In the 1990s, all healthcare professions began using a disease model of substance use disorders. Providers generally are knowledgeable and confident when it comes to disease models of illness and care. Yet while the paradigm has shifted to some degree, an attitude shift didn’t follow. Perhaps this shows that personal and institutional stigmas are slow to change, even as care structures evolve.
Resources for change
In nursing, we can identify numerous resources for support in caring for patients with substance use disorders. Unit or system educators, such as clinical nurse specialists, can design specific support programs based on patient and provider needs. Those helping to improve nurses’ attitudes (and care outcomes) toward patients with substance use disorders should investigate available support options to treat patients effectively. Ideally, they should identify local champions who have, or can pursue, addictions certification from the International Nurses Society on Addictions (IntNSA) at the registered nurse (RN) or advanced practice RN level. Also, the Providers’ Clinical Support System for Medication Assisted Treatment, a joint project of numerous substance use treatment organizations, has a mentoring program that includes nurse mentors. In addition, the American Psychiatric Nurses Association has an addictions council and offers many online resources. (See Resources for support, information, and education.)
Many effective evidence-based treatments for substance use disorders exist and can be applied to excellent effect. The Affordable Care Act and the 2016 federal budget created additional opportunities to devote public funds toward effective treatments.
Patients with substance use disorders can—and do—get better every day. According to the Kaiser Family Foundation, nurses in the United States (including both RNs and licensed practical nurses) number approximately 3.96 million. We represent the largest healthcare workforce in the country. By pursuing education and support in treating patients with substance use disorders, we can lead the way in reducing stigmas and discrimination.
But we can improve more than just our attitudes. Let’s also improve treatment for patients with substance use disorders. Our patients need and deserve it.
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