The opioid and substance use epidemic has changed the landscape of healthcare organizations across the country and redefined nursing care. Substance use disorder (SUD) has reached epidemic proportions in the United States. The death rate related to substance use overdose has quadrupled in the United States over the past two decades (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2021a; National Institute on Drug Abuse, 2021). In 2019, West Virginia had the highest SUD-related mortality rate in the country (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2021b). Individuals with SUD are at a higher risk of frequent hospitalizations and recurrent admissions (Gryczynski et al., 2016). The frequent hospitalization of patients with SUD is often because of complications associated with substance use, including overdose, infections, and endocarditis (Nordeck et al., 2018; Ronan & Herzig, 2016).
Nurses have reported challenges in caring for the increasing numbers of patients with SUD. These challenges include lacking the knowledge to properly care for this population (Russell et al., 2017) and feeling frustrated because of manipulative behaviors and frequent rehospitalization from medical complications related to SUD (Neville & Roan, 2014). Nurses reported daily encounters of unpredictable and inappropriate (i.e., aggressive) behaviors exhibited by patients with SUD and visitors (Neville & Roan, 2014). The American Nurses Association (ANA, 2019) declared aggressive behaviors toward nurses as unacceptable and harmful to the mental and physical health of nurses and cautioned that incivility in the workplace might impair patient care. In addition, a recent research study revealed that dealing with aggressive or difficult patients was associated with nurse burnout syndrome and intent to leave (Moloney et al., 2018).
The attitude of nurses caring for patients with SUD was an essential predictor of their willingness to engage with patients (Ford et al., 2008). Many nurses struggled with their personal beliefs related to SUD and pain management (Morley et al., 2015). Nurses often generalized patients with SUD as noncompliant and challenging (Morgan, 2014; Morley et al., 2015; Natan et al., 2009). The nurses' attitudes, preconceptions, and inconsistent care management of SUD jeopardized the nurse-patient trusting relationships (Johansson & Wiklund-Gustin, 2016; Monks et al., 2013), resulting in delayed care and contributing to poorer healthcare delivery (Daibes et al., 2017; van Boekel et al., 2013).
In 2019, as a part of an organizational needs assessment, a group of nurse leaders at the Magnet-designated academic medical center in rural Appalachia developed a survey to describe perceptions of nurses providing care for patients with SUD. These nurse leaders initiated an affiliation with the research faculty at West Virginia University School of Nursing to identify perceived needs and challenges in the provision of care for the population with SUD. The long-term goals of this collaborative project were to provide appropriate support, design educational training, and offer quality improvement or interventional programs for nurses to maintain optimal quality patient outcomes.
The Quality-Caring Model (Duffy & Hoskins, 2003) depicted the interplay of organizational culture and nurses' beliefs and actions to promote a caring patient-nurse relationship and achieve positive patient outcomes. The assumptions and measurable indicators of the Quality-Caring Model (Duffy & Hoskins, 2003) guided the development of the survey questions, data analysis, and interpretation of the findings to understand nurse perception of the organizational culture and nurse attitude toward caring for patients with SUD. The ANA (2015a) standards were used to develop questions about assessing nurses' perception of cultural competence and pain assessment (ANA, 2018) for patients with SUD.
PURPOSE
This study aimed to describe the perceptions of nurses who provided care for patients with SUD at the academic hospital. The information gained from this study directed the hospital leadership to provide resources and develop effective educational plans to support registered nurses providing care for patients with SUD.
The specific research question of this study was "Are there significant differences in the nurses' perception of caring for patients with SUD and healthcare by educational levels, shift of work, and years of nursing experience?"
Open-ended research questions were as follows: (a) What were the most common challenges nurses face when providing care for patients with SUD? (b) How does caring for a patient with substance use disorder influence nursing care and compassion? (c) What resources are needed by nurses to provide better patient care to a patient with SUD?
METHOD
Design
This study used a cross-sectional survey, descriptive, and content analysis. Each registered nurse on the listserv received an email describing the study and URL linking it to the Qualtrics online survey.
Sample, Setting, and Data Collection Procedure
The study was conducted at a large Magnet-designated academic medical center in the Appalachian Mountains region. All registered nurses (N = 2034) employed at the hospital were invited to participate in the anonymous survey using employee email listserv and mailed via the secured institution's intranet. On the basis of a power analysis, a sufficient sample size of 324 nurses was required to meet a 95% alpha level (p < .05). A reminder was sent to all nurses, and verbal reminders from unit managers were used during the team meeting.
The university institutional review board (IRB) approved the study procedure under the exempt category. Data were collected anonymously via Qualtrics at the convenience of the participants. The completion of the questionnaire indicated a willingness to participate in the study. Data from Qualtrics were converted into Statistical Package for the Social Sciences for analysis. All data were stored in the firewall password-protected server. Only authorized research personnel (approved by IRB) had access to the analytic database.
Measures
The survey questions were based on the Quality-Caring Model (Duffy & Hoskins, 2003) and the ANA standards for cultural competence and pain assessment. The institution's research council reviewed and approved the project and the survey questions before the IRB approval. The survey included a brief demographic, a short 12-item scale, and three open-ended questions regarding nurses' perceptions of caring for patients with SUD. On the 12-item scale, eight items were 5-point Likert scale response options from strongly disagree (1) to strongly agree (5). Four items were three response options of yes, maybe, or no. Higher scores indicated positive perceptions. Three open-ended questions were added to allow nurses to respond in their own words: (a) What challenges do you face when caring for a patient with SUD? (b) How does caring for the patient with substance use disorder influence your nursing care and compassion? (c) What resources do you feel would help you provide better patient care to patients with SUD? The survey took approximately 15-30 minutes to complete.
Data Analysis
Data analyses were conducted using the Statistical Package for the Social Sciences Version 25. Descriptive statistics were used to summarize the demographic data and the proportion of response options for each survey question. For the data analyses, participants' ages were grouped into (a) 18-35, (b) 36-55, and (c) above 55 years. Educational levels were (a) diploma/associate degree, (b) bachelor's degree (Bachelor of Science in Nursing [BSN]), and (c) graduate degrees (master's or doctoral levels). The shift of work included (a) day, (b) night, and (c) weekends. Years of nursing experience were grouped into (a) less than 1 year, (b) 1-5 years, and (c) over 5 years. This group allowed equal distribution among years of experience, as nurses with less than 5-year experience represented 55% of the workforce in the hospital.
A diagnostic analysis was performed to ensure the assumptions of normality, equal variances, and independence were met before the conduct of parametric tests. For exploratory purpose, an analysis of variance (ANOVA) was used to detect a significant difference in each survey question. The independent variables were educational level, shift of work, and years of nursing experience. The Tukey's honestly significant difference post hoc comparison was used to detect a difference between groups.
Content analysis was used to address the three open-ended questions. Content analysis was commonly used to uncover opinions important to the study participants (Krippendorf, 2004). This type of analysis can identify the meaning and relationships of words or concepts. An audit trail was maintained throughout the analysis process detailing key decisions undertaken by the researchers (McBrien, 2008). The direct quotes did not contain individual names, and all information was summarized without identifiers. Three members of the research team conducted data analysis (Miles & Huberman, 1994). Credibility, dependability, and transferability are measures to obtain the trustworthiness of qualitative content analysis (Graneheim & Lundman, 2004). The trustworthiness of this study was achieved by agreement of study findings through discussion among the research team and expert clinicians. An experienced qualitative researcher served as a second coder to seek agreement.
RESULTS
Descriptive Analysis
Four hundred eighty-eight registered nurses completed the survey (23.9% response rate). Most respondents were female (n = 432, 89.3%) and younger than 35 years old (n = 317, 65.3%). Of this sample, 26.9% (n = 131) had less than 1 year of nursing experience, whereas 28.1% (n = 137) had 1-5 years, and 45% (n = 219) had over 5 years of nursing experience. Overall, 280 (57.6%) had a BSN, 177 (36.4%) had a diploma or associate degree, and 29 (6%) had a graduate degree. The participants included registered nurses working across all shifts (days, nights, and weekends) in various inpatient and outpatient units (see Table 1). Participants' age was highly correlated with years of experience (r = .79, p < .001). For meaningful interpretation, years of experience were selected for the ANOVAs.
Table 2 provides the frequencies and percentages of responses from all participants. Over 50% of participants report that caring for patients with SUD impacts their nursing care and contributes to feeling unsafe. Greater than 90% of participants reported difficulty in managing pain, and 70% desired a standardized tool to assess pain specific to the population with SUD.
ANOVA of Nurses' Perceptions by Independent Variables
Education
There was a significant difference by education on one item, "I know where to find and document my patients' SUD history in the electronic medical records" (Q12; F = 3.18, p < .05). The post hoc comparison indicated that nurses with a BSN had higher scores than nurses who have a diploma or associate degree. There was no significant difference among educational levels on the other items (see Table 3).
Shift Work
There were significant differences by shift work on two items, (a) "I feel caring for the patients with SUD affects my nursing care" (Q1; F = 4.92, p < .01) and (b) "I feel there is a need for more standardized pain assessment tool" (Q11; F = 3.33, p < .05). The post hoc comparison indicated that nurses who work night shifts had a higher mean score on both items than nurses who work the weekend shift.
Years of Nursing Experience
There were significant differences by years of nursing experience on seven items: (a) "I feel safe when caring for the patients with SUD" (Q2; F = 5.49, p < .004), (b) "I know who to call if problems arise when caring for patients with SUD" (Q4; F = 15.54, p < .001), (c) "I feel treating pain in patients with SUD is challenging" (Q5; F = 8.33, p < .001), (d) "I feel my patients' pain level is as my patient with SUD has stated" (Q6; F = 5.22, p < .006), (e) "I feel comfortable providing alternative therapies for the treatment of pain" (Q7; F = 4.82, p < .008), (f) "I receive annual education on SUD" (Q11; F = 8.53, p < .001), and (g) "I know where to find and document patients' SUD history in the electronic medical records" (Q12; F = 8.92, p < .001).
The post hoc comparison indicated that nurses with more years of nursing experience had higher mean scores on the items identified above except two items, (a) "I feel safe when caring for the patients with SUD" (Q2) and (b) "I feel my patients' pain level is as my patient with SUD has stated" (Q6). Nurses in Group 2 (1-5 years of experience) reported significantly lower scores than nurses in Group 1 (less than 1 year) and Group 3 (over 5 years).
Content Analysis Results
The results of this study were organized into three major categories and 10 descriptive codes. The three categories, namely, everyday challenges of nurses' care, emotional responses influencing care and compassion, and needed resources, are presented in the following paragraphs. Categories, codes, and labels can be found in Table 4.
Everyday Challenges of Nurses' Care
Universally, nurses in the study reported challenges in caring for patients with SUD. Nurses reported controlling and managing the pain of patients with SUD as a primary challenge. Some nurses noted incorrect or missing orders and felt as if nothing worked to control the pain in patients with SUD. A nurse stated, "[horizontal ellipsis]Working night shift my service support usually will not give extra coverage for pain.... I do not know how to help, and it is frustrating." Many nurses reported a lack of teamwork among other nurses, physicians, and security. This lack of collaboration created difficulty for nurses and, as illustrated in the previous nurse's statement, impeded patient care. A nurse responded, "[horizontal ellipsis]physicians, nurses, and security team members do NOT work together, nor do they have the same goals for these patients."
Many nurses identified safety as a significant challenge to care. Nurses noted many instances when patients with SUD became hostile and lashed out either verbally or physically. A nurse commented, "[patients with SUD]...hostile and angry-threatening and sometimes violent verbally or physically." Many nurses perceived patient visitors, potential drug paraphernalia, and drug diversion as a major safety risk. A nurse observed, "Family bringing in drugs, patients are smuggling their drugs to sell." Nurses frequently noted not trusting or lacking a trusting relationship with patients with SUD. Nurses struggled to believe patient history and pain reports, nor did they trust the current pain scale when used with patients with SUD: "I struggle to maintain a trusting relationship with patients when I often feel manipulated with lies and incredible stories. It is mentally and physically exhausting." Some nurses voiced resentment of caring for patients with SUD that "took away" from caring for sicker patients. A nurse shared, "It's very annoying when you have to take yourself away from caring for your sick patients when I have to deal with security issues with the drug-addicted patients[horizontal ellipsis]."
Emotional Responses Influencing Nursing Care and Compassion
An alarming recurrence in the nurses' narrative was feeling defeated and becoming burned out, which were reflected in nurses' comments as anger, frustration, exhaustion, and inadequacy. A nurse commented, "[caring for patients with SUD] Causes me to become less compassionate; increased amount of burnout." Others "felt defeated" by not meeting patients' perceived needs, "I feel defeated when I know they are still in pain, and the dr won't change, assess or consider their problem to fix their pain level." Nurses voiced that it was difficult to show compassion to the patients with SUD because they often refused to comply with the treatment plan and were frequently readmitted with similar issues. A nurse commented, "It makes delivering nursing care harder, and I feel less compassionate when they won't comply with treatment." Overwhelmingly, nurses described patients with SUD as manipulative or demanding, "pts who are seeking drugs are often manipulative and demanding. They abuse the nurse with frequent requests and repeated questions[horizontal ellipsis]they have attention-seeking behavior-which makes the provider even more reluctant to treat pt."
Needed Resources
Nurses recognized several needs and called out for help and support to provide better care to patients with SUD. The needs were coded as hospital or community resource levels. Nurses identified many hospital resources, including more education, a specific pain scale for patients with SUD, alternative pain therapies, designated unit, inpatient treatment, nurse-led protocols, better visitation policies, and patient liaisons. A nurse stated she wanted "a pain scale that reflects their pain level, alternative therapies to decrease pain besides drugs." Another requested "nurse-driven alternative therapies and/or order sets." Nurses desired to know what community resources were available to patients, requested the ability to make rehabilitation referrals for patients, and recognized the need for more community resources to improve the care of patients with SUD. A nurse stated, "I would like to know what facilities and resources are available around the state to support these patients after discharge."
DISCUSSION
The findings of this study revealed essential issues associated with nurses' perception of caring for patients with SUD. Nurses with less than 1 year of experience reported significant challenges when caring for patients with SUD. Although nurses with less than 1 year of experience reported feeling safer, they described difficulty managing pain and implementing alternative pain therapies to reduce pain, finding documentation of SUD in the electronic health record, and recognizing who to contact when problems occurred. These findings reinforced those nurses with less than 1 year of experience and nurses working on the weekend shift need more education and support when providing care to patients with SUD.
Nurses with 1-5 years of experience reported higher concerns of safety when caring for patients with SUD (Q2) and lesser trust in the stated pain level of patients with SUD (Q6) than nurses with less than 1 year of experience and nurses with over 5 years of experience. This finding may be explained that some of the nurses with less than 1 year of experience are practicing with an assigned preceptor or unit mentor that may have contributed to greater perceived safety within this category of experience. Nurses with greater years of experience are more experienced and proficient in assessing the needs, providing care, and handling situations that may arise when caring for this vulnerable population. This notion is supported by the finding that nurses with over 5 years of experiences feel more comfortable in providing alternative therapies for the treatment of pain than nurses with less than 5 years of experience.
Nurses have an ethical obligation to address and adequately manage patients' pain (ANA, 2018). This study affirmed the need to improve pain management for patients with SUD (Morley et al., 2015). Overwhelmingly, nurses in this study expressed issues with safely and adequately managing the pain of patients with SUD and sought a pain scale specifically indicated for patients with SUD. Nurses recognized and provided suggestions to address gaps in care. Implementing a pain scale for patients with SUD and developing nurse-driven protocols were identified as priorities. Many nurses felt a reliable and validated pain scale developed for patients with SUD would assist in proper pain assessment. Several nurses stated they felt defeated by not knowing how to help patients and decrease pain. Nurse-driven pain management protocols may serve as a twofold solution by improving quality care and providing nurses a sense of greater autonomy at the bedside. Nurses with more autonomy report better job satisfaction, lower emotional exhaustion, and lesser intent to leave (Dos Santos Alves et al., 2017).
Our findings underscored the importance of communication and teamwork among the healthcare team. Nurses described problems discussing and obtaining orders from physicians to control the pain of patients with SUD effectively. Successful collaboration and effective communication are imperative to providing safe, quality patient care (CRICO Strategies, 2015). Implementing evidence-based strategies, such as team huddles and standardized checklists (Gluyas, 2015), may improve teamwork and communication, strengthen the healthcare team, enhance the nurse-patient relationship, and improve pain management of our patients with SUD.
In this study, nurses shared feelings of anger, frustration, defeat, and burnout from everyday challenges of caring for patients with SUD. Compassion fatigue is understood to be a preventable phenomenon that limits empathetic ability and causes emotional exhaustion (Peters, 2018). Compassion fatigue among healthcare professionals is reported as a threat to the healthcare professional's health, relationship with others, and quality of patient care and may lead to burnout (Cocker & Joss, 2016). The ANA (2015b) Code of Ethics, Provision Five, acknowledged the importance of nurses caring for themselves just as they care for others (p. 36). Support and training programs to alleviate adverse emotional outcomes of nurses are essential. Resiliency training is noted to help healthcare professionals cope and manage everyday challenges faced in practice (Hart et al., 2014) and was found as the most effective intervention to combat compassion fatigue (Cocker & Joss, 2016). Nurses with more resilience are less likely to experience burnout and lower intent to leave the profession (Brown et al., 2018), emphasizing the importance of developing strategies to maximize resiliency among nurses caring for patients with SUD to minimize compassion fatigue and burnout.
Nurses generally felt unprepared to care for this population. They requested more support from the hospital regarding knowledge and understanding of SUD, treatment, alternative pain options, and deescalation techniques. Evidence supports educational interventions (Dion, 2019; Dion & Griggs, 2020; Nash et al., 2017; Russell et al., 2017) and self-reflecting activities (Thorkildsen et al., 2015) related to SUD improve nurse knowledge and may assist in altering negative preconceptions and enhancing care. In addition, a better understanding of the neurobiology of SUD may improve nurses' views of SUD and shift addiction from an individual choice for a patient with a disease (Worley & Delaney, 2018). Patients with SUD recognized when providers lacked confidence in SUD knowledge and noted this lack of knowledge impacted care (Russell et al., 2017). Providing self-paced educational modules, simulated interprofessional educational experiences, and readily available peer support may help nurses provide high-quality care to patients with SUD. Learning programs and self-reflection activities may help nurses see patients beyond addiction and promote high-quality, compassionate care to patients with SUD.
Safety among nurses is a vital priority (ANA, 2019). Approximately half of the nurses in this study reported not feeling safe when caring for patients with SUD. This finding is consistent with previous research (Neville & Roan, 2014) and has a necessary implication for retaining nurses (Moloney et al., 2018) and sustaining quality nursing care. Healthcare organizations must take measures needed to ensure viable policies are in place to protect healthcare providers.
Limitations
One of the study's limitations may be because of response bias related to the sensitivity of the topic. The homogenous sample of data collected at one healthcare organization may limit generalizability to other settings or geographical areas. However, this study uncovers the unique, contemporary education and support needs for nurses (especially novice nurses) in caring for the escalating numbers of patients with SUD in their daily practice. The survey should be conducted among other healthcare professionals who are providing care for these patients. The survey used in this study was limited to address emerging needs at an academic hospital, limiting the generalizability to other healthcare systems or settings. Although the assumption of normality of data was met, most (55%) nurses who responded to this survey had less than 5 years of nursing experience, and 5 years or more were too large to group. A larger sample size could resolve this issue. Another limitation was our primary concerns of nurses' safety and challenges in caring for this vulnerable population. Thus, these specific needs guided the development of the individual questions, limiting other contributory factors that may impact the nursing care of patients with SUD. Regardless of these limitations, the uniqueness of these findings will add to the existing literature and support future research.
Implications
Foremost, creating a culture of safety and promoting nurse well-being is imperative and is a necessary first step to providing effective and compassionate care to patients with SUD. The issues related to nurse safety require more research and should include physical and psychological safety in the workplace of those caring for patients with SUD. The findings of this study reinforced the need for (a) offering interprofessional training programs, with an emphasis on pain assessment and management; (b) incorporating educational offerings within nurse residency programs and throughout the organization; (c) affiliating with a school of nursing in providing continuing education on this topic on an annual basis; (d) promoting and increasing the research of nurses' resilience; (e) developing nurse-driven protocols to enhance the care of patients with SUD; and (f) identifying resources in the institution and community for care of patients with SUD.
Conclusions/Recommendations
The opioid and drug epidemic dictates a change in the way we give care; thus, internal policies and procedures, and health policy, need to follow these changes. On the basis of our findings, there is a need to implement best practices to keep direct care staff and patients safe during hospital stays. In addition, the findings of this study indicate a need for additional education and resources to address the challenges nurses, especially novice nurses, experience when caring for patients with SUD. Throughout the organization and with a nurse residency program, educational offerings would allow learning and exploring ways to give quality care in a safe environment and provide new nurses the tools and confidence they need.
REFERENCES