Keywords

Attitudes, Health Care Providers, Nurse Practitioner Students, Opioid Use Disorders, Stigma, Substance Use Disorders

 

Authors

  1. Elliott, Kathleen M. DNP, ANP-BC
  2. Chin, Elizabeth RN, ANP, PhD
  3. Gramling, Kathryn Louise PhD
  4. Sethares, Kristen A. PhD, RN, CNE, FAHA

Abstract

Purpose: Nurse practitioners (NPs) are in a unique position to address the problem of opioid use disorders (OUDs) because they provide a large percentage of primary care services (Agency for Healthcare Research and Quality, 2014). This study aimed to increase doctoral NP students' beliefs/attitudes about their ability to care for and about individuals with OUDs through a multifaceted educational approach, guided by social cognitive theory.

 

Methods: Researchers used a quasi-experimental pre/post design. Five doctoral students attended lectures and 16 hours of direct clinical exposure to individuals with OUDs at a medication-assisted treatment center. The 22-item Drug and Drug Problems Perception Questionnaire examined students' attitudes toward individuals with OUDs before and after receiving this multifaceted education. Students completed reflective writings. Descriptive statistics and effect sizes were computed, and reflective writings were reviewed.

 

Results: Changes in Drug and Drug Problems Perception Questionnaire scores before and after intervention showed a fairly large effect size. This suggests that the intervention may have clinical significance for practice and is likely to attain statistical significance with a larger sample size. Greatest changes occurred in students' perceptions of role adequacy and self-esteem scores, indicative of higher self-efficacy. Measured score increases correspond to increases in confidence, knowledge, and skills to therapeutically engage with this population.

 

Conclusion: Doctoral NP students had more positive attitudes and beliefs about individuals with OUDs after the multifaceted intervention. Enhancement of self-esteem and adequacy in the caregiver role for this population were promising signals that education can reduce stigma. Further study is warranted with a larger and more diverse sample.

 

Article Content

BACKGROUND AND SIGNIFICANCE

Health care providers and academics are searching for solutions to the suffering caused by the national opioid crisis. Individuals with substance use disorders (SUDs) report being hesitant to seek treatment because they feel stigmatized by the very health care professionals who are best positioned to assist them (Brener et al., 2007; Ding et al., 2005; B. Link et al., 2004; Livingston et al., 2012). This reluctance inhibits disclosure of substance use and impedes the development of provider-patient relationships when they do seek treatment. These factors, combined with a lack of knowledge by professionals, prevent assessment and diagnosis of an unrecognized opioid use disorder (OUD). The missed opportunity to assist may lead to progression of the disease and even death. In fact, a growing body of literature makes strong connections between substance abuse, stigma, and poor patient health outcomes (Larochelle et al., 2018; S. Link et al., 1997; O'Connor et al., 2011; Sleeper & Bochain, 2013; van Boekel et al., 2015; Volkow & Wargo, 2018). Likewise, unaddressed health issues lead to multiple visits to emergency departments and primary care offices, fragmented care, and a burdened healthcare system (O'Connor et al., 2011). After a systematic review of 28 studies of provider beliefs regarding the care of persons with SUDs, researchers urged "the necessity for interventions to change health professionals' attitudes" (van Boekel et al., 2013, p. 33).

 

The approximately 234,000 nurse practitioners (NPs) in the United States provide a considerable proportion of primary care services (Agency for Healthcare Research and Quality, 2014), and more than 80% of NP students are trained in primary care (American Association of Nurse Practitioners, 2018). Although primary care NPs are generally reported to be more willing than other providers to care for the underserved population (Buerhaus et al., 2015), little research has focused on nurses' attitudes, confidence, and working knowledge related to the care of persons with OUDs. Therefore, these researchers created a study to report on a multifaceted educational intervention delivered by course faculty over a period of 13 weeks, focusing on improving attitudes, increasing working knowledge, and boosting confidence of NP students regarding the care of persons with OUDs.

 

Purpose Statement

The purpose of this study was to design, implement, and test a theory-guided didactic and experiential intervention within a graduate course focusing on caring for patients with OUDs. The goal was to improve student NP attitudes and confidence about caring for this vulnerable population. The research question was: Does a multifaceted educational intervention improve NP students' attitudes, confidence, and role development about caring for persons with OUDs?

 

Theoretical Framework

Social cognitive theory guided the study (Bandura, 1986). A social cognitive perspective acknowledges the social origin of thinking and behavior while recognizing that human beings filter information through their own cognitive processes, motivations, and personal factors (Bandura, 1986). Bandura (1986) emphasized that much learning does not involve a tedious trial-and-error approach but instead occurs through observing and processing the performance of others. However, people do not automatically absorb and mimic their environments. Bandura (2006) viewed observation as an active process by which a person could consider rules of behavior and patterns of thought to guide future action. Through self-reflection, a person then judges his or her own capability of performing in a future similar situation. Bandura (1986) uses the term self-efficacy to denote a person's belief in his or her ability to perform in a designated way. In this view, the learner becomes an "agent of experience," not just an "undergoer of experience" (Bandura, 2006, p. 168). Belief in one's efficacy, or confidence, is a key to motivation and undertaking desired action.

 

This study designed and tested the effects of a multifaceted, theory-guided, experiential educational intervention for doctoral NP (DNP) students that employed (a) accurate knowledge about OUDs through lecture, (b) observation (role modeling/vicarious experience) of expert faculty interactions/exposure to persons with OUDs, (c) practice opportunities with feedback, and (d) self-reflective exercises focusing on attitudes toward individuals with OUDs.

 

LITERATURE REVIEW

Stigma was described as a combination of prejudice, stereotyping, and discrimination by Earnshaw et al. (2013) in their study of persons on methadone maintenance therapy. These individuals may be subject to strong stigmatization, which may be encountered in two ways, enacted and anticipated. Enacted stigma is actually experienced, whereas anticipated stigma involves expectations of stigma in the future. Both are powerful stressors that threaten health seeking and treatment success (Earnshaw et al., 2013).

 

Caring for patients with OUDs is complex. They are more prone to human immunodeficiency virus, hepatitis, and other infectious diseases and are more susceptible to multiple medical problems that can have cardiovascular, respiratory, gastrointestinal, musculoskeletal, and neurologic effects (National Institute on Drug Abuse, 2012). OUDs often follow a course of relapses but are considered preventative and treatable (Ball et al., 2006). There is also the underuse of effective medications and the tragedy apparent when available treatment is not utilized. For example, a recent cohort study involved 17,568 adults who survived an opioid overdose in Massachusetts and were tracked for mortality and the use of medication-assisted treatment (MAT) over the year after the overdose (Larochelle et al., 2018). Despite the fact that prior nonfatal overdose is identified as a risk factor in future fatal overdose, only one third of the participants received one of the three medications that are Federal Drug Administration approved in that year. Both methadone and buprenorphine were associated with significant reductions in mortality; higher mortality resulted when the two medications were not used. Volkow and Wargo (2018) posited such tragedy will only be avoided when we remove the stigma from the disease of addiction and from the medications that can be used to treat it (p. 2).

 

NP Role

The NP is one of the critical players for success in the primary care provider role of screening, recognizing, and recommending treatment options during this opioid crisis. The American Association of Nurse Practitioners (2018) approximated 1.2 billion NP visits are completed each year; this is equivalent to three NP visits per year for every patient in the United States. However, no professional literature was found that addressed whether NPs hold stigmatizing beliefs regarding caring for persons with OUDs. Interestingly, an early national study of physician practices revealed multiple shortcomings that warrant attention from future NPs who take on this provider role (National Center on Addiction and Substance Abuse at Columbia [CASA], 2000). The following will highlight key points to the CASA study as an acknowledgment of known provider challenges to be addressed. Furthermore, the literature about nurses' beliefs, experience, and education with this vulnerable population is reported.

 

Health Care Personnel

A systematic review of 28 studies of health care professionals' attitudes about SUDs in the first decade of the 21st century revealed evidence of negative beliefs (van Boekel et al., 2013). Varied disciplines were included in many samples, making it difficult to understand if there were differing beliefs by professionals. Only five of the reviewed studies were conducted in the United States. The research from different countries may reflect divergent beliefs. Overall, the review found that "health care professionals" have low regard and dissatisfaction because in part of the perception that patients with SUDs are potentially violent, manipulative, or poorly motivated (van Boekel et al., 2013, p. 33).

 

Likewise, in a large study of 648 primary care physicians (CASA, 2000), more than 40% of the patients seen by the physicians were mistakenly not diagnosed with a substance abuse disorder (CASA, 2000). Physicians in the CASA study provided evidence of more avoidant approaches toward patients with SUDs than they have toward other patients within their practices (CASA, 2000). This may have resulted in shorter visits, less empathy, and diminished personal engagement, resulting in substandard care (Siegal et al., 2000; van Boekel et al., 2013).

 

Nurses' Attitudes

Nurses have shared that caring for individuals with SUDs can be "emotionally challenging and potentially unsafe" (van Boekel et al., 2013, p. 2) and dangerous and unpredictable (Ford, 2010; Sleeper & Bochain, 2013, p. 93), and nurses have been found to be less motivated and less satisfied with caring for patients with SUDs (Ford et al., 2008). For example, Johansson and Wiklund-Gustin (2016) revealed dilemmas for nurses in creating boundaries and structure while balancing support and encouragement. Being aware of their own attitudes about patients was important, as well as being realistic on views about potentially manipulative behaviors. Sleeper and Bochain (2013) described what patients in a residential treatment center viewed as stigmatizing. The interviewees shared experiences with "treatment staff," making it difficult to know if nurses were actually being represented. Nonetheless, residents revealed a theme of "stigmatizing experiences" in which "staff disregarded their physical and emotional needs" (Sleeper & Bochain, 2013, p. 95), delayed or ignored requests, yelled at patients, made wrongful accusations, and gave patients no personal attention (Sleeper & Bochain, 2013, p. 95). Sleeper and Bochain also noted ways that patients felt cared for.

 

Ford (2010) asked 311 Australian nurses to identify impediments to caring for persons who use illicit drugs. In addition to the danger and unpredictability, nurses believed that patients required more time and thus compromised their ability to meet the needs of other more acutely ill patients. Nurse respondents also struggled with what they viewed as a lack of accountability by patients for their own health (Ford, 2010).

 

Nursing Education

There are no recent studies of the amount or character of substance use content in nursing education found in the literature. A Canadian study of the barriers to accessing care by those who inject drugs (Lang et al., 2013) emphasized the lack of formal and continuing education about drug use and abuse. The lack of adequate curriculum, infrequent exposure to SUDs, and the lack of faculty expertise may contribute to providers' negative attitudes (van Boekel et al., 2013). In general, health professionals who had frequent contact with patients with substance abuse expressed more positive attitudes (Brener et al., 2007; Ding et al., 2005). Exposure frequency was related to less stigma in a study of Canadian nurses at a metropolitan hospital that treats many inner-city patients (Chu & Galang, 2013). Researchers call for nurse educators to create dedicated efforts to prepare nurses with the knowledge and skills to care for persons with SUDs (Harling & Turner, 2012; Lovi & Barr, 2009; Rassool & Rawaf, 2008; van Boekel et al., 2013).

 

In summary, the literature supports the need for addressing the presence of stigma, the need for clinical experience, and working knowledge in caring for patients with OUDs in the nursing education of future practitioners. The lack of research in the education and attitudes of NPs highlights the significance of this research. This study designed and tested a multifaceted educational approach to improving attitudes, enhancing confidence, and developing roles in the care of persons with OUDs by NP students.

 

METHODS

Sample and Setting

This study focused on a convenience sample of the entire cohort of second-year NP students from one doctorate program at a northeastern university. The clinical setting for this cohort took place in a local comprehensive treatment center that serves individuals with OUDs.

 

Procedures

The first author was the primary investigator and faculty of record. Initially, the Drug and Drug Problems Perception Questionnaire (DDPPQ) was administered; participants received 3 hours of face-to-face lecture in a traditional classroom setting. The class content addressed the biological basis for classifying SUDs as a chronic disease, the physiological effects of substance use on the brain, patient experiences with shame and discrimination, and an overview of evidence-based treatment options.

 

In addition, the researcher designed a 16-hour clinical experience at a medical assistive treatment setting in southeastern Massachusetts. The center is an outpatient medical assistive treatment facility that provides daily care, counseling, and medication to more than 800 adult men and women with diverse backgrounds. Methadone, naltrexone, and buprenorphine are Federal Drug Administration-approved medications administered at this center based on patient needs. Each student's clinical experience lasted 4 hours and consisted of separate interactions with patients who were receiving treatment at the center. Students were directly supervised by an NP faculty member with expertise working with this population. First, the NP student observed the faculty member as she performed an annual physical examination with a patient in treatment. During the examination, the faculty showed how to make connections that are trusting and nonstigmatizing during a challenging interview. The intent of faculty modeling was to exemplify attentive, meaningful, unbiased presence while examining and interviewing a patient at the MAT, which included difficult questioning about OUDs. Patient trust is developed by incorporating conversations that are challenging, but at the same time caring, and students observed the faculty unfolding a deeper understanding of their disease and the development of patient trust.

 

Next, the student was observed conducting their own assessments. Subsequently, a faculty/student debriefing took place underpinning factors that promoted a therapeutic alliance. Students reflected in writing about their clinical experiences each week, with each student creating four reflective writing entries. Students were asked to reflect on their feelings and levels of confidence when performing assessments of individuals with OUDs.

 

Ethical Considerations

Researchers obtained approval from the university institutional review board and obtained informed consent from student participants. Students were given the opportunity to self-select out of the research study if they so choose. To minimize threat of grade penalization for nonparticipation or performance, reflective assignments were graded as pass (assignment was submitted) or fail (assignment was not submitted). All data were de-identified, with each participant assigned a unique number. Data were stored in a locked cabinet and were reported as aggregate data. Upon giving their consent to participate, students completed the two study instruments.

 

Instruments

Attitudes

The 22-item DDPPQ (Watson et al., 2006) measures the attitudes of health professionals toward working with individuals who have OUDs. The measure produces total scores ranging from 22 to 154. The measure is divided into five subscales: work satisfaction (four questions), self-esteem (four questions), role adequacy (seven questions), role legitimacy (two questions), and role support (three questions). Scores on each subscale range from 1 to 7, with higher scores signifying greater disagreement with the item. A high DDPPQ subscale score signifies a low therapeutic attitude, whereas a low score indicates a high therapeutic attitude. The subscale of role adequacy is defined as feeling comfortable working with individuals with OUDs and is similar to self-efficacy, and scores on this subscale range from 7 to 28. The subscale of role legitimacy measures the students' identification of their role in caring for those with OUDs. The work satisfaction subscale measures students' job satisfaction in working with those with OUDs, with scores on that section ranging from 4 to 28. The subscale of self-esteem measures students' roles related to the self-esteem associated with working with patients with OUDs, producing a score range from 4 to 28. The role support subscale measures assistance and support from colleagues while working with patients with OUDs (Watson et al., 2006). Scores on this subscale range from 3 to 21.

 

Reliability and validity of the DDPPQ have been established with health professionals, with a reported Cronbach's alpha coefficient of .87 (Watson et al., 2006). For this study, the DDPPQ tool was administered before and after the educational experience to identify possible changes in the participating DNP students' beliefs and attitudes about persons with OUDs, about caring for persons with SUDs, and about their confidence in their abilities to provide care to this population (self-efficacy). Self-reflective comments added depth to the thinking during the experiences.

 

Data Analysis

Data were entered into SPSS 23.0 and were cleaned and analyzed. Mean scores for the preclinical and postclinical DDPPQ total score and the five subscales (work satisfaction, role specific, role adequacy, role legitimacy, and role support) were calculated. Effect size calculations were computed using pretest and posttest DDPPQ total and subscale scores according to Cohen (1992). A review of reflective writing assignment was undertaken to understand quantitative score changes.

 

RESULTS

All were women with an average of 7.2 years of nursing experience and with a mean age of 32 years. The participants all had baccalaureate degrees in nursing, and none of them had prior training in talking to patients about substance use. Of the sample, three participants (66%) worked in acute care and one (17%) worked in primary care. The fifth participant (17%) reported working with the underserved population but did not specify the setting.

 

With this study, the researcher aimed to facilitate positive attitudes and reduce the negative beliefs of DNP students toward patients with OUDs by implementing a multifaceted educational intervention. By using the DDPPQ instrument before the classroom learning and after the 13-week intervention, students showed attitude changes in the expected direction. There were positive changes in the total overall mean scores in students after they completed the multifaceted educational intervention. The mean precourse baseline total score on the DDPPQ (M = 79.2, SD = 11.7) was higher than the follow-up total mean score on the DDPPQ (M = 64.0, SD = 11.7), with results indicating that DNP students' attitudes toward those patients with OUDs shifted. The calculated effect size (d) was 1.30, which according to Cohen (1992), constitutes a large effect size.

 

The subscales of self-esteem and role adequacy showed the greatest response. Table 1 presents pre and post mean scores and effect sizes for total instrument and the five therapeutic subscales of the DDPPQ. The table displays favorable change in all subscales. Subscale scores changed in expected directions. The findings were substantiated with written reflective assignments. For example, one student wrote: "I saw drug addicts as frightening and criminals" and, 10 weeks later, "I feel an obligation that could be my brother, my son, my friend or it could be me." Students indicated that the clinical experience provided them with the confidence to interview, connect, and provide care to those with OUDs. One student wrote: "I feel more comfortable discussing drug addiction usage with patients." Journals were replete with contemplation about patients' life stories and the student NPs' personal discoveries about their own biases.

  
Table 1 - Click to enlarge in new windowTABLE 1 Changes in Therapeutic Attitudes: Paired-Samples Test

DISCUSSION

This is the first study of its kind that we found that implemented a multifaceted practice-based intervention aimed at enhancing therapeutic attitudes of future NPs toward serving those with OUDs. This study incorporated direct clinical exposure, as well as a didactic and self-reflective learning process over time, guided by social cognitive theory. The study results indicated that the participant DNP students became more confident in their role as future providers to compassionately respond and treat those with OUDs. The change in DDPPQ scores indicated a positive change in participants' attitudes toward patients with OUDs after the intervention.

 

Bandura's theory proved helpful by organizing several modes of learning in one course. Graduate NP students became their own agents of change. Students began to reshape their approach to patients after observing a faculty practice champion. Written reflections supported score changes and indicated that the clinical exposure in the MAT center provided students with the confidence to interview, connect with, and provide care about OUDs. The results of reflective writing are supported by studies (Brondani & Pattanaporn, 2013; Siegal et al., 2000) that showed the value of clinical practicums that includes interacting with and providing care for those struggling with OUDs. Through the stories, students described and shared the meaningful experiences that resulted from their personal interactions with the patients. Most of the patient stories included major losses and traumatic experiences. Students wrote about the compassion and empathy they felt toward the patients at the treatment center.

 

LIMITATIONS

Participants were students registered in a DNP primary care course. The small sample precludes significance and generalizability. Future studies should have greater power and more diversity. The first author was a teacher of record and also the interventionist; therefore, there is a risk for bias. The nature of educational intervention was embedded in the student course, which could have led to results that were not authentic.

 

RECOMMENDATIONS AND CONCLUSIONS

The aim of this study was to decrease the negative beliefs of DNPs regarding the care of individuals with OUDs. The small sample prohibited statistical significance and generalizability. However, the change in participants' mean scores and large effect sizes indicated movement in the desired direction toward more therapeutic attitudes toward this vulnerable population. The study design engaged participants in a multidimensional, 13-week program of didactic, role modeling, and clinical experience that was grounded in a strong theoretical base.

 

Study participants' positive attitude changes and personal reflections point to the possibility that such educational encounters bode well for developing more confident, skilled, and compassionate DNPs to meet the opioid crisis. Nurse educators must continue to evaluate and rethink curricula in ways that address underlying stigmatizing beliefs that interfere with full professional role enactment. Faculty knowledge, skills, and passion are prerequisite to effective change.

 

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