Improving nurses' therapeutic attitude to patients who use illicit drugs: Workplace drug and alcohol education is not enough

Patients, colleagues, systems, and self: Exploring layers of physician emotions in caring for pregnant people who use substances and their newborns

INTRODUCTION

Pregnant people who use substances experience significant stigma, including in healthcare settings, where physicians make high-stakes decisions about treatment plans, resource allocation, and even a person's ability to parent. Previous psychology research has demonstrated the influence of emotions on decision-making, as well as on the development and expression of stigma. Yet the specific content of physician emotions, as well as approaches to processing these emotions, has been relatively under-examined. We sought to better understand the emotional experiences of physicians who practice in safety-net labor and delivery/inpatient settings to inform strategies to facilitate more humanizing, equitable care.

METHODS

From March 2021 to June 2022, the study team conducted semi-structured interviews with 24 San Francisco Bay Area-based physicians (obstetrics-gynecology, pediatrics, family medicine) caring for pregnant people who use substances and/or their newborns. We used deductive and inductive coding and identified themes regarding the nature, etiology, and processing of physician emotions.

RESULTS

Physicians described experiencing a range of emotions related to interpersonal (patients, colleagues), systems-level, and internal dynamics. Emotions such as anger, sadness, frustration, and helplessness resulted from their deep care and empathy for patients, witnessing stigmatizing colleague behaviors, disagreement with punitive systems, and recognition of their own limitations in effecting change. Few participants identified strategies for processing these emotions, and several described efforts to disengage from their emotional experience to preserve their sense of well-being and professionalism.

CONCLUSIONS

Physicians caring for pregnant people who use substances and their newborns experienced intense, multi-layered emotions. This study posits that additional efforts to support physician emotional processing and structural competency could improve healthcare experiences and outcomes for pregnant people who use substances.

Integrating Hospital-Based Harm Reduction Care-Harnessing the Nursing Model

Hospitals are risk environments for people who use drugs, and most hospitals are unprepared to deliver substance use disorder (SUD) care, including harm reduction (HR) interventions. HR philosophy clashes with traditional hospital hierarchy and norms, and staff may resist HR interventions due to stigma, fear of enabling substance use, legal and safety concerns. Nurses are central to hospital culture and care and could promote and deliver HR care. Our US hospital has an inter-professional addiction consult service (ACS) that includes medical providers, social workers, and peers. We developed and launched a hospital-based registered nurse-(RN) led HR intervention, including distributing safe-use supplies (eg, syringes). We describe model development and early experience, using an Exploration, Preparation, Implementation, and Sustainment framework. ACS experiences and community HR interventions informed our exploration phase. In the preparation phase we secured funding from Medicaid payers for a 2-year pilot, including full-time RN salary and HR supplies. We elicited buy-in from hospital executive leaders, partly by partnering with nurse champions who described unmet patient care and staff education needs. We consulted hospital lawyers and developed an institution-wide media campaign targeting staff, including in-person booths distributing naloxone and materials promoting international overdose awareness day (eg, "#EndOverdose" buttons). We collaborated with local and national experts to develop the intervention, which includes RN bedside HR education and staff trainings. The Implementation was from September 2022 to March 2023. We trained 459 staff (over 15 trainings) and conducted 209 patient encounters. Generally, patients and staff embraced the HR RN role, including previously controversial safe-use supply distribution. Sustainment efforts include engaging stakeholders in continuous improvement and evaluation efforts. A nurse-led hospital-based HR intervention can expand patient services, support staff, and bridge HR and medical models.

Implementation of a nursing oral health care protocol in a university teaching hospital: A cluster-randomized stepped-wedge design

INTRODUCTION

Providing oral care is an essential part of basic nursing care but receives little priority in daily practice, with a risk of adverse events. Also, nurses report many barriers to adequate provision of oral care, such as time restraints, insufficient materials, fear of causing pain, lack of knowledge and a negative attitude towards providing oral care.

METHODS

We performed a cluster-randomized, stepped-wedge study to explore the effect of the the implementation of a new nursing evidence-based oral care protocol on nurses' knowledge, attitude and protocol adherence. The study population included both nursing students, graduated nurses and patients in selected wards. The implementation strategy included oral and written information, instruction videos and reminders. Nurses' knowledge and attitude towards oral care were assessed at baseline and after the implementation of the protocol with a validated 47-item questionnaire with a score range of 0-100. Secondarily, nurses' protocol adherence to teeth brushing, measured in Activities of Daily Living (ADL) dependent patients, was evaluated. The Standards for Reporting Implementation Studies (StaRI) Statement was used.

RESULTS

At baseline, the questionnaire was completed by 226 nurses; after implementation by 283. Knowledge had significantly improved from 68.8 to 72.3. Nurses' attitude improved not significantly. Protocol adherence was assessed in 73 ADL-dependent patients at baseline, in 51 after implementation. Adherence to teeth brushing significantly decreased in patients with permanent teeth. Also, adherence to both teeth brushing and usage of soap decreased in patients with (partial) dentures.

CONCLUSION

Nurses' knowledge and attitude of oral care increased somewhat after the implementation of a new nursing evidence-based protocol. After implementation, there was an unexplained decreased adherence to oral care in ADL-dependent patients.

Factors Associated with Nurses' Motivation to Provide Care for Patients with Alcohol Use and Alcohol Use-Related Problems

BACKGROUND

There is a high human and economic cost associated with alcohol use and alcohol use-related problems. Nurses have a pivotal role in addressing the needs of this patient population. Purpose: The study aimed to examine the correlation between nurses' demographics/background characteristics, personal attitudes, professional attitudes, and their motivation to provide care to patients with alcohol use and alcohol use-related problems.

METHODS

A descriptive, cross-sectional correlational design was utilized. Nurses were recruited from four Southwestern Pennsylvania hospitals. The study variables were examined using questionnaires that explored nurses' demographic/background characteristics, their personal and professional attitudes, and motivation to care for patients with alcohol use and alcohol use-related problems.

RESULTS

The sample included 234 nurses. Demographic/background characteristics were identified as associated with nurse's alcohol use-related motivation, including gender, primary work setting and specialization. Previous personal experience with alcohol use-related problems (nurses themselves or co-workers), familiarity, perceived dangerousness, fear, social distance, personal responsibility beliefs and disease model were also associated with nurses' alcohol use-related motivation to care for these patients. In addition, all professional attitudes were associated with nurses' motivation toward caring for patients with alcohol use and alcohol use-related problems.

CONCLUSIONS

The study revealed that certain demographic/background characteristics and personal and professional attitudes were associated with nurses' motivation to provide care to this patient population. This study provides the foundation for future studies aimed at exploring predictors of nurse's motivation to care for patients with alcohol use and alcohol use-related problems.

Inpatient care provider perspectives on the development and implementation of an addiction medicine consultation service in a small urban setting

BACKGROUND

To evaluate provider perspectives on the development and implementation of an inpatient Addiction Medicine Consult Service, including their awareness of the service, its perceived role in the continuum of care, and changes over time in their perceptions of care quality for inpatients with substance use disorders.

METHODS

Repeated cross-sectional survey of hospital-based physicians, nurses and social workers performed at service launch (April-June, 2017) and 4 years later (March-June, 2021).

RESULTS

Providers had generally positive perceptions of the service and its impact on care quality, but encountered significant barriers at both time points in meeting patient needs (related to high patient complexity and difficulty connecting patients with community services post-discharge). Relative to physicians and social workers, nurses were less likely to be familiar with the service or see it as beneficial.

CONCLUSIONS

Findings indicate that the service fills a gap that existed previously in the local system of care; however, numerous opportunities exist to further strengthen the system beyond the hospital setting to promote longer-term health among people who use substances. For nurses in particular, outreach, education, and other resources (e.g., dedicated nursing role support, nurse liaison) are warranted to ensure that nurses feel supported and confident caring for this patient population.

An Experimental Study of the Effects of Patient Race, Sexual Orientation, and Injection Drug Use on Providers' PrEP-Related Clinical Judgments

Social biases may influence providers' judgments related to pre-exposure prophylaxis (PrEP) and patients' consequent PrEP access. US primary and HIV care providers (n = 370) completed an experimental survey. Each provider reviewed one fictitious medical record of a patient seeking PrEP. Records varied by patient race (Black or White) and risk behavior (man who has sex with men [MSM], has sex with women [MSW], or injects drugs [MID]). Providers reported clinical judgments and completed measures of prejudice. Minimal evidence of racially biased judgments emerged. Providers expressing low-to-moderate sexual prejudice judged the MSM as more likely than the MSW to adhere to PrEP, which was associated with greater PrEP prescribing intention; sexual prejudice was negatively associated with anticipated MSM adherence. Providers judged the MID to be at higher risk, less likely to adhere, less safety-conscious, and less responsible than both the MSM and MSW; adverse adherence and responsibility judgments were associated with lower prescribing intention.

Roles and Perceptions of Nurses During Implementation of a Medication Treatment for Opioid Use Disorder National Initiative

BACKGROUND

In the United States, a national priority exists to improve access to medication treatment for opioid use disorder (MOUD). Nurses can be an essential component of that care. We examined the perceptions and evolving roles of nurses in a national Veterans Health Administration (VHA) initiative designed to improve MOUD access within general medical settings.

METHODS

From April 15, 2021, to June 16, 2021, we recruited nurses participating in VHA's Stepped Care for Opioid Use Disorder Train the Trainer Initiative-a national program intending to implement MOUD in general medical settings-to participate in an interview about their roles, perceptions, and experiences. The respondents answered our inquiries through an interview or responded to an email solicitation with written responses, which were then recorded, transcribed, and independently coded to identify themes.

RESULTS

Nurses from 10 VHA facilities participated in an interview (n = 7) or completed the questionnaire (n = 4). Inadequate staffing, high patient-to-provider ratios, and time constraints were identified as barriers to MOUD care. Mentorship activities, existing VHA informational resources, and patients' willingness to accept treatment were identified as facilitators of MOUD care. The Stepped Care for Opioid Use Disorder Train the Trainer Initiative processes were acknowledged to promote role confidence, which in turn increased job satisfaction and empowered nurses to become content experts. Respondents often identified nurses as local lead facilitators in MOUD care.

CONCLUSIONS

In a national initiative to implement MOUD within general medical settings, nurses identified several barriers and facilitators to MOUD implementation. Nurses play vital collaborative care roles in enhancing access to MOUD.

Attitudes, perceptions, self-efficacy and knowledge levels of Israeli nurses in relation to opioid misuse: A cross-sectional survey

BACKGROUND

In an opioid epidemic that is imposing heavy health burdens on individuals, families and health systems, nurses are the main front-line caregivers in the battle against the unrelenting increase in opioid medication misuse. Yet, little research has been conducted on nurses' opinions and knowledge surrounding this issue worldwide and in Israel as well.

OBJECTIVES

To evaluate Israeli nurses' attitudes, their knowledge about opioid use and misuse, their perception of institutional support, and their perception of their role and self-efficacy in preventing and treating opioid misuse.

DESIGN

Cross-sectional study.

METHODS

The data were collected through an electronic questionnaire from 414 Israeli registered nurses using the Qualtrics platform for on-line surveys.

RESULTS

The majority of the sample perceived their role positively, held positive attitudes toward people with opioid addiction, and were willing to take care of persons who misused opioids. Nurses reported low scores on knowledge, perceived institutional support, and self-efficacy relating to the issues surrounding opioid pain medication use and misuse.

CONCLUSIONS

The results clearly indicate a lack of up-to-date knowledge among nurses concerning opioids use. This situation must be urgently corrected through revisiting the subject of opioids across undergraduate, graduate, and continuing nursing education programs. Improved knowledge, combined with a supportive organizational culture, should strengthen nursing care provided to this frequently neglected patient population.

CLINICAL RELEVANCE

Broad insight into nurses' attitudes, their level of knowledge about opioid use and misuse, and their perceptions of their own role in preventing and treating such misuse are essential for creating targeted, relevant educational interventions for nurses with the aim of providing safe and effective opioid treatment for individuals with pain.

Personal and professional attitudes associated with nurses' motivation to work with patients with opioid use and opioid use-related problems

BACKGROUND

Opioid use and opioid use-related problems contribute significantly to increased morbidity rates and premature deaths as well as an increased economic burden. Nurses have key roles in providing care to this patient population; however, they often report low motivation toward working with these patients. Examining personal and professional attitudes associated with nurses' motivation to work with this population can present a valuable opportunity to enhance their willingness to intervene at an earlier stage when patients do not have a diagnosable opioid use disorder. Methods: A descriptive, correlational design was used. Nurses were recruited from four hospital settings in Southwestern Pennsylvania. Data on nurses' demographic/background characteristics, personal attitudes, professional attitudes, and motivation related to working with patients with opioid use and opioid use-related problems were collected via a paper/pencil survey and analyzed using linear regression. Results: A sample of 234 nurses were included in the final analyses. Personal attitudes associated with nurses' motivation included personal experience with a family member related to alcohol and/or other drugs, and stigma perceptions (familiarity, perceived dangerousness, fear, social distance and personal responsibility beliefs). Professional attitudes associated with nurses' motivation included working experience with substance use (SU), SU education as continuing education or other educational resources, role security, therapeutic commitment, role responsibility, and self-efficacy. Conclusions: This study's findings provide valuable information regarding the bivariate relationships between nurses' personal attitudes, professional attitudes, and motivation to work with patients with opioid use and opioid use-related problems. The study provides a base for future studies aimed at developing interventions to enhance nurses' motivation to work with this patient population particularly related to preventing the progression of opioid use to a diagnosable disorder.

Critical care nurses' experiences of nursing intoxicated patients after abuse of drugs

BACKGROUND

Patients intoxicated after abusing illicit drugs constitute a significant proportion of patients cared for in intensive care units. Intensive critical care nurses who nurse accidentally intoxicated patients face complex and demanding situations, and there is a lack of studies regarding this topic.

AIMS AND OBJECTIVES

To illuminate Swedish intensive critical care nurses' experiences of nursing accidentally intoxicated patients after abuse of illicit drugs.

DESIGN

A qualitative design with an inductive approach was used.

METHODS

Semi-structured interviews were conducted with eight intensive critical care nurses at an intensive care unit in Sweden. Data were analysed using qualitative content analysis.

FINDINGS

The themes found illuminate intensive critical care nurses' experiences of nursing accidentally intoxicated patients after their abuse of illicit drugs: feeling empathy and a wish to provide dignified care; dreading nursing the patient and feeling a lack of empathy; feeling frustration and questioning the care; lacking knowledge about a complex and challenging situation.

CONCLUSIONS

It is essential to respond to intoxicated patients with empathy and dignity. Intensive critical care nurses should learn how to identify factors that lead to provocation and agitation in order to reduce the occurrence of dangerous situations in intensive care units.

RELEVANCE TO CLINICAL PRACTICE

To create a caring environment where the interaction becomes more positive and harmonious, an intensive care nurse needs a deep understanding of what a drug abuse disorder means. Moreover, the ability to see the person behind the abuse and to provide non-judgemental support is required. WHAT IS KNOWN ABOUT THIS TOPIC Patients intoxicated after abuse of illicit drugs constitute a significant proportion of patients cared for in ICUs worldwide. Intensive critical nurses who nurse accidentally intoxicated patients face complex and demanding situations, and few studies have addressed this topic. WHAT THIS PAPER CONTRIBUTES It is essential to respond to intoxicated patients who are admitted to the ICU with empathy and dignity, as well as to learn how to identify factors that lead to provocation and agitation in order to reduce the occurrence of dangerous situations. Education is warranted and must be enhanced, including knowledge about drug abuse and training in communication and empathy Nursing should include an understanding of what the disease of drug abuse means and the development of the ability to see the person behind the abuse and to provide non-judgemental support.

Leveraging Nurses to Improve Care for Patients with Concurrent Disorders in Inpatient Mental Health Settings: A Scoping Review

Objective: Several challenges have been identified for patients with concurrent disorders and the providers that care for them, contributing to a pressing need for interventions to improve outcomes, particularly within inpatient mental health settings. Methods: A systematic search of peer-reviewed literature was conducted using four online databases: CINAHL, MEDLINE (Ovid), PsycInfo and Web of Science. Articles were selected based on inclusion criteria and additional articles were identified through hand searches. Study details were charted and qualitative synthesis was conducted. Results: Thirty two articles met inclusion criteria. A substantial focus within the literature was education, with higher levels of education shown to improve healthcare provider attitudes and practices. Within this overarching focus, four themes were identified: 1) education as an intervention to improve attitudes and increase confidence and knowledge; 2) strategies to support practice change, including interventions aimed at clinical leaders and methods to address substance use among inpatients; 3) frameworks to guide care; and 4) opportunities to expand nursing scope of practice. Conclusions: Given the substantial evidence indicating that education improves nurses' knowledge, attitudes and practices, there is great promise in expanding educational intervention opportunities for nurses to improve care and outcomes for patients with concurrent disorders-a priority patient population.

Burnout and Mental Health Stigma Among Juvenile Probation Officers: The Moderating Effect of Participatory Atmosphere

Despite high rates of mental health problems among juvenile justice-involved youth, mental health stigma among juvenile probation officers (JPOs) is under-studied. This cross-sectional study examined effects of job burnout and workplace participatory atmosphere on mental health stigma among JPOs across Indiana (n = 226). Participatory atmosphere moderated the relationship between JPO burnout-related cynicism and mental health stigma (interaction β = - 0.14, p = .04); burnout was related to greater mental health stigma at low levels of participatory atmosphere. Findings suggest participatory atmosphere mitigates effects of burnout on mental health stigma among JPOs. Organizational-level interventions might help to reduce mental health stigma and combat negative effects from burnout among JPOs.

Improving Care Provision to Older Adults with Dual Diagnosis: Recommendations from a Mixed-Methods Study

Older adults with dual diagnosis remain an under-diagnosed population in mental health services, with complex needs and high rates of medical comorbidity. Dual diagnosis is a significant challenge to contemporary mental health services, with recognition of the increased rate of relapse and costs of care of poorly managed dual diagnosis identified through comprehensive research. Unfortunately, the research attention paid to those with dual diagnosis in younger age groups has not been replicated in the older adult cohort, with few studies specifically exploring the treatment needs of these individuals. Of the studies that do exist, many identify poor screening and assessment, clinician frustration and a lack of cohesive treatment for co-occurring alcohol and other drug use disorders for older adults. We draw from a mixed methods exploratory study conducted in an inner Melbourne community older adult mental health service providing care to consumers with dual diagnosis to formulate recommendations to improve the care provision to this cohort. We discuss changes to the way older adult mental health services operate that are essential to improve the care and response to consumers presenting with dual diagnosis. Ultimately, we aim to discuss how older adult mental health services can improve to provide timely, responsive care to those with dual diagnosis.

Barriers and facilitators in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs: A qualitative study of midwives' experience

BACKGROUND

Screening pregnant women for substance use is highly recommended in antenatal care settings. Although midwives provide routine screening for substance use and referral for treatment in pregnancy, little is known about the barriers and facilitators they experience.

AIM

The study explored barriers and facilitators experienced by midwives in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs.

DESIGN/SETTING

A semi-structured interview was adopted to explore barriers and facilitators experienced by midwives in screening and referring pregnant women for alcohol or other drugs specialised services. Eighteen midwives were recruited from urban, regional and rural antenatal settings in Victoria. Interviews were tape recorded and transcribed verbatim. Themes were generated by thematic analysis, the process of identifying patterns within the data.

FINDINGS

Of the seven themes identified under barriers, five could be categorised as "institution and provider-related", namely: (i) lack of validated screening tool, (ii) inadequate support and training, (iii) discomfort in screening, (iv) lack of multidisciplinary team and specialised treatment in regional and rural areas, and (v) workload and limited consultation time. Conversely, two themes could be classified as 'client-related', namely (i) non- or partial-disclosure of substance use, and (ii) reluctance and non-adherence to referrals. All five themes under facilitators were "institution and provider-related." They are (i) a woman-centred philosophy of care, (ii) evidence of harms from substance use on neonates, (iii) experience and training, (iv) continuity of care, and (v) availability of multidisciplinary team and funding.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

To the best of our knowledge, this is the first study of its kind conducted in Victoria. This study not only adds to the limited body of knowledge on barriers experienced by midwives but also identifies facilitators in antenatal settings that promote screening and referral of pregnant women who use substance. Most of the barriers and facilitators are interrelated. Despite midwives' willingness to screen all pregnant women for substance use and provision of referral, they often felt limited in their capacity. Availability and accessibility to validated screening tool(s), in addition to regular, ongoing training for all midwives to maintain clinical competence and provide effective communication are imperative. Availability of a multidisciplinary team, funds and specialised care facilities such as detoxification and mental health services, especially in regional and rural areas, are necessary to effectively support at-risk pregnant women.

Patient perspectives on a harm reduction-oriented addiction medicine consultation team implemented in a large acute care hospital

BACKGROUND

Addiction medicine consultation teams [AMCTs] are a promising strategy for improving hospital care for patients with substance use disorders. Yet very little research has examined AMCT implementation in acute care settings. To address this gap, we conducted a process evaluation of a novel harm reduction-oriented AMCT. Our specific aims included examining patients' perspectives on factors that facilitated or hindered AMCT delivery, and its impact on their hospital care and outcomes.

METHODS

The AMCT provided integrated addiction medicine, harm reduction services, and wraparound health and social supports for patients of a large, urban acute care hospital in Western Canada. We adopted a focused ethnographic design and recruited 21 patients into semi-structured interviews eliciting their views on the care they received from the team.

RESULTS

Participants highlighted the AMCT's harm reduction approach; reputation amongst peers; and specialized training as especially important intervention facilitators. Key barriers that constrained the impact of the team included unmet expectations; difficulty accessing follow-up care; and residual conflicts between the AMCT's harm reduction approach and the abstinence-only orientation of some hospital staff. For a few participants these conflicts led to negative experiences. Despite this, participants reported that the AMCT had positive impacts overall, including declines in substance use, enhanced mental and emotional wellbeing, and improved socio-economic circumstances.

CONCLUSIONS

A novel harm reduction-oriented AMCT led to better hospital experiences and perceived outcomes for patients. However, further efforts are needed to ensure adequate post-discharge follow-up, and a consistent approach to substance use disorder care amongst all hospital staff.

"You're kind of at war with yourself as a nurse": Perspectives of inpatient nurses on treating people who present with a comorbid opioid use disorder

BACKGROUND

In the midst of an opioid epidemic, health care workers are encountering an increasing number of patients who have opioid use disorder in addition to complex social, behavioral and medical issues. Of all the clinicians in the hospital, nurses spend the most time with hospitalized patients who have opioid use disorder, yet there has been little research exploring their experiences in caring for this population. The objective of this study was to assess the attitudes, perceptions, and training needs of nurses in the inpatient setting when caring for patients who have opioid use disorder.

METHODS

One-on-one in-depth interviews were conducted with nurses working at a large academic medical center in Boston, MA, using a semi-structured interview guide. Nurses were recruited via email notifications and subsequent snowball sampling. Interviews were recorded, transcribed and analyzed using a grounded theory approach.

RESULTS

Data from in-depth interviews with 22 nurses were grouped into six themes: (1) stigma, (2) assessing & treating pain, (3) feelings of burn out, (4) communication between providers, (5) safety & security, and (6) opportunities for change. These themes were organized within four ecological levels of the Socio-Ecological Model: I) societal context, II) hospital environment, III) interpersonal interactions, and IV) individual factors. Nurses were cognizant of the struggles that patients who have opioid use disorder confront during hospitalization such as pain, withdrawal and stigma, and elaborated on how these challenges translate to professional and emotional strain among nurses. Nurses offered recommendations by which the hospital could streamline care for this population, including expanded role support for nurses and more structured policies regarding care for patients who present with a comorbid opioid use disorder.

CONCLUSION

Our results highlight the need for the development of programs targeting both organizational culture and the inpatient nurse quality of life to ultimately enhance quality of care for patients who present with opioid use disorder.

Moving from stigmatization toward competent interdisciplinary care of patients with functional neurological disorders: focus group interviews

PURPOSE

To explore facilitating and inhibiting factors in the inpatient care of patients with functional neurological disorders as experienced by interdisciplinary teams of healthcare professionals.

METHOD

Qualitative focus group interviews were conducted with 18 healthcare professionals of various professions. Data were analyzed using qualitative content analysis with inductive coding of data.

RESULTS

Two main categories were formulated: (a) Giving the diagnosis to patients - a moment of fragility and opportunities, and (b) Organization of care - ensuring the continuity and protecting patients' self-image. One overarching theme tied the two categories together: Establishing coherence in the inpatient trajectory - moving from stigmatization toward competent care. Coherence and steadiness in care was a prerequisite for transparency in goalsetting and for designating the responsibilities of individual healthcare professionals. Stigma and having clinical experience and knowledge of functional neurological disorders, as two counter-factors, influenced the extent to which this was achieved. Examples of facilitating factors for enhancing competent care were documentation of symptoms, effective ways of passing on clinical information, education, professional dialog, and organizational support.

DISCUSSION

To nurture competent care, guidelines, structured educational initiatives and other supportive actions should be promoted. We provide ideas for the next logical steps for clinical practice and research.IMPLICATIONS FOR REHABILITATIONClose collaboration between interdisciplinary healthcare professionals plays an important role for reaching optimal results in the rehabilitation of inpatients with functional neurological disorder.There is currently limited knowledge regarding the facilitating and inhibiting features encountered by interdisciplinary healthcare professionals in the provision of care for patients with a functional neurological disorder.The findings show that a working environment that endorses a skillful culture of practice and which facilitates actions to reduce problems that hamper effective teamwork needs to be promoted.Solutions that help to solve many obstacles encountered by the team of healthcare professionals in the care provision of patients with functional neurological disorders include open dialog regarding symptoms, diagnosis and treatment, effective ways of documenting and reporting symptoms, and availability of guidelines and supporting educational material.

Pharmacists' attitudes and practices about selling syringes to people who inject drugs in Tajikistan: Results of a syringe purchase audit and a survey

BACKGROUND

In Tajikistan, governmental policies leave the decision whether or not to sell syringes to people who inject drugs (PWID) to pharmacists' discretion. This exploratory study tests a theory-driven model explaining Tajikistani pharmacists' actual syringe sale practices to inform future HIV advocacy activities.

METHODS

Data were collected via attempts to purchase syringes without prescription and a subsequent survey among a sample of 232 pharmacists in two cities (Dushanbe and Kulob) in Tajikistan in 2015. The survey collected data on attitudes and beliefs related to selling syringes to PWID, stigma against PWID and background contextual factors such as social conservatism, HIV and drug use knowledge. Structural equation modelling was used to assess the relationships between syringe sale practice and pharmacists' attitudinal and background factors.

RESULTS

The majority (87.9%, n = 204) of sampled pharmacists agreed to sell syringes to the study research assistants without a prescription. According to the final model, agreeing to sell syringes was moderately associated with the reported intent to provide syringes without prescription (β = 0.36, p < 0.001), lower stigma against PWID (β=-0.43, p = 0.01), and stronger social conservatism (β = 0.35, p = 0.02). Intent to provide syringes correlated with positive attitudes towards provision of syringes (β = 0.35, p = 0.008), which in turn were negatively associated with stigma (β=-0.54, p < 0.001) and positively with age (β = 0.20, p = 0.03). Stigma against PWID was directly associated with social conservatism (β = 0.47, p < 0.001) and inversely with university-level education (β=-0.28, p < 0.001).

CONCLUSION

We demonstrated the accessibility of over-the-counter syringes in urban pharmacies of Tajikistan and emphasized the role of stigma in shaping pharmacists' syringe sale practices. Advocacy interventions should target pharmacists to reduce stigmatization of PWID and ensure access to clean syringes.

Assessing prevalence of alcohol consumption in early pregnancy: Self-report compared to blood biomarker analysis

Providing appropriate antenatal and postnatal care for women who drink alcohol in pregnancy is only possible if those at risk can be identified. We aimed to compare the prevalence of alcohol consumption in the first trimester of pregnancy using self-report and blood biomarker analysis. Six-hundred routine blood samples from 2014, taken at the antenatal booking appointment, in the first trimester of pregnancy, were anonymously analysed for the presence of Carbohydrate Deficient Transferrin (CDT), a validated marker of chronic alcohol exposure (normalising 2-3 weeks from abstinence) and Gamma-glutamyltransferase (GGT), a liver enzyme elevated for up to 8 weeks after alcohol exposure. In a separate sample of women, from 2015, data taken during the antenatal visit, documenting women's self-reported alcohol consumption, were collected. The percentage of women who reported alcohol intake in the first trimester was 0.8%. This compared to 74.1% of women who reported consuming alcohol before pregnancy. CDT analysis revealed a prevalence rate of 1.4% and GGT a prevalence rate of 3.5% in the first trimester of pregnancy. Although those with elevated CDT generally had high levels of GGT, only one person was positive for CDT and GGT. Results from CDT analysis and self-report may underestimate prevalence for different reasons. GGT appeared to lack specificity, but it may have value in supporting findings from CDT analysis. Further studies using additional blood biomarkers, or a combination of blood biomarkers and self-report, may be beneficial in accurately detecting alcohol drinking history in pregnancy.

Exploring the experiences of staff working at an opiate assisted treatment clinic: An interpretive descriptive study

There have been many advances in harm reduction over the past three decades. One of the newest approaches is the provision of medical grade heroin to people with opiate addiction, known as opiate assisted treatment (OAT). There is one clinic in North America which provides this service. The goal of this study was to uncover how clinic staff provide care to those who attend this clinic, their perspectives on how the clinic program impacted them and their patients, and their opinions about the program itself. This was a qualitative study with an interpretive descriptive methodology underpinned by critical social theory. Convenience sampling yielded 22 participants - 18 nurses, two social workers and two peer support workers. Thematic analysis was undertaken to identify recurring, converging and contradictory patterns of interaction, key concepts and emerging themes. The study location was the OAT clinic located in the downtown eastside of Vancouver, BC. The findings were organized around the following six themes: from chaos to stability, it's not all roses, a little preparation would be good, putting the patient at the centre, the stigma hasn't gone away, and the clinic is life transforming. Taken together, these themes indicate the complexities of working in this environment. The findings can guide clinic staff, including nurses, in how they provide care to patients with addiction problems and also provide direction for policy makers on harm reduction planning. CONTRIBUTION OF THE PAPER: What is already known about the topic? What does this paper add?

A survey of attitudes, beliefs and practice regarding alcohol use and screening in pregnancy: an opportunity for support and education?

Providing antenatal and postnatal support for women who drink alcohol in pregnancy is only possible if those at risk can be identified. However, screening will only be helpful if women feel comfortable with the method used. We conducted a survey of pregnant women and their partners to investigate self-reported beliefs and practice regarding drinking during pregnancy and the acceptability of screening. Pregnant women and their partners attending antenatal clinics in North-East England were asked to complete a short survey regarding their alcohol consumption in pregnancy, their beliefs about safe levels of alcohol in pregnancy and whether they would be happy to have their blood or their baby’s meconium analysed for alcohol biomarkers. The data were summarised using descriptive statistics and thematic analysis. A total of 171 pregnant women and 41 partners participated. Of the pregnant women, 153 (89.5%) felt women should abstain from alcohol consumption, although only 70 (40.9%) reported not drinking in pregnancy. Of 96 women who reported drinking in pregnancy and reported when they stopped, all but six (6.3%) stopped drinking when they found out they were pregnant. Of women and partners who recorded an answer, 177 (87.2%) said they would consent to blood biomarker analysis. Confusion over what level of alcohol is safe and using screening as an opportunity for education and support emerged as key themes from free-text responses. Most women viewed screening for alcohol in pregnancy positively, although its acceptability in the small number of women who continue to drink is unclear.

How strong is the evidence for using blood biomarkers alone to screen for alcohol consumption during pregnancy? A systematic review

Accurate and early identification of women at risk from alcohol consumption during pregnancy allows education and support programmes to be targeted at those most in need. We aimed to conduct a systematic review to compare the efficacy of blood analysis and maternal self-report in detecting at risk women during pregnancy. This review investigated diagnostic accuracy. We searched four databases (Medline, Embase, Psychinfo and CINAHL) for relevant articles and conducted hand searches of recent issues of key journals in the field. No restriction was placed on inclusion in terms of publication date or language. Studies were deemed eligible if they were original research and included a direct comparison of the results of blood biomarker analysis and self-reported alcohol use for the detection of alcohol consumption in pregnant women. Quality appraisal of included studies was conducted using the QUADAS II tool. Eight studies met the inclusion criteria. Gamma-glutamyltransferase (GGT) was investigated in five studies, mean corpuscular volume (MCV) and phosphatidylethanol (PEth) in three studies and carbohydrate deficient transferrin (CDT), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and whole blood associated acetaldehyde assay (WBAA) were each investigated in two studies. Although all of the studies were rated of good methodological quality, none of the biomarkers had both high sensitivity and specificity when compared to self-report. There was some evidence that a combination of biomarkers, or combining biomarkers with self-report, increases accuracy. In summary, the blood biomarkers examined were of limited use in screening for low and moderate alcohol consumption in pregnancy when compared to self-report. However, certain biomarkers, such and CDT and PEth may complement self-report and help improve the accuracy of diagnosis.

Alcohol and Other Drug (AOD) Education for Hospital Staff: An Integrative Literature Review

Alcohol and Other Drug (AOD) education amongst hospital staff is often inadequate. This leads to suboptimal care of patients and is a missed opportunity for early identification and treatment. This integrative review evaluates the core features of current education for hospital-based doctors and nurses in AOD, including country of origin, content, duration, and pedagogy. The majority of included studies were conducted in the USA (72%), target alcohol rather than AOD in general (72%), adopted a purely medical model of treatment (94%), and utilised a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model (94%). The overall quality of the studies was weak-moderate, which led to small effect sizes in most studies and limits the generalizability of any conclusions. More high quality research trials are needed to establish the core features of effective AOD education for hospital staff. Future research should include a focus on the psychosocial context of addiction, other drug use and the impact of negative attitudes on care delivery.

Relationship between Provider Stigma and Predictors of Staff Turnover among Addiction Treatment Providers

To further our knowledge about feasible targets for improving quality of addiction treatment services, the current study provides preliminary assessment of the relationship between provider stigma and indicators of staff turnover. As predicted, results suggest that higher provider stigma was significantly related to lower ratings of job satisfaction and workplace climate. However, provider stigma was not significantly related to burnout. Our preliminary findings, if replicated, suggest the importance of considering provider stigma as a risk factor for future staff turnover and job dissatisfaction. Promising provider stigma interventions do exist and offer viable opportunity for improving quality of addiction treatment.

Nursing students' experiences with screening, brief intervention, and referral to treatment for substance use in the clinical/hospital setting

Although Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an effective early intervention when used across healthcare settings, its implementation has been difficult, in part because of lack of training, healthcare providers' feelings of low self-efficacy in performing SBIRT, and negative attitudes about people who use alcohol and drugs. This study used qualitative descriptive methods to examine baccalaureate nursing students' experiences with practicing SBIRT in clinical rotations following in-depth classroom work and skill-based training. Fifty-five junior level nursing students participated in four focus groups. Three overarching themes describe students' experiences with SBIRT. Students expressed a positive impact of the training on their attitudes and feelings of self-efficacy regarding the use of SBIRT, differences in opinions about whether SBIRT should be used universally with all patients or as a targeted intervention with only some patients, and that SBIRT is a nursing responsibility. These results suggest that education and training can affect attitudes and efficacy, but that attention needs to be paid to how SBIRT is implemented within different healthcare settings.

Challenges in nursing practice: nurses' perceptions in caring for hospitalized medical-surgical patients with substance abuse/dependence

OBJECTIVE

The objective of this study was to investigate nurses' perceptions of caring for hospitalized medical-surgical patients with comorbid conditions of substance abuse/dependence.

BACKGROUND

Critical to this issue of quality patient care is the rising incidence of comorbid drug and alcohol abuse among hospitalized patients. Little research exists on the perceptions of nurses providing care to substance abuse/dependent medical-surgical hospitalized patients. There exists the need to further explore nurses' perceptions regarding caring for this challenging population.

METHODS

Using a qualitative inductive approach, a convenience sample of 24 nurses completed research questions regarding their perceptions of caring for hospitalized patients with substance abuse/dependence.

RESULTS

Data analysis revealed ethical duty to care, negative perceptions toward patients with substance abuse/dependence, need for further education, sympathy, and issues with pain management. Providing quality nursing care for the hospitalized medical-surgical patient with concomitant alcohol and/or drug dependence is challenging for nursing. Nurses need additional education and professional support in caring for these individuals.

Knowledge and attitudes of nurses towards alcohol and related problems: the impact of an educational intervention

An exploratory study of quasi-experimental approach that aimed to verify the impact of an educational intervention on attitudes and knowledge of nurses towards alcohol use and associated problems. The sample included 185 nurses, divided into two groups: 84 submitted to a training course and formed the experimental group. Data were collected through a knowledge survey and an attitude scale. The attitudes of the participants of both groups were positive. There were no significant differences between groups in relation to knowledge. The strongest predictors of positive attitudes were possessed preparation to act with chemical dependents (OR = 2.18), "have received increased workload during graduation on the theme, 'alcohol and other drugs'" (OR = 1.70), and "completed graduate school" (OR = 2.59). The educational intervention had a positive impact on the attitudes of nurses towards alcoholics, work and interpersonal relationships with such clientele.

Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review

BACKGROUND

Healthcare professionals are crucial in the identification and accessibility to treatment for people with substance use disorders. Our objective was to assess health professionals' attitudes towards patients with substance use disorders and examine the consequences of these attitudes on healthcare delivery for these patients in Western countries.

METHODS

Pubmed, PsycINFO and Embase were systematically searched for articles published between 2000 and 2011. Studies evaluating health professionals' attitudes towards patients with substance use disorders and consequences of negative attitudes were included. An inclusion criterion was that studies addressed alcohol or illicit drug abuse. Reviews, commentaries and letters were excluded, as were studies originating from non-Western countries.

RESULTS

The search process yielded 1562 citations. After selection and quality assessment, 28 studies were included. Health professionals generally had a negative attitude towards patients with substance use disorders. They perceived violence, manipulation, and poor motivation as impeding factors in the healthcare delivery for these patients. Health professionals also lacked adequate education, training and support structures in working with this patient group. Negative attitudes of health professionals diminished patients' feelings of empowerment and subsequent treatment outcomes. Health professionals are less involved and have a more task-oriented approach in the delivery of healthcare, resulting in less personal engagement and diminished empathy.

CONCLUSIONS

This review indicates that negative attitudes of health professionals towards patients with substance use disorders are common and contribute to suboptimal health care for these patients. However, few studies have evaluated the consequences of health professionals' negative attitudes towards patients with substance use disorders.

Nurses' attitudes toward clients with substance use problems

PURPOSE

This study aimed to examine factors associated with nurses' attitudes toward clients with substance use problems.

DESIGN AND METHODS

A cross-sectional design was used, and 489 nurses working in two medical centers in Taiwan participated in this study.

FINDINGS

Age, total nursing experience, work unit, personal experience, experience of taking care of clients with substance use problems, substance use education in school, and continuing education were significantly associated with nurses' attitudes. Hierarchical regression revealed that continuing education predicted nurses' overall attitudes. However, the model explained a low variance.

PRACTICE IMPLICATIONS

Education-focused training alone may not be adequate. Nursing workforce development needs to incorporate multiple strategies, including clinical supervision, when designing substance use education for clinical nurses in order to generate better improvements on attitudes.

Student nurses' attitudes to illicit drugs: a grounded theory study

The aim of this research was to identify the factors that influence the attitudes of student nurses towards illicit drugs. This insight is important in providing a foundation for the development of educational approaches aimed at challenging what appear to be negative attitudes to illicit drug users within nursing. The absence of a testable hypothesis prior to the investigation led to the generation of theory from the data (inductive enquiry) with a constructivist approach to grounded theory (Charmaz, 2006), being employed. Data generation involved informal conversational interviews (n=12), semi-structured interviews (n=9), four focus groups and an audit of the education received by students (n=61) around substance misuse issues. The final grounded theory indicated that: Student nurses enter training with a wide range of personal experiences relating to illicit drug use. The influences of society's negative views and the image of drug use presented in the press appeared to be significant factors in developing their attitudes on the subject. In the absence of effective approaches to education, and given that many professionals in the practice environment appear to view illicit substance users in a negative way, it is likely that interventions with identified drug users will be influenced by negative attitudes.

Staff regard towards working with substance users: a European multi-centre study

AIMS

To compare regard for working with different patient groups (including substance users) among different professional groups in different health-care settings in eight European countries.

DESIGN

A multi-centre, cross-sectional comparative study.

SETTING

Primary care, general psychiatry and specialist addiction services in Bulgaria, Greece, Italy, Poland, Scotland, Slovakia, Slovenia and Spain.

PARTICIPANTS

A multi-disciplinary convenience sample of 866 professionals (physicians, psychiatrists, psychologists, nurses and social workers) from 253 services.

MEASUREMENTS

The Medical Condition Regard Scale measured regard for working with different patient groups. Multi-factor between-subjects analysis of variance determined the factors associated with regard for each condition by country and all countries.

FINDINGS

Regard for working with alcohol (mean score alcohol: 45.35, 95% CI 44.76, 45.95) and drug users (mean score drugs: 43.67, 95% CI 42.98, 44.36) was consistently lower than for other patient groups (mean score diabetes: 50.19, 95% CI 49.71, 50.66; mean score depression: 51.34, 95% CI 50.89, 51.79) across all countries participating in the study, particularly among staff from primary care compared to general psychiatry or specialist addiction services (P<0.001). After controlling for sex of staff, profession and duration of time working in profession, treatment entry point and country remained the only statistically significant variables associated with regard for working with alcohol and drug users.

CONCLUSIONS

Health professionals appear to ascribe lower status to working with substance users than helping other patient groups, particularly in primary care; the effect is larger in some countries than others.