Examining nurses’ attitudes toward patients who use substances in the hospital setting

Abstract

Objectives This dissertation had two objectives. The first objective was to examine how to assess nurses’ attitudes toward patients who use substances (PWUS) in the hospital setting. The second objective was to describe nurses’ attitudes toward PWUS, factors related to these attitudes, and perceived barriers to providing high-level care to this patient population to facilitate organizational change. Methods A cross-sectional electronic survey was presented in the fall of 2024 to the 1,400 registered nurses (RNs) and registered practical nurses (RPNs) employed in direct patient care roles at an acute care academic hospital in northwestern Ontario, Canada. The outcome of interest was nurses’ attitudes toward PWUS as measured by the Alcohol and Alcohol Problems Perceptions Questionnaire (AAPPQ) and the Drug and Drug Problems Perceptions Questionnaire (DDPPQ). Participants were randomly assigned to complete either of the two measures noted or revised versions of those measures to include person-centred (PC) language (e.g., PC-AAPPQ and PC-DDPPQ). Factors related to these attitudes were assessed using validated measures of social desirability, workload, burnout, and adverse childhood experiences (ACEs), along with open-ended questions to explore the nurses’ experiences caring for PWUS in the hospital setting. Descriptive statistics, psychometric analyses, hierarchical regression, and inductive content analysis were used to address the study objectives. Results Manuscript 1 This scoping review found that nurses generally held negative attitudes toward PWUS in the hospital setting. Key contributing factors included limited knowledge of and education about substance use, challenges with pain management, and a lack of organizational support. These themes highlighted systemic issues that shaped the nurses’ attitudes and underscored the need for targeted interventions at multiple levels of the health care system. Manuscript 2 Modifying the AAPPQ and DDPPQ to reflect PC language (e.g., PC-AAPPQ and PC-DDPPQ) resulted in changes to their underlying factor structures, with neither the original nor the revised versions demonstrating optimal model fit. Exploratory analyses produced shortened, alternate factor models, suggesting that both the original and PC tools may require further refinement to remain psychometrically sound and conceptually aligned with contemporary societal and academic discourse on PC language. Manuscript 3 This study identified multiple factors associated with nurse’ attitudes toward PWUS in the hospital setting, with results varying across attitude measures and scales. Although contextual factors such as workload, burnout, and social desirability yielded inconsistent associations, education or training in substance use and/or addiction as professional development was consistently associated with more positive attitudes. Nurses working in mental health in-patient units also reported significantly more favourable attitudes, though this result may have reflected self-selection bias. These findings underscore the potential value of targeted education while highlighting the need for further research into contextual influences and the real-world impact of attitudinal change on patient care. Manuscript 4 Qualitative analysis identified six key barriers that the nurses faced delivering quality care to PWUS: (a) moral and professional tension, (b) lack of resources, (c) limited knowledge, (d) staffing shortages and high workload, (e) absence of organizational policy, and (f) negative and stigmatizing provider attitudes. To improve care, the nurses recommended five corresponding supports: (a) enhanced education and training, (b) increased resources, (c) additional staffing, (d) clear hospital policies, and (e) strengthened safety measures. Investing in in-hospital addiction medicine teams may be a particularly effective strategy to address multiple concerns raised by the nurses. Conclusions This dissertation highlighted gaps in the ways that the nurses’ attitudes toward PWUS were measured and influenced. The results indicated a need for improved assessment tools, targeted education, and organizational investment in supports such as addiction medicine teams. Addressing these areas is essential to fostering more compassionate, evidence-based care and equitable health outcomes for PWUS in the hospital setting.