Health Science Journal

Keywords

Nurses; Attitudes; Substance use; Patient

Background

Substance use disorder (SUD) is common problem globally [1- 5]. In the US, there is a significant increase in the percentages of males and females addicted on heroin from 2002-2013 [6]. The American Psychiatric Association [7] (DSM-V) published the diagnostic criteria of substance use disorder, including clinical significant disruption in various dimensions of individual life (academic, social, and economic) and they are more likely engaged in reckless behavior as loss of control, risky behavior, and social impairment [1]. Furthermore, the substance disorder is commonly seen among health care professionals. Previous studies showed that prevalence of SUD among nurses could influence the quality of nursing care provided and nursing profession [3,8- 13]. This problem prevents nurses to accomplish their tasks and jeopardizes ethical consideration in delivering nursing care [14].

Attitudes and beliefs about substance use are shaped by personal knowledge about this disorder, knowing and interacting with someone living with substance use, cultural stereotypes about substance use [15-22]. When such attitudes and beliefs are expressed positively, they can result in supportive and inclusive behaviors, and when such attitudes and beliefs are expressed negatively, they may result in avoidance, exclusion from daily activities, and, in the worst case, exploitation and discrimination. It is known that the general population has a negative attitude, pessimistic and stereotypical opinions toward people with stigmatized illnesses that may cause stigma in the society due to their chronic and infectious nature, such as patients with AIDS, mental illness and psychoactive drug users [4].

Generally, the public view individuals with substance use as dangerous, prone to violence, unpredictable, and in some measure responsible for their illnesses. The attitude of the professionals about substance users is highly influenced by the value and belief system prevailing in the society as health care providers are an integral part of the community and actively interacting with the society compositions [21]. The negative attitude of nurses toward patient diagnosed with substance use disorder may affect significantly their emotional responses, therapeutic nurse-patient relationship, rapport, and trust which are necessary for enhancing consumer outcomes and quality of care.

Substance use and substance users stir up difficult responses in the community. Community impression and responses like stigma, rejection, and disciplinary responses to “addicts” are common [22]. However, lack of awareness and understanding of substance use results in many substance users remaining unnoticed and untreated properly. Such responses make it hard for substance users to recover and successfully mix in the society [16]. Health care providers are likely to be exposed to biased and uninformed philosophies and attitudes regarding substance use and substance use disorders. It is expected that education and clinical training and supervision overcome these biases, but this is not always the case for all healthcare providers [19]. The purpose of the study was to assess the psychiatric nurses’ attitude towards people diagnosed with substance use disorder.

Methods

Design

The study employed cross sectional descriptive design.

Setting

The study conducted in Iradah and Mental Health Complex for psychiatry in Jeddah, KSA. The Iradah hospital was established in 1992. It serves substance use patients in the Western region. Moreover, the Iradah and Mental Health Complex provides treatment to substance use patients from other Gulf countries. Iradah and Mental Health Complex is a governmental hospital, providing free services for Saudi citizen. The hospital has around 200 beds with 271 nurses. The reason behind choosing this setting is that the availability of patients with history of substance use, it serves the majority of patients who have substance use disorder, and it was easy to be accessed by the researcher. The complex is concerned with providing psychiatric and social rehabilitation services to meet the needs of psychiatric patients and substance use patients. Approximately, 271 nurses work in the health complex in all nursing designations.

Sampling

The current study used a convenience sampling. The rational of choosing this sampling is obtain large and representative participants numbers. Furthermore, convenience sampling it is the easiest procedure to distribute a questionnaire to the largest number of participants. Moreover, the majority of studies in health disciplines and nursing field rely on nonprobability samples [20]. The required sample size was calculated based on the study power 80%, level of significance 5% with medium effect size. Then the required sample size is 155 to be adequately powered study.

In this light, the sample criteria for this study are defined as follows: inclusion criteria

a) Nurses from both gender male or female work at Iradah and Mental Health Complex in Jeddah

b) All nursing positions -assistant nurse to head nurse

c) Has at least 6 months experience.

Participants will be excluded: exclusion criteria

(a) Nurses who have less than 6 months experience.

(b) Nurses who declined to participate in the study.

Outcome measure

The study administered two parts of scale. The first part was related to sociodemographic data, including gender, age, marital status, job description, education qualification, work setting, years of experience, attendance professional or training sessions.

In addition, the second part encompassed the Drug and Drug Problems Perceptions Questionnaire (DDPPQ) to assess the study participants attitudes towards people diagnosed with substance use disorder. The DDPPQ scale is a 22- item self-report questionnaire, was developed by Hazel Watson, Cartwright et al [6]. The DDPPQ has six subscales: role adequacy, role support, job satisfaction, role related self-esteem, motivation and role legitimacy. Each item is rated on a 7-point Likert scale ranging from 1 (strongly agree) to 7 (strongly disagree). Low scores denote positive attitudes, whereas high scores are associated with negative views. Items 15, 16, 17, and 18 are worded negatively, so the scores for these items should be reversed before tallying a total score for the entire questionnaire. The minimum possible score is 22 and the maximum is 154 [23-25]. The scale has an internal consistency (Cronbach's α=0.87) and construct and content validity of these measures have been reported as satisfactory [26]. The translated version of the scale in Arabic is used to calculate the reliability which reveals that scale is adequately reliable (0.81). Also, the content validity index revealed to be 0.84.

Ethical consideration

The study obtained the ethical approval from the Scientific Research Committee at Fakeeh College for Medical Sciences (Ref No: 45/IRB/2019). Informed consent was obtained from all of the study participant. Confidentiality of the study participants was assured. The study participants were informed that they have the right to leave the study at any time without justification.

Data analysis

Descriptive statistics, consisting of numerical and graphical techniques for data summarization, were performed and used to analyse frequency of data distributions on numerical and categorical variables (sociodemographic variables). The independent variables (sociodemographic variables) identified differences in distributions of the dependent variables in two categories. One-way ANOVA was used to assess whether the mean score in the attitude of psychiatric nurses toward tackling illicit drug use was different across the values of discrete variables with more than two categories. Results were considered significant if the p-values were smaller than 0.05 at reliability estimate of 95% confidence interval (Table 1) [9,23,24].

Characteristics	Frequency	%
Gender
Male	130	83.10%
Female	55	16.90%
Age
<25 years	0	0.00%
26-35 years	103	66.50%
36-45 years	45	29.00%
>45 years	7	4.50%
Marital Status
Single	20	12.90%
Married	131	84.50%
Widow	2	1.90%
Others	1	0.60%
Education Qualification
Diploma	99	63.90%
Bachelor	54	34.80%
Master	2	1.30%
PhD	0	0.00%
Working Setting
Detoxification A	34	21.90%
Detoxification B1	37	23.90%
Detoxification B1	13	8.40%
Behaviour Modification C	16	10.30%
adolescent	2	1.30%
ER	18	11.60%
Outpatient clinic	10	6.50%
Female ward	21	13.50%
Extended care	4	2.50%
Years of experience in Nursing
<5 years	20	12.90%
6-10 years	51	32.90%
11-15 years	64	41.30%
16-20 years	11	7.10%
>20 years	9	5.80%
Years of experience in Iradah Mental Health Hospital
<5 years	45	29.00%
6-10 years	65	41.90%
11-15 years	36	23.20%
16-20 years	4	2.60%
>20 years	5	3.20%
Attended in Training/Professional Workshop related to substance use
Yes	135	87.10%
No	20	12.90%

Table 1 Demographic Characteristics of The Study Participants.

Results

One hundred and fifty-five completed questionnaires were received, giving an overall response rate of 68%. A scan be noted from Table 2, just around two-third of the study sample who responded to the survey males (83.1% [n=130]) and the least proportion was females (16.9%). Additionally, the majority (66.50% [n=103]) were aged between 26 and 35 years as well as 33.4% of the participants were aged more than 36 years. It is apparent from this table that very few had job description as nurse assistant (1.30%) compared to 66.5% of the participants were classified as nurse technician and 63.9% of responded attained diploma level of education. In addition, only 34.8% of the study participants obtained bachelor’s degree of education in nursing. From this data, we can see that the vast majority of the participants (87.1% [n=135]) had practiced nursing tasks for more than 5 years. Interestingly, the two-third of the study participants were observed to have more than six years of clinical experience in the Iradah Mental and Psychiatric Hospital where the study conducted. Approximately, 87.1% of the study responded attended or participated in training and workshop in field of substance use (Table 1).

Questions	Strongly Agree	Agree	Disagree	Strongly Disagree	Mean	SD	Variance
WORKNOW (Q1)	120 (77.4%)	24 (15.5%)	9 (5.8%)	2 (1.2%)	1.82	1.11	1.25
MYROLE (Q2)	134 (86.5%)	12 (7.7%)	7 (4.5%)	2 (1.3%)	1.62	0.96	0.92
PHYSICAL (Q3)	138 (89.0%)	10 (6.5%)	6 (3.9%)	1.00 (0.6%)	1.59	0.85	0.73
PSYCHOLOGICAL (Q4)	133 (85.8%)	15 (9.7%)	4 (2.6%)	6 (1.9%)	1.65	1.01	1.03
FACTORS (Q5)	128 (82.6%)	19 (12.3%)	1 (0.6%)	1 (0.6%)	1.74	0.99	0.99
COUNSEL (Q6)	110 (71.0%)	28 (18.1%)	4 (2.6%)	5 (3.2%)	2.05	1.33	1.77
ADVISE (Q7)	125 (80.7%)	12 (8.4%)	1 (0.6%)	4 (2.5%)	1.88	1.19	1.43
SATISFIED (Q19)	123 (79.3%)	9 (5.8%)	16 (10.3%)	7 (4.5%)	2.04	1.57	2.49

SD: Standard Deviation

Table 2 Descriptive Statistics Results of the Role Adequacy Subscale.

The perception of MHPs toward tackling substance use and related disorders were assessed using the Drugs and Drug Users’ Problems Perceptions Questionnaire (DDPPQ) developed by Watson et al [26]. The 22-item DDPPQ adopted in this study was scaled psychometrically using a seven-point Likert scale to avoid neutral responses. All questions were associated with six subscale factors, as illustrated in Table 2. Before analyzing the data related to outcome variable, the study participants answers were categorized participants perception of their role in two categories (as binary variables), the Likert scale was condensed into a dichotomous response. Thus, the strongly agree was incorporated into the agree category, and the strongly disagree was incorporated into the disagree category. In addition, the perception of psychiatric and mental health nurse (PMHN) was measured in a continuum with the theoretical assumption that PMHN with positive perception scored lower while those with negative perception scored higher.

For the subscale of role adequacy, PMHNs’ notion of being well informed and enlightened in dealing with substance use related disorders were assessed using 8-item questions on the DDPPQ. The questions included the following items: (1) “I feel I have enough working knowledge of drugs and drug related problems” (WORKNOW), (2) “I feel I know enough about the causes of drug problems to carry out my role when working with drug users” (MYROLE), (3) “I feel I know enough about the physical effects of drug use to carry out my role when working with drug users” (PHYSICAL), (4) “I feel I know enough about the psychological effects of drugs to carry out my role when working with drug users” (PSYCHOLOGICAL), (5) “I feel I know enough about the factors which put people at risk of developing drug problems to carry out my role when working with drug users” (FACTORS), (6) “I feel I know how to counsel drug users over the long term” (COUNSEL), (7) “I feel I can appropriately advise my patients/ clients about drugs and their effects” (ADVISE), and (8) “on the whole, I am satisfied with the way I work with drug users” (SATISFIED).

It is evident from this Table 3 that the majority of respondents, 92.9% (n=144, Mean=1.82, M2=1.62, SD1=1.11, SD2=0.96), expressed that they had working knowledge of drugs and its related problems. They also expressed that they knew enough about the causes of problems related to drug use to carry out their role sufficiently toward individuals who presented with substance use problems. Almost all the respondents, 85.1% (n=136, M=1.88, SD=1.19), believed they could appropriately advice clients/patients about drugs and the related problems. A majority of the PMHNs who responded to the survey, 95.5% (n=148, M1=1.59, M2=1.65, SD1=0.85, SD2=1.03), believed they knew enough about both psychological and physical effects of drug use to enable them appropriately to carry out their role when working with clients that misuse substances. A few of the participants, 14.7% (n=23, M=2.04, SD=1.57), expressed dissatisfaction with the way they worked with substance users. Just 5.8% (n=9, M=2.05, SD=1.33) of the study participants expressed that they did not know how to counsel clients/patients who were drug users over the long term (Table 2).

Questions	Strongly Agree	Agree	Disagree	Strongly Disagree	Mean	SD	Variance
RIGHTQUESTION (Q8)	118 (76.2%)	19 (12.3%)	8 (5.2%)	10 (6.5%)	2.04	1.57	2.49
RIGHTTOASK (Q9)	102 (65.8%)	26 (16.8%)	15 (9.7%)	12 (7.8%)	2.36	1.61	2.69
RIGHTTOINFO (Q10)	109 (70.4%)	21 (13.5%)	3 (1.9%)	22 (14.1%)	2.18	1.56	2.44

Table 3 Descriptive Statistics Results of the Role Legitimacy Subscale.

As regards the role legitimacy subscale, PMHNs’ were confident in their prerogative right to handle substance use related disorders were assessed using 3-item questions on the DDPPQ. The questions included the following items: (1) “I feel I have the right to ask patients/clients questions about their drug use when necessary” (RIGHTQUESTION), (2) “I feel that my patients/ clients believe I have the right to ask them questions about drug use when necessary” (RIGHTTOASK), and (3) “I feel I have the right to ask a patient for any information that is relevant to their drug problems” (RIGHTTOINFO). A majority of the PMHNs who responded to the survey, 96.5% (n=115, M=1.65, SD=0.572) and 95.8% (n=115, M=1.69, SD=0.547), felt they had the right to ask about clients’ drug use when necessary and to ask for any information relevant to drug use problems respectively. However, a few of the respondents, 12.9% (n=37, M=1.89, SD=0.634), felt their clients/patients believed they had the prerogative right to ask drug use related questions, when necessary, as described in Table 3.

The independent sample t test was used to compare between sociodemographic data of the study participants measured at two levels and the dependent variables (scores on attitudes scales). The results showed that female participants showed more statistically significant informed and enlightened in handling substance use related disorders compared to males’ participants (p<0.05). Additionally, female participants demonstrated higher role of support related to handling individuals who misuse substances (p<0.05) and they reported higher motivated compared to males’ participants (p<0.05). However, there was no statistically significant difference in other subscales related to gender (p>0.05). Moreover, the effect of attending or participating in professional workshop significantly influenced the study participants perception and attitudes towards substance user. This was evident of the level of significance less than 0.05 in subscales of adequacy, support and satisfaction. The results of one-way ANOVA revealed that age has significant effect in attitudes and perception of nurses towards substance user. As regards the marital status, the results indicated no significant impact was reported in any subscale. The most interesting results is that job description of the study participants had no significant impact on the DDPPQ subscales. However, the higher education qualification showed significant and more positive attitudes and perceptions. More importantly, nurses who work in detoxification unit appeared to have more positive and favorable attitudes towards substance use patients. Also, the results reflected that experienced nurse were able to be more supportive, motivated and more confident in handling substance user. Similarly, experience nurses in Iraida hospitals were more able to support, well informed and more supportive to drug users, as reported in Table 4.

	Role Adequacy	Role Legitimacy	Role Support	Motivation	Work Satisfaction	Role Specific Self-Esteem
Gender Male	1.36*	6.39*	0.741	0.288	0.579	1.42
Attended Yes	1.13*	1.001	1.002*	4.777*	4.77	1.266
Age	0.55	2.280	2.542	1.156	0.724	0.723
Marital Status	1.934	1.299	1.237	0.897	1.045	1.495
Job Description	0.309	0.080	0.872	1.288	0.284	0.499
Education Qualification	2.88*	1.38*	3.41*	2.45*	3.21*	2.78*
Work Setting	2.48*	2.64*	3.21*	2.96*	4.21*	3.21*
Experience Generally	0.65	0.37	2.41*	2.64*	0.29	2.18*
Experience in Iraida Hospital	2.98*	0.87	2.58*	2.74*	0.65	0.34

Table 4 Difference in DDPPQ by Demographic Data of the Study Participants.

Discussion

The results of current study demonstrated that mental health nurses expressed that they had working knowledge of drugs and its related problems. In addition, the study results showed that they have adequate knowledge about psychological and physical effects of drug on various body systems function. Furthermore, the study participants appeared confident in their prerogative right to handle substance use related disorders. The current study found that MHPs’ was able withstand or sustain any form of pressure that could be related to handling individuals who misuse substances based on perceived support of their role. Another important finding was that psychiatric nurses motivated substance users to make goal-oriented behaviour by utilizing various forces (i.e., cognitive, emotional, social, and biological). The results of this study indicated that the study participants had high level of self-esteem in dealing with such patients which in turns influenced on their job satisfaction and quality of service being provided.

Interpretation of the study findings: Links to existing study

Study conducted by Vauclair and Fischer [25] established that moralistic attitudes displayed by individuals could be based on the discourse of a community or a particular group that appraise themselves as being right or wrong based on social obligations, roles, and interpersonal duties. These studies explored the influence of cultural values against the backdrop of moral attitudes. They demonstrated that individual moral attitudes, as expressed by PMHNs in my study, could be due to cultural embeddedness [25]. Responses to treatment intervention and treatment optimism were fairly homogenous and relatively high. PMHNs displayed positivity toward successful outcome of drug dependent care and treatment. An overwhelming number of participants believed family involvement and group therapy were integral to the treatment of drug substance use. This is supported by previous studies which indicated that when PMHN showed a positive attitudes towards ill patients improved the treatment outcomes and compliance rate [19].

Participants expressed the opinion that substance use to drug was treatable even in individuals with a history of relapse. However, their responses also suggested that they did not find working with drug-dependent persons as pleasant. The study results is also asserted by another study who documented that he attitudes exhibited toward treatment optimism did not deviate from the study conducted by Kelleher and Cotter [12], as this view was expressed by a majority of their study participants. Peckover and Chidlaw [19] established discourses of risk and prejudice as factors that affect provision of service to individuals who misuse substances. Healthcare practitioners perceive themselves as vulnerable to care for clients who misuse substances; therefore, they described their overall experience as unpleasant [19]. However, this attitude might translate into ineffective and judgmental care to clients who misuse substances [13].

PMHNs’ who responded to the survey exhibited distinctly defined perceptions of their role in tackling substance use and related disorders. An overwhelming number of respondents believed they knew enough about both the psychological and physical effects of drug use (95.5%) and could appropriately advice clients who misuse substances (93.3%). The participants also expressed confidence in their right to handle substance related disorders (96.5%) and exhibited goal-oriented behaviours due to the support they received in the area of clarifying their professional responsibilities (75.2%). In this study, role support was a strong predictor of perception toward tackling substance use and related disorders as these accounts for 12.6% of the total variability in the dependent variables. In other words, for every single increase in role support, PMHNs’ had the potential to exhibit distinctly defined perception of their role toward tackling substance use and related disorders. This was in line with the study conducted by Ford et al [10]. Role support, as indicated by these studies, is an integral determinant of therapeutic attitude exhibited to clients who misuse substances. However, existing literature reported low levels of role support for mental health practitioners subsequently resulting into lack of adequate care to this population group as their healthcare providers struggle to provide adequate treatment [8]. This also reflects outcomes of previous study [2,10,15] on the importance of ongoing further support for multidisciplinary healthcare workers toward clients who misuse substances as they expressed deficit in support structure. This study identified educational attainment as a predictor of PMHNs’ role perception toward tackling substance use and related disorders. Responses from the study participants suggest that obtaining only undergraduate degree might not be enough to handle drug-using populations effectively. In this current study, educational attainment of participants beyond undergraduate degree increased positive role perception in tackling substance use. Happell and Taylor [11] attributed negative perception of role to inadequate educational preparation in substance use treatment and care.

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