Abstract: Rassool, G.H. (2006) Undergraduate nursing students’ perceptions of substance use and misuse. www.nursingtimes.net
Negative attitudes towards substance misusers are likely to make nurses reluctant to work with alcohol and drug misusers or provide minimal care to this group of patients. Such attitudes have been associated with substance misusers’ reluctance to enter treatment or influencing their premature discharge. There is limited nursing literature on the attitudes of undergraduate nursing students towards substance misusers in the UK.
To examine the attitudes of undergraduate nursing students towards substance misusers, and the implications of these attitudes for nurse education.
A 21-question Likert-style questionnaire was developed and distributed to 110 undergraduate mental health nursing students from three higher education institutions. The questions measured attitudes to issues related to substance misuse.
A large proportion of participants agreed that recreational drug illicit use leads to addiction and that cannabis use leads to mental illness, and disagreed that using illicit rugs at home should be legal. Although many participants accepted negative moral stereotypes of illicit substance misusers, they generally held positive attitudes towards therapeutic intervention in combating substance misuse.
Discussion and conclusion
The generally optimistic view of therapeutic interventions with substance misusers should enable the students to provide appropriate care and intervention strategies. Although many held moral views about taking illicit substances, most held non-discriminatory attitudes to substance misusers. Further research is needed to examine more widely the attitudes of nursing students to substance misusers and the effectiveness of strategies in challenging and modifying negative attitudes, and whether substance misuse education is a key predictor of therapeutic attitudes. Despite the education and preventive efforts, legislative controls, law enforcement and therapeutic interventions, alcohol, drugs and tobacco continue to threaten the health and socio-economic fabric of society.
The widespread misuse of psychoactive substances has created a variety of health and social care needs in the general population that demands a workforce that is skilled in nursing interventions and able to provide generic and specialist care to misusers and their carers. Since drug and alcohol misuse is more likely to be the norm than the exception among patients attending residential and community settings, it is likely that most nurses and midwives regularly encounter patients who misuse. Negative attitudes towards substance misusers are likely to make nurses reluctant to work with alcohol and drug misusers or provide minimal care to this group of patients. This means there is a pressing need for nurses and midwives, as generic workers, to develop their knowledge and clinical expertise in substance misuse in order to respond effectively to the needs of this group of patients.
It is estimated that over three million people in the UK use illegal drugs every year, with more than half a million using those considered to be the most harmful, such as heroin and crack cocaine. There are 280,000 heroin and/or crack users in the UK at any one time, but only 20% are receiving treatment (Prime Minister’s strategy unit, 2003). Heroin and crack are by far the most addictive drugs and result in social harm among users and society as a whole. While HIV prevalence among injecting drug users in England and Wales remained at less than 1% in 2001, prevalence of hepatitis C among this group was about 30%, and the rate increased with number of injecting years (Jeffery et al, 2002).
In addition to problems caused as a result of illegal drug use, health and social problems are caused by the misuse of legal substances including alcohol and tobacco. Alcohol misuse is linked to over 30,000 hospital admissions annually for alcohol dependence syndrome and causes up to 22,000 premature deaths a year. In recent years, the term ‘binge drinking’ - referring to a high intake of alcohol in a single drinking session - has gained currency. It is reported that, at peak times, up to 70% of all admissions to A&E are related to alcohol use (Prime Minister’s strategy unit, 2004). In Great Britain, there were 16,800 casualties in traffic incidents involving illegal alcohol levels, which constituted 5% of all traffic incident casualties (Department of Health, 1999). More than 120,000 people die each year in the UK as a result of tobacco smoking (DH, 1998).
Despite the magnitude of the problem, and even when alcohol and drug problems are identified, healthcare professionals may be reluctant to respond appropriately due to the lack of adequate preparation and negative attitudes. Social prejudice, negative attitudes and stereotyped perceptions of substance misusers (Rassool, 1998; Selleck and Redding, 1998; Hanna, 1991; Sullivan and Hale, 1987) and dual diagnosis patients (Richmond and Foster, 2003; Williams, 1999) are held widely among healthcare professionals and this may lead to minimal care being given to this population.
There is some evidence that health professionals’ attitudes towards substance misusers exert a significant influence on their willingness to intervene and the quality of such interventions (Karam-Hage et al, 2001; Roche and Richard, 1991; Chappel et al, 1985). Therefore, negative attitudes towards substance misusers are likely to make nurses reluctant to work with alcohol and drug misusers or provide minimal care to this group of patients. Negative attitudes have been associated with substance misusers’ reluctance to use health services for drug-related or other health problems, reduced likelihood of pursuing referrals and reluctance to engage in management and treatment of substance misuse (Groves and Strang, 2001; Mistral and Velleman, 2001; McLaughlin et al, 2000).
Much professional education and training reinforces the view that dealing with substance misuse is the job of a specialist (Rassool, 2000; 1993), and there is a real need for educational programmes for nurses on alcohol and drug education (Rassool and Oyefeso, 1993). There is limited nursing literature on the attitudes of undergraduate nursing students towards substance misusers in the UK. The aims of this study were to examine the attitudes of undergraduate nursing students towards substance misusers and consider the implications of these attitudes on nursing education.
This descriptive survey was carried out with a convenience sample of first-level undergraduate nursing students who had completed the common foundation programme following the mental health pathway. Four cohorts of undergraduate students enrolled at a course leading to a diploma or BSc in nursing were identified to take part in the study, drawn from three educational institutions in south-east England. Two educational institutions were based in an urban area and one in a rural area.
There are few reliable and validated available instruments for measuring the attitude of undergraduate nursing students towards substance misusers in the UK. Those that have been used to include: the Marcus alcoholism instrument (Marcus, 1963), the Tolor and Tamerin attitudes towards alcoholism scale (Tolor and Tamerin, 1975) and the substance abuse attitude survey (SAAS) (Chappel et al, 1985). With the exception of the SAAS, these instruments are biased toward the use of alcohol. The SAAS is the only instrument that combines alcohol and drug misuse, has a quantifiable score and can be used for group comparisons of attitudes. However, it is limited in that results are based on self-rating by medical students and clinicians, and no data has been published to support its psychometric properties with undergraduate nursing students and nurses in the UK.
Due to the limitations of attitudinal measurement instruments, a new instrument was designed, developed and tested. The attitude towards substance misusers (ATSMQ-21), based on the SAAS, was subjected to both validity and reliability analysis. The findings indicate that the ATSMQ-21 questionnaire had a strong measure of face validity and internal consistency and with a Cronbach’s alpha of 0.88. A Likert-type response format was chosen, with items measured on a five-point scale from 1 = ‘strongly agree’ to 5 = ‘strongly disagree’.
Ethical approval for this study was granted by the relevant NHS trusts and the nursing research ethics committee. All students in the four cohort groups were given a general information sheet. Those who agreed to participate were given a consent form, which informed them that all information would be treated as confidential. In collaboration with course directors, a schedule was developed for the researchers to meet the different cohorts to explain the purpose of the study. In order to achieve a maximum response, and to answer questions students may have had during completion, the questionnaire was administered in formal class time and under the supervision of the author or module leader.
Ticehurst and Veal (1999) describe this approach to a questionnaire survey as a ‘captive group survey’ and suggest it is expeditious and less problematic than approaches in less controlled situations. For data analysis, five categories were used: 1=Strongly disagree; 2=Disagree; 3=Not sure; 4= Agree; 5= Strongly agree. These were combined into three major categories Agreement (Strongly agree and Agree); Not sure; and Disagreement (Strongly disagree and Disagree). Data analysis was undertaken using the Statistical Package for Social Science (SPSS).
The questionnaire was completed by 110 nursing students, of whom 47 (43%) were male and 63 (57%) female. The mean age of the participants was 32.91 years (SD=7.98; range 20-55). Ethnicity was grouped into three categories: white; black African and Caribbean; and Asian and other. Forty-five participants (41%) were white, 49 were black African and Caribbean (45%) and 16 (15%) were Asian and other. Educationally, 49 (44.5%) had GCSE O and A-levels, 34 (30.9%) had a diploma and 27 (24.5%) had a degree. The responses to the attitude questionnaire are shown in Table 1.
|Table 1. Nursing students’ attitudes towards substance misuse|
|1 Recreational use of illicit drugs leads to addiction||19 (17)||31(28)||46||25(23)||10(9)||32||25(22)|
|2 Taking illicit drugs is morally wrong||19(17)||34(31)||48||18(26)||8(7)||33||21(19)|
|3 Providing health risk information about substance use||47(43)||34(31)||76||10(9)||5(5)||14||12(11)|
|4 Use of illicit drugs should be legal in the confines of ones home||13 (12)||21(19)||31||30(27)||11(10)||37||35(32)|
|5 Drug addicts suffer from feelings of inferiority||17(16)||24(22)||37||23(21)||4(4)||25||42(38)|
|6 Addictions are different from physical/psychological illness||10(9)||31(28)||37||39(36)||5(5)||40||24(22)|
|7 Users of illicit drug do not respect authority||13(12)||22(20)||32||49(45)||7(6)||51||19(17)|
|8 Heroin is so addictive that no one can fully recover||8(7)||12(11)||18||52(47)||12 (11)||58||26(24)|
|9 Random drug testing should be carried out routinely||15(14)||28(26)||39||36(33)||9(8)||41||22(20)|
|10 Addiction to drug is not a treatable illness||8(7)||8(7)||15||54(49)||22 (20)||69||18(16)|
|11 Cannabis use leads to mental illness||15(14)||28(26)||39||31(28)||5(5)||33||30(27)|
|12 Abstinence is a realistic goal in the treatment of alcohol misusers||16(15)||32(29)||44||19(17)||3(3)||21||40(36)|
|13 Treatment and rehabilitation of drug misusers leads to failure||7(6)||5(5)||11||62(56)||19(17)||74||16(15)|
|14 Illicit drug misusers are a monetary and social drain in the community||3(12)||29(26)||38.2||36(33)||4(4)||36||27(25)|
|15 Compulsory treatment is necessary for addicts||11(10)||26(24)||34||40(36)||7(6)||43||25(23)|
|16 Alcohol misusers should be referred to specialists||20(18)||62(56)||75||8(7)||2(2)||9.1||18(16)|
|17 Drug misusers are unpleasant to work with||10(9)||18(16)||26||42(38)||6(6)||44||34(31)|
|18 Professionals addicted to drugs should be banned from practice||17(16)||11(10)||26||45(41)||7(6)||47||30(27)|
|19 Random alcohol testing should be carried out for all health professionals||13(12)||35(32)||44||35(32)||6(6)||37||21(19)|
|20 Drugs addicts are stigmatised by health professionals||12(11)||47(43)||54||13(12)||3(3)||15||35(32)|
|21 Once addicted to drug or alcohol a person cannot be rehabilitated to remain drug or alcohol free||6(6)||9(8)||14||62(56)||21(19)||76||12(11)|
|SA = Strongly agree; A = Agree; *A = Agreement; D = Disagree; SD = Strongly disagree; *D = Disagreement; UN = Uncertain|
Most participants strongly agreed that ‘recreational use of illicit drugs leads to addiction’ (46%) and that ‘cannabis use leads to mental illness’ (44%) but disagreed that ‘illicit drug use should be legal in the confines of one’s home’ (37%). Nearly half held ‘moral stereotypes’ such as ‘taking illicit drugs is morally wrong’ (48%), ‘drug addicts suffer from feelings of inferiority’ (37%) and ‘illicit drug misusers are a monetary and social drain on the community’ (40%).
Many rejected the notions that ‘addictions are no different from physical or psychological illness’ (40%), ‘users of illicit drugs do not respect authority’ (51%), ‘heroin is so addictive that no one can fully recover’ (58%) and that ‘once addicted to drugs or alcohol, a person cannot be rehabilitated or remain drug or alcohol free’ (76%). Seventy-six per cent agreed with the ‘provision of health risk information about substance use’ (76%).
On non-discriminatory views, fewer than half of the participants regarded that ‘drug misusers are unpleasant to work with as clients’ (44%) and the majority endorsed the statement that ‘drug addicts are stigmatised by health professionals’ (54%). Forty-one per cent agreed that agreed that ‘random drug testing should be carried out routinely for health professionals’ but rejected the notions that ‘random alcohol testing should be carried routinely for all health professionals’ (44%) and ‘professionals addicted to drugs should be banned from practice’ (47%).
With regard to treatment optimism, a significant majority believed that ‘addiction is a treatable illness’ (69%) and that ‘abstinence is a realistic goal in the treatment of alcohol misusers’ (44%). The majority rejected the notion that ‘treatment and rehabilitation for drug users leads to failure’ (74%) and 43% disagreed with the statement that ‘compulsory treatment is necessary for addicts’ (43%). Seventy-nine per cent said that ‘substance misusers should be referred to specialists’ (79%).
The results of the study showed that the participants generally held positive attitudes regarding substance use and misuse, particularly about therapeutic interventions. A significant majority showed therapeutic optimism in relation to addiction to drugs being treatable and awareness of the need to refer substance misusers to specialist workers, but rejected the view that mandatory treatment is necessary for those who are addicted to alcohol or drugs. This should enable them to provide a good therapeutic alliance, appropriate care and intervention strategies with substance misusers. It is clear that most held non-discriminatory attitudes towards substance misusers and to their professional peers. They rejected the notion that professionals addicted to drugs should be banned from practice. However, they held moral views about taking illicit psychoactive substances and perceived that recreational use of illicit drugs leads to addiction.
These findings are congruent with recent studies on nurses’ attitudes towards substance misuse. Rassool et al’s (2006) study of 227 undergraduate nurses in the south and south-eastern part of Brazilshowed that they had positive views towards substance misusers. Most of their participants rejected the stereotypes that that drug and alcohol misusers were unpleasant to work with and that alcohol is due to weak morality. A study of mental health professionals’ attitudes to drugs and substance misuse by Pinikahana and Happell (2002) found that the majority held positive views on treatment interventions and they are optimistic that drug and alcohol dependence are treatable illnesses. They hold non-discriminatory attitudes and reject some ‘moral stereotypes’.
The present study confirms the findings of Gerace et al (1995) in relation to ‘treatment optimism’. Their findings indicate that nurses became more optimistic about addiction as a treatable disease and became more hopeful about the effectiveness of treatment. Richmond and Foster’s (2003) study examined the mental health professionals’ attitudes towards substance misusers and found that those educated to a postgraduate level were less moralistic and had greater treatment optimism. In a major exploration of the role of substance misuse nurses in Scotland, Matheson et al (2004) showed that the majority of nurses had positive attitudes to drug misusers before they worked in this field.
This study shows that undergraduate nursing students generally hold positive attitude towards substance misusers. Their attitudes may reflect prevalent attitudes in society in general. The small sample size and the use of self-reported instruments may limit the generalisation of the study. In addition, the paucity of studies on attitude of undergraduate nurses towards substance use and misuse in the UK made it difficult to make valid comparison. It is often assumed that positive attitudes towards substance misusers must lead to effective clinical practice. This tenet is not supported by research evidence (Roche, 1996).
Attitudes are brought into educational programmes and attitude change and the effect of such change is difficult to measure and may not be the key determinant in changing desired skills-orientated behaviours. The major determinants of effective practice are not ‘the level of knowledge or positive attitudes’ to substance misusers but skills development, role confidence and realistic expectations of response to interventions (Saunders and Roche, 1991).
Attitude cannot solely be changed by simple education. It is important to recognise that work colleagues, supervisors and the organisational culture may also influence attitudes towards individuals who use alcohol and drugs (Pidd et al, 2004). A range of strategies have been found to be useful in enabling workers to re-evaluate or reconsider their personal beliefs and attitudes towards substance misuse. Experiential techniques such as role play have been found effective in changing attitudes, in particular stereotypes (Wilks and Austin, 1991; Donaldson, 1980).
Further research is needed to examine the perceptions of undergraduate nurses towards substance misuse and misusers, the effectiveness of strategies in challenging and modifying negative attitudes and whether substance misuse education is the key predictor of therapeutic attitudes.
Chappel, J.N. et al (1985) The substance abuse attitude survey: an instrument for measuring attitudes. Journal of Studies on Alcohol; 46: 1, 48-52.
Department of Health (1999) Statistical bulletin (1999) Alcohol: 1976 onwards. www.dh.gov.uk/assetRoot/04/02/15/12/04021512.pdf
Department of Health (1998) Our Healthier Nation. London: DH.
Donaldson, J. (1980) Changing attitudes toward handicapped persons: a review and analysis of research. Exceptional Children; 46: 7, 504-514.
Gerace, L.M. et al (1995) Improving nurses’ responses towards substance-misusing patients: a clinical evaluation project. Archivesof Psychiatric Nursing; 9: 286-294.
Groves, P., Strang, J. (2001) Why do general practitioners work with opiate misusers? A qualitative study of high and low activity general practitioners. Drugs: Education, Prevention and Policy; 8: 131-139.
Hanna, Z.E. (1991) Attitudes towards problem drinkers revisited: patient-therapist factors contributing to the differential treatment of patients with alcohol problems. Alcoholism: Clinical and Experimental Research; 15: 6, 927-931.
Jeffery, D. et al (2002) UK Drug Report on Trends in 2001. Report from the UK Focal Point to EMCDDA. London: Drugscope.
Karam-Hage, M. et al Nerenberg (2001) Modifying residents’ attitudes about substance abuse treatment and training. American Journal on Addictions; 10: 40-47.
Marcus, A. (1963) Alcoholism Instrument. Toronto: Alcohol and Drug Research Foundation.
Matheson, C.I. et al (2004) An exploration of the role of substance misuse nurses in Scotland. Effective Interventions Unit, Scottish Executive Drug Misuse Research Programme www.scotland.gov.uk/Resource/Doc/26800/0012666.pdf. Accessed 28 May 2006.
McLaughlin, D. et al (2000) The perceptions and aspirations of illicit drug users hold towards health care staff and the care they receive. Journal of Psychiatric and Mental Health Nursing; 7: 435-441.
Mistral, W., Velleman, R. (2001) Substance-misusing patients in primary care: incidence, services provided and problems. A survey of general practitioners in Wiltshire. Drugs: Education, Prevention and Policy;8: 61-71.
Pidd, K. et al (2004) From Training to Work Practice Change: An Examination of Factors Influencing Training Transfer in the Alcohol and Other Drugs Field. Adelaide: National Centre for Education and Training on AddictionFlindersUniversity.
Pinikahana, J., Happell, B. (2002) Mental health professionals’ attitudes to drugs and alcohol. Nursing and Health Sciences; 4: 57-62.
Prime Minister’s Strategy Unit (2004) Alcohol harm reduction strategy for England. www.strategy.gov.uk/work_areas/alcohol_misuse/index.asp.
Prime Minister’s Strategy Unit (2003) Drug Report Phase One. www.strategy.gov.uk/work_areas/drugs/index.asp.Rassool, G.H. et al (2006) Undergraduate nursing students’ perceptions of substance use and misuse: a Brazil
ian position. Journal of Mental Health and Psychiatric Nursing; 13: 1, 85-89.
Rassool, G.H. (2000) Guest editorial. Addiction: global problem and global response complacency or commitment? Journal of Advanced Nursing; 32:3, 505-508.
Rassool, G.H. (1998) Contemporary issues in addiction nursing. In: Rassool, G.H. Substance Use and Misuse: Nature, Context and Clinical Interventions. Blackwell Science: Oxford.
Rassool, G.H. (1993) Nursing and substance misuse: responding to the challenge. Journal of Advanced Nursing; 18: 1401-1407.
Rassool, G.H., Oyefeso, A.O. (1993) The need for substance misuse education in health studies curriculum: a case for nursing education. Nurse Education Today; 13: 2, 107-110.
Richmond, I.C., Foster, J.H. (2003) Negative attitudes towards people with co-morbid mental health and substance misuse problems: an investigation of mental health professionals. Journal of Mental Health; 12: 4, 393-403.
Roche, A.M. (1996) Increasing primary care providers’ willingness to intervene in alcohol and drug-related problems: a review. Substance Abuse 17, 201-217.
Roche, A.M., Richard, G. P. (1991) Doctors’ willingness to intervene in patients’ drug and alcohol problems. Social Science and Medicine; 33: 1053-1061.
Saunders, J.B., Roche, A.M. (1991) Medical education in substance use disorders. Drug and Alcohol Review; 10: 263-275.
Selleck, C., Redding, B. (1998) Knowledge and attitudes of registered nurses toward perinatal substance abuse. Journal of Obstetric, Gynecologic and Neonatal Nursing; 27: 1, 70-77.
Sullivan, E.J., Hale, R.E. (1987) Nurses’ beliefs about the aetiology and treatment of alcohol abuse: a national study. Journal of Studies on Alcohol; 48: 5, 456-460.
Ticehurst, G.W., Veal, A.J. (1999) Business Research Methods: A Managerial Approach. Melbourne: Longman.
Tolor, A., Tamerin, J.S. (1975) The attitude towards alcoholism instrument: A measure of attitudes towards alcoholics and the nature and causes of alcoholism. British Journal of Addiction; 70: 223-231.
Wilks, J., Austin, D.A. (1991) Evaluation of a strategy for changing group stereotypes of the heroin user. Drug and Alcohol Review; 10, 107-113.
Williams, K. (1999) Attitudes of mental health professionals to co-morbidity between mental health problems and substance misuse. Journal of Mental Health; 8: 6, 606-13.